Patient cues about end-of-life matters: An observational study of palliative care consultations using conversation analysis.

Objective: This article examines instances of patients making allusive or ambiguous potential reference to death and dying (cues) and analyses how they are built and received in consultations.

Methods: Conversation analysis of video and audio recorded interactions in a large UK hospice. These consultations occurred between patients and companions and a variety of healthcare professionals (HCPs), comprising six palliative medicine consultants, five occupational therapists, and three physiotherapists.

Results: Patients may foreground the end-of-life (EoL) aspect of a cue by, for example, producing it while launching a topic or making a pronouncement/report. This exerts sequential pressure for HCPs to address the EoL implication (unmarked case), but HCPs may avoid engaging with it (marked case). Sometimes, patients allusively or ambiguously refer to death and dying in the course of another interactional activity, thereby backgrounding the EoL implication. The unmarked case involves the HCP attending to the ongoing activity, which maintains the backgrounding. However, HCPs can target the EoL implications in cues produced in the service of other activities or in cases in which the patient has unpacked with a non-EoL concern.

Conclusion: Although not determinative, the sequential environment in which the cue is deployed shapes how HCPs respond to it. This is important because it permits HCPs avenues for engaging in EoL discussion.

Practice Implications: HCPs can better understand the interactional work done with cue like utterances if there are contextualised in the ongoing sequence of interaction. For patients reticent to talk about EoL issues, stepwise engagement with the topic, even when EoL has been backgrounded may provide an opportunity for discussing difficult but essential topics.