title: Initiating decision-making conversations in palliative care: an ethnographic discourse analysis.
abstract: BACKGROUND
  Conversations about end-of-life care remain challenging for health care providers. The tendency to delay conversations about care options represents a barrier that impedes the ability of terminally-ill patients to participate in decision-making. Family physicians with a palliative care practice are often responsible for discussing end-of-life care preferences with patients, yet there is a paucity of research directly observing these interactions. In this study, we sought to explore how patients and family physicians initiated decision-making conversations in the context of a community hospital-based palliative care service.
  
  
  METHODS
  This qualitative study combined discourse analysis with ethnographic methods. The field research lasted one year, and data were generated through participant observation and audio-recordings of consultations. A total of 101 consultations were observed longitudinally between 18 patients, 6 family physicians and 2 pivot nurses. Data analysis consisted in exploring the different types of discourses initiating decision-making conversations and how these discourses were affected by the organizational context in which they took place.
  
  
  RESULTS
  The organization of care had an impact on decision-making conversations. The timing and origin of referrals to palliative care shaped whether patients were still able to participate in decision-making, and the decisions that remained to be made. The type of decisions to be made also shaped how conversations were initiated. Family physicians introduced decision-making conversations about issues needing immediate attention, such as symptom management, by directly addressing or eliciting patients' complaints. When decisions involved discussing impending death, decision-making conversations were initiated either indirectly, by prompting the patients to express their understanding of the disease and its progression, or directly, by providing a justification for broaching a difficult topic.
  
  
  CONCLUSIONS
  Decision-making conversations and the initiation thereof were framed by the organization of care and the referral process prior to initial encounters. While symptom management was taken for granted as part of health care professionals' expected role, engaging in decisions regarding preparation for death implicitly remained under patients' control. This work makes important clinical contributions by exposing the rhetorical function of family physicians' discourse when introducing palliative care decisions.
authors: Department of Social and Preventive Medicine, Université de Montréal, 7101 Parc Avenue, Montreal, H3N 1X9 Quebec Canada ; Department of Family Medicine, McGill University, Montreal, Canada.
authors: Emmanuelle
authors: E
authors: Bélanger
authors: Department of Family Medicine, McGill University, Montreal, Canada.
authors: Charo
authors: C
authors: Rodríguez
authors: Department of Psychiatry, McGill University, Montreal, Canada.
authors: Danielle
authors: D
authors: Groleau
authors: Department of Emergency and Family Medicine, Université Laval, Quebec City, Canada.
authors: France
authors: F
authors: Légaré
authors: Division of Oral Health and Society, McGill University, Montreal, Canada.
authors: Mary Ellen
authors: ME
authors: Macdonald
authors: Champlain Hospital, Montreal, Canada.
authors: Robert
authors: R
authors: Marchand
mesh_terms: D032722:Advance Care Planning; D000368:Aged; D000369:Aged, 80 and over; D000884:Anthropology, Cultural; D001294:Attitude to Health; D016887:Cardiopulmonary Resuscitation / Q000523:psychology*; D003142:Communication; D003657:Decision Making; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D010358:Patient Participation; D010817:Physician-Patient Relations; D036301:Qualitative Research; D013727:Terminal Care / Q000523:psychology*
keywords: Decision-making; Discourse analysis; Ethnography; Family medicine; Health communication; Palliative care