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Bad News in Oncology: How Physician and Patient Talk About Death and Dying Without Using

Bad News in Oncology: How Physician and Patient Talk About Death and Dying Without Using Those Words Author(s): Karen Lutfey and Douglas W. Maynard Source: Social Psychology Quarterly, Vol. 61, No. 4 (Dec., 1998), pp. 321-341 Published by: American Sociological Association

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Social PsychologyQuarterly 1998,Vol.61,No. 4,321-341

Bad Newsin Oncology:How Physicianand PatientTalk about Death and DyingwithoutUsingThose Words*

KAREN LUTFEY DOUGLAS W.MAYNARD IndianaUniversity

Wefocusonthesocializationofpatientstotheprocessofdeathanddyingbyexamin-

ingactualinteractionsamongmedicalpractitioners,patients,and theirfamilymem- bers.Ourdataconsistofthreemedicalinterviews.In eachone,theoncologistdelivers

thenewsthatthepatient'scanceris no longertreatable.Althoughnotstated,the impliedmessageis thatthepatientwillsoondie.Because,intheseepisodes,thesame doctoris attemptingtoconveya similarmessageto threedifferentpatients,wecan comparethewaysin whichthepatientsrespondtothemessageand thusaffectthe deliveryofthenews.In variouspracticalways,bothphysicianandpatientexhibit interactionalcautionindiscussingdeathanddying.

Social psychological approaches to deathanddyinghavebeenpreoccupiedwith individuals'perceptionsof theirillnesstra- jectories.In herclassicworkOn Death and Dying (1969), for example, Elisabeth Ktibler-Rossarticulatesa seriesof psycho- logical stages throughwhichpeople pass whenconfrontedwithdeath,suchas denial, isolation,anger,bargaining,depression,and acceptance.Otherresearchon chronicand terminalillnessproposestheimportanceof awareness contexts (Glaser and Strauss

1965),identitylevels(Charmaz1987,1991),

and viewsof self(Corbinand Strauss1987; Kutner1987;Yoshida1993)as theyrelateto

processesofnormalization(Robinson1993)

and adaptation(Davis [1963]1991).Previous

research,inshort,emphasizesabstract,inter-

*We wish to thankProf.Richard M. Frankelfor

facilitatingthisstudyin manyways.We also grateful- ly acknowledge insightfulcommentswe received fromBill Corsaro,JeremyFreese,and VirginiaGill. We are extremelygratefulto the physician who allowed himselfto be taped while discussingvery difficulttopicswithhis patientsand who took time froma busyclinicalscheduleto be interviewed.Not least,we thankthe patientsand theirpartnerswho participated in the study. From the Indiana UniversityCollege of Artsand Sciences,the second authorreceiveda grantthatsupportedthisresearch. Finally,our gratitudegoes to the anonymousSPQ reviewerswho gave us helpfulsuggestionsand com- mentary. Correspondence to: Karen Lutfey (klutfey@indiana.edu) at the Department of Sociology, Indiana University,Bloomington IN

47405.

321

nal experiencesofindividualswhoconfront mortalorchronicillness. In theirreviewofthemedicalliterature on breaking bad news, Ptacek and Eberhardt(1996:496) identifya need for more empirical work, suggesting that "research should begin with the simple question of whetherhow thenews is con- veyedaccountsforvariancein adjustment beforemovingintomorespecificquestions aboutwhichaspectsof conveyingbad news are most beneficial" (our emphasis). We want to change the emphasis of existing workand to examinethe role of talk and interactionas embedded in processes of deathand dying.Thisstrategyis attunedto Longhofer's(1980) neglectedargumentthat dyingis a socialprocessbetterunderstoodin the contextof interactionand communica- tionthanas theinternaland inherentlypro- gressivestagesdescribedbyKubler-Ross. Previous researchon terminalillness also reliesheavilyon typificationsand gen- eralizations.Glaser and Strauss(1965), for example,discussvarious typesof medical work includingmachine,clinical, safety, comfort,sentimental,and informationwork. In another,moreinteractionistapproachto theseissues,researchersworkto makegen- eralassertionsbased on detailedanalysesof actualinteractions.Perakyla(1991) usesspe- cificexamplesfromhis fieldnotesto illus- tratephysicians'controloversituationsand theirspecificationof identities.Sudnow

322

SOCIAL PSYCHOLOGY QUARTERLY

(1967),who is orientedto hospitalemploy- ees' everydaypractices,discussestheirtypi- cal reactionsto situationsand their"main strategies"fordealingwithproblems. Our approachis relatedmostcloselyto Sudnow's (1967) PassingOn, whichexam- ines death and dyingas sociallyorganized processes.Sudnowfindsthattheseprocesses are definedand managed collaboratively throughtheinteractionsand mundaneprac- tices of hospitalstaffmembers,including doctors,nurses,aides, orderlies,chaplains, and others.We also approach death and dyingas socially organized interactional phenomena,butconcentrateon communica- tions thatSudnow (1967) explicitlymini- mized,involvingdirecttalkbetweendoctor and patient(and families)and the attempt to socializepatientsto thedyingand death process. More recently,Bor and Miller (1988) and Perakyla(1995) have examined how,in counseling,professionalsand clients addressdeathand dyingas "dreadedissues" thatrequirepreparationof an appropriate or auspiciousinteractionalenvironment.A

differencebetweenthesemorerecentstud-

ies andoursis thatcounselingoftenseeksto get clientsor patientsto discuss dreaded issues,whereas the physicianin our data solicits specific kinds of talk from his patientsbutalso seekstoinformthemabout theirillnesstrajectories. More specifically,we examinetheways inwhicha physiciancan conveyto a patient, and how thepatientreceives,thenewsthat his canceris no longertreatable,thathe is

closeto dying,andthatthephysicianis shift-

inghistreatmentfocusfromcuringthecan-

cer to managingpain symptoms.Maynard

(1996),followingcharacterizationsthatsub-

jectsprovidein theirnarrativesofbad news experience, argues that the problem for recipientsis one of"realization."In medical settings,forexample,patientsface the task of comingto understandthata featureof theirlifeworld-the presumptionof their body'sownrelativelygood healthor,in the cases examined here,theirtrajectoryfor recovery-hasbeenalteredsignificantly.The physicianmustdeliver the bad news and elicittherealizationfrompatientsand fami- lymembersthatthepatients'conditionsare nowterminalandthattheyaredying.

The interactionalprocesswherebythe doctorinourdataattemptstogenerateopen awarenessandrealizationis organizationally similarto theconversationanalyticphenom- enonthatJefferson(1986) terms"unpackag- ingofa 'gloss."'A "gloss"refersto an inac- curate,incomplete,or maskedconversation- al generalizationof"whatreallyhappened" (Jefferson1985:436).Thata piece oftalkis a glossis not available in itsfirsttelling,but emergesas a consequenceoftherecipient's activities;recipientsmayor maynotprovide an auspiciousenvironmentforthe unpack- agingprocess.Insofaras an auspiciousenvi- ronmentexists and the gloss is actually unpackaged,the talkwillbe producedin a waythatis sensitiveto theongoinginterac- tionratherthanbyone speakerunilaterally announcing "what really happened" or "whatone reallymeans."Whena recipient does not providean appropriateenviron- ment,the potentialunpackagingmay not occur. We use detailed,turn-by-turnanalyses of threeepisodesof doctor-patientinterac- tionto examinethe interactive,contingent natureof awarenesscontextsand how they are shapedthroughconversation.We assert thatphysicians'attemptsto achieve open awarenessand realizationvaryin significant waysaccordingto the contingenciesof the patients'responses.Specifically,we examine thewaysin whichthephysician,thepatient, and thepatient'sfamilymemberscautiously approachthedelicatetopicof thepatient's terminalillness;theinteractionalresources thatare availableto physiciansforbroach- ing the topic of death and dying;and the resources available to the recipients to deflect,divert,avoid,or euphemizethemat- ter.

DATA AND METHODS

The secondauthorcollectedthedatafor thisstudyat a hospital associated witha medical school in an eastern state. The physician,a participantin a largerstudyof thehospital'soncologyclinic,coincidentally had threemalepatientswithdifferentforms of terminalcancer. Two of the patients, "Robert"and "John,"wererecuperatingin the hospital fromunsuccessful surgical

BAD NEWS IN ONCOLOGY

323

attemptsat treatingtheircancers.The third patient,"David," was visitingthe oncology clinic as an outpatient.Because, in these episodes,the same doctoris attemptingto conveya verysimilarmessageto threedif- ferentpatients,we can comparethevaried waysin whichthe patientsrespondto the messageand therebyaffectthe deliveryof thenews. The second authorvideotaped in the hospitalroomsoftheadmittedpatientsand, fortheoutpatient,in an examinationroom thatwas partofa clinicattachedto thehos- pital.In each case he obtainedthepermis- sion of theoncologist,thepatient,and the patient'spartner.(John'sand David's wives werepresent,as wasRobert's"girlfriend,"to usehisterm.) In an interviewwiththesecondauthor, the oncologistin thedata volunteeredthat he "feltawkward"whenhe was talkingto Robert:

I don'tthinkithad anythingto do withthe factthatI wasbeingobserved.It wasmore withthe factthatsometimeswhenI say thingstopatients,I'mtryingtocuethem.Im

tryingto getthemto ask me some questions,

orto findoutwhattheyknowabouttheill- ness.Howsevereitis,orwhethertheyknow thattheymightdie,or whethertheythink that'simminent.ButwhenI talkedto himI didn't get any of the responses that I

would've like to get thatwould help me to buildon things.

Thisaccountis importantto our analy- ses, and we will elaborate on it later. In termsofdata collection,however,thephysi- cian'scommentssuggestthat,fromhis per- spective,the presenceof a video recorder and observerdid notinfluencetheinterac- tion.The firstauthortranscribedthe data usingJeffersoniantranscriptionconventions (Atkinson and Heritage 1984:x-xvi; see appendix). Althoughmuchofconversationanalysis is based on collectionsof sequential phe- nomena frommultipleconversations,we workherealongthelinesofthe"single-case analysis."Schegloff(1987) organizes the conversationanalyticenterpriseinto (at least) two typesof analyses.He describes thefirsttypeas

the effortto elucidate and describethe structureofa coherent,naturallybounded phenomenonor domainofphenomenain interaction,how it is organized,and the

practicesbywhichitisproduced.(p.101)

In the second"mode of data analysis," Schegloffsuggeststhat

[i]na sortofexercise,theresourcesofpast workon a rangeofphenomenaandorgani- zationaldomainsin talk-in-interactionare broughtto bearon theanalyticexplication

of a single fragmentof talk. (p. 101; our

emphasis)

Our analysistakesthelatterform,although we examinethreemedicalinterviewsrather thana singleoccasionoftalk.Because single episodesare the"locusoforder"'(Schegloff 1987:102),we analyze each of our doctor- patientinterviewsas an entityin its own right.At the same time,we can drawfrom

existingconversationanalyticresearchon patient-practitionerinteractionto linkthese episodes to other,similaroccurrences.Our analysisis also comparative:The conver-

genceamongthesethreeepisodesinperson-

nel,disease category,and typeofinforming makesit possibleto investigatesimilarities

and differencesin the organizationof the interviews.We also drawon ethnographic interviewsthatthesecondauthorconducted

to supplementour primaryconcernswith therecordedinteractionalmaterial(Kinnell

andMaynard1996;Maynard1989).

In two of our episodes,the analysisis framedin termsof the perspectivedisplay

series(PDS). This"device

interactionallyorganized manner to implicatethe recipient'sperspectivein the

presentation of diagnoses" (Maynard 1983:333),althoughin thepresentdata the physicianpresentsa prognosisratherthana diagnosis.The PDS allows a physicianto deliver news cautiouslyby solicitingthe recipient'sopinionbeforeprovidinghisown assessment,and then,throughsuggesting clinical agreementwiththatopinion,co-

operatesin an

co-

'Conversationanalysisoperateswiththeassump-

tionthateveryinteractionhas locallygenerated

orderliness,suchthatevensingleepisodesoftalkare

interactionallycoherentandmeaningfulforpartici-

pantsregardlessoftheirbackgroundcharacteristics.

324

SOCIAL PSYCHOLOGY QUARTERLY

implicatingtherecipientin thefinalpresen- tationof the news.Further,thisapproach helpsthephysicianto forecastdiagnosticor

prognosticnewsforpatientsinsteadofdeliv-

eringit in a bluntor forcefulway,which impedesrealizationand adaptationto the

news(Maynard1996).

Allusive talk is a phenomenonin our analysis.Like Schegloff(1996:181),we use the termsallude and allusion (as well as

euphemism)broadly.Our workdiffersfrom Schegloff's,however,in thatwe addressa relatedbutessentiallydifferentinteractional phenomenon.Schegloff(1996) analyzes a sequenceinwhichone partyto conversation "plants" somethingin the talk thatis not said "in so manywords"or is notsaid expli- citly.Thena recipientofthistalkformulates an explicitunderstandingoftheinexplicitor allusiveutterance.The originalspeakernext

repeatsthat"explication,"therebyconfirm-

ingboththe recipient'sunderstandingand thatthe originalutterancewas indeed an allusion.In our data,whenthepartiestalk allusively,no suchexplicitunderstandingsor confirmationsoccur. The methodologicaladvantage of the phenomenon explicated by Schegloff (1996:192)is a "data-internalverification"of whattheparticipantsunderstandas an allu-

sive conveyance.Because our data contain "candidate"allusionsthatare notnecessari- lyexplicitlyunpackagedor confirmedin the interaction,theyoffera special challenge

(Schegloff1996:191);thisderivesfromana-

lyticallyproposingwhatparticipantsaresay-

ingwhentheyseem to be purposefullynot sayingitinso manywords.Here ouranalytic strategyforexplicatingtheallusivetalkis to

proceed withextremecaution,to discuss euphemismand allusion as possibilitiesin the talk,and to draw on otherresources (suchas posthoc interviewmaterial)beside theinteractionitself.

ROBERT: MINIMAL UNPACKAGING OF THE GLOSS

Roberthas been underyear-longtreat- mentforcancerofthegallbladder.He is in the hospitalrecoveringfroman operation duringwhichthe surgeondeterminedthat the cancerwas too faradvancedto permit anyfurtherremovalof damagedcells.Now Dr. T mustconveytheinformationthatthe cancercan no longerbe treated,although painmanagementis possible.The encounter we examineinvolvesa seriesofexchangesin which Dr. T approaches the topic of Robert's dyingin a progressivefashion, along the lines of a stepwisequestioning strategythat Perakyla (1995) identified. Robertand hisgirlfriendKatherine,howev- er,resisteachstepwisemove. Dr. T opens the interviewby asking Roberthow he is feeling;Robertresponds thathe has improved.Dr. T thensaysthat the surgeonsare happywithhis recovery andbroachesthetopicofhisdischargefrom thehospital(Excerptla, lines64-70).After

a 1.2 second silence elapses without a response fromRobert or Katherine(line 69), Dr. T commentsthatRobert'sfamilyis also thinkingabout thepatient'sdischarge, and produces,a question:"Has Tanybody had the opportunityto talkto you abou:t"

(lines70-72).

Excerpt Ja

64 Now(0.3) I knowthatthe:surgicaldoctorshavebeenpretty

65 ha:ppywithhowquicklyyou'verecover:ed:(0.4) fromthe

66 su rgery=Iwasjustlookingatthehospitalchart.That's

67 whattheirnotes:notessa::y.I knowthey'rethinkingabou:t

68 planningfer:whenyoucangetoutofthehospitaltoo:.

69 (1.2)

70 uhm>1 knowyourfamily<is thinking(.) aboutthattoo:.

71 (0.4)

Dr:

Dr:

72 Has lanybodyhadtheopportunitytotalktoyouabou:t

73 (0.8)

74 ((R pointstoK, Dr lookstoher))

Dr:

BAD NEWS IN ONCOLOGY

75 Ouho=

Dr:

76 =yes.Mis[sus] Parker

77 P:

78 (0.4)

79 Abou:t.((Dr looksbacktoR))

80 (0.3)

81 K:

82 R: [Sh-s]herelatestowhat-whatwenton:

83 (0.2)

84 Dr:

85 (0.5)

86 Whowasthatlady[ Is-]

87 K:

88 (0.5)

K:

Dr:

[she]

[yeah]

Oh

R:

[Miss]usParker.

89 Did shetalktoyouabou:t=

Dr:

90 =Ya.

R:

91 theprogramcalledHo:spic:e?

Dr:

325

Althoughthisquestionis notgrammatically topic associated with death and dying.

completeand is followedby a silence(line 73), Robertrespondsbynonverballyselect- ingKatherineto speak(line74). She replies affirmativelyand namesa Mrs.Parker(line 76). Dr. T then solicits a more elaborate responseabout the contentof the interac- tionby usingan "abou:t" component(linse 79), as he had in his earlierquery.Robert nowverballyindicatesthatDr.T is to speak to Katherinebecause "she relatesto what- whatwenton:" (line82).Afterreceivingthis indicationwithan "oh" or "change-of-state token"(Heritage1984),and afterRobert's

queryabouttheirvisitor'sidentity(lines86),

Indeed, Dr. T later remarkedabout this interview:

SometimesI use thediscussionofhospice notso muchbecauseit's importantto me thatthepatientaccepta homehospicepro- gram,butit'sa wayofintroducingthemto theidea thatthey're-ofhowsicktheyare, really.So I was tryingto use it moreas a platform that'ssometimesa goodideato gettheconversationreallydirectedwhere you wantit to go,whichis on deathand dyingissues.

In the AIDS counseling discourse that Perakyla (1995:262-63) examined, the deviceofretrievinga themeabsentfromthe client's previous replycan occasion talk about a fearor worrythatsubsequentlyis pursued.RobertandKatherine,however,do notrespondto the"deathand dying"aspect ofDr.T's questionabouthospice. Indeed, Katherine's responses (lines 93-94,97-98in Excerptlb) to Dr. T's ques- tionsabout hospice and Mrs.Parkerocca- siontalkthatmovesawayfromhospicecare andhencefromthedyingprocess.

2In her work on Candidate Answers,Pomerantz (1988:367) suggests that "offering a Candidate Answer is functional whenever a speaker has a reason to guide a co-participantto respondin a par- ticularway."

Dr. T (line 89-91) asks his questiona third time,tying(Sacks 1992:150-68)thisversion to the previous two by elongating and emphasizing"abou:t"whenhe asksexplicit- lyiftheydiscussedhospice. As Perakyla(1995:241)has observedin thecontextofAIDS counseling,counselors who attemptto address "dreaded issues" withtheirclientsoftenstartwithan "elicita- tion" such as Dr. T uses here.When that does notinducethepatientto volunteerany descriptionof a future"hostileworld,"the counselorsemploya questionthatspecifies

a themethatis absent fromthe previous

answer or narrows the relevant issues

(Perakyla1995:254-61).Here,byprofferring

a CandidateAnswer2(Pomerantz1988:365)

about hospice,the physicianintroducesa

326

SOCIAL PSYCHOLOGY QUARTERLY

Excerptlb

91 theprogramcalledho:spic:e?((Dr lookstoK)) Is-is that

92 whatMissusPar[ker-]

93 K:

94 an< (0.4) hereferredhimselftotheParkVie:w

95 (0.4)

96 I see= ((Dr looksbacktoR))

97 =Andthenshetoldhimaboutlif:e(0.4) uh((Dr lookstoK))

98 support[>youknow<]

99 Dr:

100 ifhewantedthat(0.4) I've gotthe papers anI'll giveitto

101 himtosgn.= ((Dr lookstoR)) 102 =1see (0.4)1 see. (1.2)1 see. (0.8) SOUndslikeshewas 103 prettystraightFORwardwithall thedetai:l[s:?huh ]= 104 [OH yeah]shegives

105 hima lotof(.) in[formati ]on.

106 Dr:

107 (0.6)

108

109

110 (1.6)

111 WHERE do youthinkyou'llbe hea:dingafteryouleavethe(.)

112 ho:spital.

Dr:

[No.]>she askedabouta nursinghomefor'im

Dr:

K:

K:

Dr:

K:

[Uhhuh

]

[?alright?]

Dr:

R:

Dr:

Ookayo=

=Verygood

InitiallyKatherinerespondstoDr.T's candi- dateanswerabouthospicewitha "No" (line 93). Then she indicates that Mrs. Parker inquiredabouta "nursinghome"forRobert (line93-94).The emphasison "nursing"sug- gests this as a contrastwiththe hospice topic.Dr. T respondsin a delayedfashion with"I see" (lines 96). Subsequently(lines 97-98) Katherineclaims thatMrs.Parker also discussed "lif:e support"withthem, whichfurtherdisplayscontraststressingand marksa differencebetweenherinterpreta- tion of the conversationwithMrs.Parker and the topic (hospice) that Dr. T has offeredwithhislineofquestioning.Goingto a nursinghomealso can suggesta less seri- ous prognosisforRobertthandoes hospice. Nevertheless,Katherine'stalk about "life support"preservesthegeneraltopicof the illness trajectorywhile shiftingthe focus awayfromhospicecarespecifically. In response,at line 102 Dr. T says "I see," waits,saysit again,waits,repeatsit a thirdtime,and waitsyetagain beforepro- ducinga "my-sidetelling"(Pomerantz1980) (lines 102-103).In thisformof information seeking, the recipient is interactionally encouragedto volunteerinformationin lieu

ofbeingaskedoutright.Togetherwiththe"I sfee"sand the silences,thismy-sidetelling "fishes"formore informationabout their meetingwithMrs.Parkerwithouttheneed to ask themdirectlyabout the "details."3 Katherine and Robert,however,provide responses that implicate topic closure:

Katherineproduces an agreeing,general gloss of the conversation(line 104-105), while Robert (line 109) aligns with her assessment. Afterthisexchange,Dr. T asks Robert abouthisplansforleavingthehospital(lines 111-12).BeforeExcerptlc, in an exchange

notshownhere(lines113-78),Robertstates

thathe wouldlike to returnto thenursing home where he lived beforeenteringthe hospital.Despite thisresponse,Dr. T sug- geststhatRobertmightconsiderjoiningthe hospiceprogrambecause it is a good pro- gramforpatientswhohave had cancer;this shiftfromdiscussingthenursinghometothe hospiceprogramreintroducesa topicrelated

3AlsonotehowDr. T raiseshis intonationon

"details"andattaches"huh"totheendofhisutter-

ance.These actionsstronglyinvitean expansive

responsetohiscandidateinterpretationoftheearli-

erdiscussion.

BAD NEWS IN ONCOLOGY

327

to deathand dying,therebyalludingto the

topicof Robert'sterminalillnesstrajectory. couple plansforRobertto go afterleaving

Robert,however,rejectsthe optionof hos- pice,claimingthathe wouldhave to spend

his nightsalone and thatit is inconvenient Robert'slong-termhealthneeds and illness

forhisfamily.Then,at line179(Excerptlc), Dr. T poses an unmarkedperspectivedis- play invitation4 by asking about what Robertsees "as happeningin thefuture."In

thedoctor'spreviousqueryaboutwherethe

the hospital(Excerptlb, lines 111-12),he tacitly solicited their perspective on

trajectory;inthisquestion(lines179,181)he

asksmoreovertlyfortheirassessmentofthe

future.

ExcerptIc

179 wh-Whatdo yousee: as (0.8) as the-happening inthefu:tur:e.

180 (1.4)

181 Areyouhopingthatyou'llg-getbetter:?

182 (0.5)

183

184 K:

185 (1.1)

186 Dr: Do youthinkthere'sa possibilitythat(1.5) youmightno:t?

187 (0.2) getbetter?

188 (1.1)

189 R: I've hadthoses::econdthoughts.

Dr:

Dr:

R:

OH yes:doc[tor

oh yes

sure

[ohgoodlor:d(that'strue)]

190 Uhhuh

Dr:

191

(1.1)

192

R:

WhatI wentthroughyesterday?

193

(0.2)

194

Dr:

Mmhmm.=

195

R:

=andthedaybefore.

196

Dr:

Mmhmm.

197

(0.2)

198

R:

Yougo throughthose

199

(0.4)

200

Dr:

right

201

(0.4)

202

R:

seriesofwhatever.

Aftera 1.4secondsilence(line180),thedoc- torreformulateshisquestion:Usinga candi- dateanswer,he asksifRobertis "hopingthat (he'll) get better"(line 181). Robert and

Katherineprovideresoundinglypositivereac-

tions(lines183-84),thusexhibitinga strong better"(lines186-87).5Thisis similarto the

orientationto a desiredrecoveryscenario.

(Recall thatat lines64-65,Dr. T character- (1995:264-71) analyzes:When the patient

ized the surgeonsas pleased withRobert's recovery.)Now,in line 181,by offeringan optimisticcandidateanswerto his previous questionabout Robert'sfuture,Dr. T may have invitedRobertand Katherineto adopt an optimisticoutlook,whichtherebypartially

accountsfortheirstrongalignmentat this pointintheconversation. The doctor then offersa contrastive assessment,askingifRoberthas considered thepossibilitythathe "mightno:t (0.5) get

"hypothetical questions" that Perakyla

has notnamedanyobjectsoffearor worry, as here,the physicianoffersa candidate "hostileworld."

5Noticethe use of the litotes(suggestingan affir- mative-getting worse-by negatingits contrary- "not gettingbetter"), which Bergmann (1992:150) argues is a methodof alludingto delicate subjects. This formulationdisplaysa tacitorientationto the possibilityof dying;if the topic were formulated more overtly(as "dying") it could be perceptibly moreharsh.

4Maynard(1991:170) refersto perspectivedisplay invitationsas "unmarked"or "marked,"accordingto whethera queryis statedin a neutralwayor favorsa particularresponse.

328

SOCIAL PSYCHOLOGY QUARTERLY

Althoughsuch a questioncan elicitan answerthatdeals withthehypotheticalsitu- ation,Robertresiststhepremise(Perakyla 1995:315-21).He respondsthathe has had such "second thoughts"in previous days (lines 189,192,195),therebyproposingthat

these"second"thoughtsare less significant personis to desireto recoverand to make

mize their importance or seriousness. Therefore,in a varietyofways,thepatient's talk here is consistentwith the cultural expectationsdescribedby Parsons (1951) withrespectto the"patientrole,"in which one of the social responsibilitiesof a sick

orlessvalidthanhisideas aboutgettingbet- ter. Furthermore,Robert's generalized "you" (line 198) can referto otherpeople's also havingthese typesof thoughtswhen dealing withserious illness,and thereby

exhibitshis own reactionas relativelytypi- cal.6This is consistentwithSacks's (1984)

notionof"doingbeingordinary,"whichsug-

geststhatinterpretinga situationas normal and ordinary,as opposedto extraordinaryor catastrophic,is a regularresponseto experi- ence. In Jefferson's(1984) terms,Robert may be displaying"troubles resistance." Finally,by colloquially characterizinghis thoughtsabout nonrecoveryas a "seriesof whatever"(line202),Robertoffersto mini-

everyefforttodo so. Nevertheless,Dr. T pursuesthistopic and produces a thirdcomponent of the PDS-an announcementof theclinicalper- spectivein lines214-15ofExcerptld-in a cautious, somewhat circuitous way. He assertshis ownconcernabout"that,"which we takeas tyingto hispreviousreferenceto "not gettingbetter,"tellingthemthathe is personally concerned (lines 205-206). Further, by reaching for and holding Robert's hand duringthisutterance(i.e., offeringsupportorcomfort),thedoctormay demonstratenonverballythathe is broach- inga serioustopic.

ExcerptId

203 Dr:

204 (3.7)

205 Cause that'ssomethingthatI've been((Dr reachestoholds

Oright?

Dr:

206 R's hand))kindofconc-cemedabou:t.

207 (0.7)

208 I mean(0.3) I don-can'tcounttheda:ys,but(.) you'vebeen

209 inthehos:?pitallikequitea- whatthree:wee:ks:yaknow

210 (1.5)

211 kinda(0.7) letsyoukno:wthat(1.0) you'rehavingsome

212 pro:blemswhenyou'reherethatlo:ng.

213 (1.1)

214 ?But?(.) I'm concemedthat(.) >youknow<there'sa

Dr:

Dr:

Dr:

215 possibilitythatthingsmightnotgo so: well:foryou:

216 (0.8)

217 So I wanttomakesurethat,I cananticipateanynee:ds

218 ((R shakeshead))thatyoumighthaveafteryouleavethe

219 ho:.spital.

220 R:

221 (2.2)

222 You'reso muchconcern:ed.

223 (2.1)

224 I reallyappreciatethat.

225 (1.8)

226 Can'tthankyouenough.

Dr:

That'swonderful.

R:

R:

R:

6Alsosee also Kinnelland Maynard(1995) fora discussionoftheuse of"you"in HIV testcounseling.

BAD NEWS IN ONCOLOGY

329

ByremindingthemofthelengthofRobert's hospitalstay(lines 208-209), Dr. T impli- cates Robert's and Katherine'scommon- sense knowledge,suggestingthatsuchlong staysgenerallyindicate serious problems (lines 211-12).7Robertmeanwhileremains silent. The doctor'stalkin thisinstancefunc- tionsas somethingsimilarto an incomplete syllogism(Gill and Maynard1995); sucha turnorganizationoccursfrequentlyin the deliveryofdiagnoses,to parents,abouttheir

developmentallydisabledchildren.Clinicians

providethefirsttwocomponentsofthesyllo-

gism,suggesting,forexample,that(1) people withmentalretardationexhibitsymptomsx, y,and z and (2) theparents'childexhibits symptomsx,y,andz. Clinicianstherebyinvite parentsto completethesyllogismby infer- ringthattheirchildhas mentalretardation.

In thepresentcase, the doctorsets up the firsttwopartsofthesyllogismbynotingthat (1) Roberthas been hospitalizedforthree weeks(lines208-209),andthat(2) suchlong hospitalizationsgenerallyindicateserious problems(lines 211-12). Formally,Robert maybe invitedto completethe syllogism, withoutitsbeingstated,byconcludingthat hehasserioushealthproblems. An ambiguitymay be present here, however.The extentto whichthe seriesof "you"sin lines211-12refersto thegeneral population("lets one know one is having

problems

") as opposed to Robert specif-

ically ("lets us knowyou're havingprob-

lems

") is unexplicated. Insofar as Dr. T

uses"you"in a generalizedfashion,he may be employinga syllogisticconstruction.On theotherhand,insofaras Dr. T is referring to Robert in particular,he accomplishes something that is more direct than an incompletesyllogism.Withthisutterance, Dr. T appears to walk a fineline between

7An ironic parallel exists between Robert's and Dr. T's rhetorical argumentsin this conversation

(lines 189-99 and 206-10,respectively).WhereasDr.

T cites commonsenseevidence consistentwithnon-

recovery,Robert (lines 189-99) provides common- sense evidence forrecovery.Althoughhe admitsto havinghad transitorythoughtsabout not recovering, he casts these ideas as typical for someone in his

position. Each participantuses "you" as a way of invokingwhat any competentactor could know or believe.

bluntlyinformingRobert of his condition and moregently"forecasting"thenewsand helping him to "calculate the news in advanceofitsfinalpresentation"(Maynard

1996:109).

When Robert and Katherine remain silent(line213),Dr.T proposesan upshotor completionof the syllogismby once more usinglitotesandtellingthecouplehe is con- cernedthat"there'sa possibilitythatthings mightnot go so well" for Robert (lines

214-15).Again,thedoctorcautiouslyshifts

fromallusiveto moreexplicittalkaboutthe futureas Robert and Katherine'ssilences disaffiliatewiththe delicatetopicof death anddying. Afterthisseriesof turnsand silences, the doctorshiftsthefocusof his talkfrom thepossibilityofnonrecoveryto theimpor-

tanceofpalliativetreatment,allusivelyindi-

catingthathe wantstobe surehe can"antic- ipate any needs" (line 217) Robert might have afterhe leaves the hospital (lines

218-19).Also,incontrasttothelongsilences

followingthedoctor'stalkin thefourprevi- ous utterances,Robert now takes several turnsof talk,respondingto the doctor's statementof concernbyfashioninga series

ofgratuities(lines220,222,224,226).

Our analysisofthisdoctor-patientinter- view is consistentwithDr. T's own later reflections.Recallfromourdiscussionofthe data and methodsthatDr. T had feltawk- ward duringthe interview.In addition,he remarkedthathe was "trying"to findout whatRobertknewabouthisillness:

ButRobert,he sortofhad hisownagenda insteadandalmostat timeswe weretalking aboutdifferentthings.Whichin partmay havebeenbecausehe wantedto avoidtalk- ingaboutwhatI wantedtotalkabout.So it's notthatunusualthatthingsare awkward. BecauseI don'tthinkit'sveryeasytotalkto peopleaboutdyinganyhow,andneverwill be. But in thatcase itwasprobablya little MORE awkwardthanusualbecauseI really didn'tseethatI wasgettinganywhere.

Our analysisdemonstrateshow Dr. T could have sensed that the patient "wanted to avoid" talkingabout his illnesstrajectory and thattheywere"talkingabout different things."The doctorattributestheavoidance

330

SOCIAL PSYCHOLOGY

QUARTERLY

of the topic of impending death to the patient,but our analysissuggeststhatsuch resistanceto delicatetopicsis also achieved interactionally.Dr. T employeda succession ofquestionsthatprogressivelycanmoveto a fullerdiscussionof the "dreaded issue" of death and dying (Perakyla 1995). Nevertheless,in theirrepliesto Dr.T's ques- tions,the patientand his partnerglossed, shifted,and movedto close thetopic.In the

end,Dr.T also alludedto butdidnotformu- pied withconcernsabout David's shortness

late explicitlya concernwithRobert'sdying anddeath.

ofbreathandanemia.Dr.T marksan impor- tanttopicshiftwithhisuse of"well"(line 1 ofExcerpt2a) (Sacks 1992:773)to introduce hisown"known-in-advance"agenda(Button

suffersfromleukemiaand,withhis wife,is visitingtheclinicas an outpatient.Although David respondsto Dr. T's proposalsabout discontinuingtreatmentby remainingstoic and largelysilentduringthe conversation, Dr. T neverthelessmeetswithmodestsuc- cessindeliveringthenewsas he workstoco- implicateDavid in thedecisionto discontin- ue thechemotherapy. The beginningoftheencounteris occu-

DAVID: LIMITED UNPACKAGING OF THE GLOSS

andCasey1984).

The patientin thisconversation,David,

Excerpt2a

1 Well.(0.3) I'm gladyoucameincauseI didwanna(0.4) ((Dr

Dr:

2 nods))talk-talktoyouaboutuh,a- fewthings::

3 (1.2) ((D nods))

4 I knowwhenyouwereintheho:spitalwe wereonthefence

5 aboutwhetherto:(1.0) considersomemore((D nods))

6 chemothe:rapy.hhhhhhapdhhhhI thoughtitwasworthwhileto

7 see howyoudidatho::meandhowyoufel::t.

8 (0.2) ((D nodsslightly,gazesintohislap))

9 .hhhhhum(2.0) Myfeelingis: that(0.9) atIthispoint

Dr:

Dr:

10 Tprobablythechemotherapy((Dr nods))wouldn'tdo (0.6) you

11 muchgood.

12 (0.6)

13 D:

>itwon't?<

Dr. T proceedsto reviewa previousconver-

sationwithDavid concerninghischemother- mentdisplays"receptiveness"(Heath 1984)

ment(lines3 and8) precedingDr.T's assess-

to David's participationand is consistent withthecautiousnessdemonstratedin typi- cal PDS series.Furthermore,David's non- verbalresponses(head nods)inlines3 and8 demonstratethathe is trackingandrespond- ing to the doctor's extendedturnof talk. Afterprovidinga second opportunityfor David to respond(line8), thedoctormoves into his own assessmentof the prognosis, whichimpliesthatthe treatmentat home hasnotworkedwell. At lines9-11,Dr.T proposesa courseof action.Noticethathe characterizestherec-

ommendationas a "feeling,"a subjective evaluation,ratherthanas an objectiveclini- cal fact.He furthermitigatestheforceofhis recommendationwiththreequalifiers:"at

"

Ithis point,"

probably" and "muchgood"

apy treatment(lines 4-7, 9-11), and offers his own assessmentthatthe chemotherapy "wouldn'tdo muchgood"(lines10-11). Thisepisodediffersfromtheothertwo we consider(Robertand John)in thatDr.T

offershisownassessmentofthechemother-

apy withoutofferinga perspectivedisplay invitationto thepatient.Some elementsof the conversation,however,are consistent withthe PDS organization,For example, althoughDr. T does not explicitlysolicit David's assessmentof chemotherapytreat- ment,histalkbeforelines9-11 is grounded largelyin topicsthathe claimshe discussed previouslywithDavid. Further,theseriesof "transition relevance places" (Sacks, Schegloff,and Jefferson1974) in thisseg-

BAD NEWS IN ONCOLOGY

331

Aftera silence(line12),David produces

way.Finally,thesuggestionthatchemothera- a requestforconfirmation.Thequeryinginto-

pywouldbe undesirableis placedatthevery endoftheutteranceina "dispreferred"fash- ion, displayingthe cautionwithwhichthe news is beingbroached(Pomerantz1984). By noddingwhilehe deliversthisnews(line 10), Dr. T may be solicitingan accepting responsefromDavid.

(lines9-11). He also nods in an affirmative

nationof"it won't?"(line 13) possiblyindi- catessurprise,andmayoccasiontherelevance ofa justificationfortherecommendation.Dr.

T respondsto David's questionbysuggesting

thatcontinuedchemotherapyactuallycould harmhimbecauseoftroublesomesideeffects

(lines14-15,17-21inExcerpt2b).

Excerpt2b

14 .hhNo ((Dr shakinghead))I don'tthinkso=I thinkitcould

15 possiblydo yousomeha.rm((Dr nodding,D nodsslightly))

16 (0.2)

17 .hh?um?becauseit-itdoeshavesi:deeffectsthatwe've

18 ta:lkeda?bou:t?.hhh((D looksawayfromDr)) and(0.6) >I

19 thinkit< (.) ((D returnsgaze toDr)) m:ightbe a goodidea:

Dr:

Dr:

20 N:OT ta(.) pressonwiththechemotherapytreatment.

21 ((D looksawayfromDr))

22 (2.7)

23 'How canyoukeep-sp-?(0.4) how((D motionstohimself))

24 canyougetbetterthen.

25 (0.2)

D:

Again,Dr.T mitigateshisassertionbyclaim- ingthathe doesnot"think"thechemothera- pywillhelp. Throughhis talk,Dr. T works to co- implicateDavid in thetreatmentdecisionin twoimportantways.First,he uses theinclu- sive "we" whentalkingabout beingon the fence(line 4 in Excerpt2a) and havingdis- cussed side effects(line 17 in Excerpt2b).

Second,insofaras thedecisionto discontin- assumptionsthatpropermedicaltreatment

ue chemotherapy is based partially on knowledgethathe purportedlyshareswith the doctor about harmful side effects (Excerpt 2b, lines 17-18), David is being asked to act in his own best interestby avoidingthesesideeffects.Dr.T nowrecom-

mendsa discontinuationofthechemothera- newsdeliverythatthereis no effectivetreat-

py (note the litotes formulation,"not to

press on") (lines 18-20); afterthis,David turnshis gaze away again,remainingsilent for2.7 seconds(line22). When he speaks (lines 23-24), David returnsto theearliertopicof discontinuing the treatment.By askinghow he will"get better"ifthechemotherapyis discontinued, David maybe challengingDr. T's recom- mendationon the basis of commonsense

focuseson a cure,and solicitinga forthright prognosticassessment. In a waythatis organizationallysimilar to a perspective display series, Dr. T

responds by using the issue David

raises

about"gettingbetter"to helpformulatehis

mentforthecancer.

Excerpt2c

26 We:ll:it-it's-it'sha:rdto-itis hardtogetbetterwhen

27 (0.6) youdon'thavea treatmentthat'seffectiveagainstthe

28 Ica:ncer.hhhmbu:t

29 ((D gazesawayfromDr))

30 (0.2)

31 um(1.0) I would(0.4)

32 ((D returnsgazetoDr))

33 trytowork(0.3) onotherthingslike(.) yournutri:tio:n(.)

34 andmakingsureyou'regettingplentyofflu:ids:and

35 preventinginfections:becausetruthfully(0.5) I don'tfeel

36 likethe(0.3) chemotherapywouldmakemuchofanimpa:ct

Dr:

Dr:

Dr:

332

SOCIAL PSYCHOLOGY QUARTERLY

37 (0.6)

38 ((D nodsslightly))

Dr:

D:

41 Dr:

42 (1.1)

40

39

onthings

Uhhuh

Makebe-makethings he-ter.

Dr.T placesthenewsthatthereisnoeffective mentof chemotherapy(lines 35-36),which

treatmentforthecancerbehind"we:ll:,"sev- Davidreceivesbynodding(line38).

eral repetitionsof "it's,"and "it's ha:rdto"

(lines26-28),whichagainindicatethedispre-

ferredstatusofthisnews.Afterthis,a contrast marker("mbut,"line28) helpsprovidea tran- sition to what the doctor can "try,"and

Afterthisexchange,in talk not repro-

ducedhere,Dr. T reiteratesthebasisforhis recommendation.David intermittentlynods

andgazesawayorintohislap.Shortlythere-

after,he asks about"theblood transfusion" (lines54-55below),whichhe and Dr. T had discussed earlierin the interview(before Excerpt2a) as a temporarymeansofallevi- atingDavid's symptoms.

changesthefocusto palliationand thepre- ventionoffurtherproblemssuchas infections (lines33-35).Next,Dr.T revertstohisassess-

Excerpt2d

54 Do youthinkthebloodtransfusion((D motionstohimself))

55 willbringitback?a little.

56 (0.5)

57 I thinkthebloodtransfusionwillmakeyou.hh((Dr nodding)) 58 fee:lbetteratleasttemporarilyit'llgiveyoumore 59 (0.5) erbreathingspaceLtterallyyou'll [feel(comfor-)] 60 [That's(why-)]

61 That'snoteasybreathing((D gazingawayfromDr))

62 Dr:

63 (0.4)

64 Umitcan'tdo anything(0.2) to::(.) affectthe

65 leukemiadirectlybutitwou:ldmakeyoufee:lbette:r.((Dr

66 nodding))

67 (1.0) ((D gazesawayfromDr))

68 That'sprobablysomethingthat(0.4) is (.) worthus

69 co:ncentratingonnow.Makingsurethatyou'reas

70 comfortableas possiblein-ineverywaypossible.

D:

Dr:

D:

'Right.'

Dr:

Dr:

As in his previousquestionabout "getting

better"(Excerpt 2b, lines 23-24), David's

queryhere (Excerpt2d,lines 54-55)

tionsDr. T's assertionthatthereis no effec-

tivetreatmentforthe cancer (Excerpt2c, lines27-28),and does notacknowledgethe preventiveplanDr.T hadproposed(Excerpt 2c, lines 33-35). Dr. T respondsto David's questionbyformulatingthepalliativeeffects

oftheplan(lines57-59),dismissingthecura-

tivepossibilities(lines64-65),and repeating

the"feelbetter"consequences(line65).

ques-

AlthoughDavid is receptiveto thedoc-

tor'ssuggestionthata transfusionwillgive

himmore "breathingspace" (line 61)8 he againdisaffiliatesbylookingawayafterthe doctorrejectsthepossibilityofa transfusion as a curativemeasure (line 67) (Goodwin 1980). His gaze away continuesthrougha longperiodwhileDr.T summarizeshisposi-

8David is having difficultybreathing not only

because the leukemiahas affectedhis lungs,but also

because

blood to deliveroxygento variouspartsof his body. Althoughhe is currentlyusingoxygen(and carriesa portablesupply),David is aware thatblood transfu- sionsare one wayofalleviatingtheproblem.Thispar- tiallyexplainshis suggestionof a transfusionin lines 54-55 and hisenthusiasticresponseinlines60-61.

he is anemic;thusit is more difficultforhis

BAD NEWS IN ONCOLOGY

333

tionbyreiteratingtheimportanceofpallia-

tivecare(lines68-70).

In thisinterview,then,Dr.T informsthe patientabouttheimminenceofhisdyingby recommending a discontinuation of chemotherapy.David's initialreactionques- tionsthe doctor'sposition;his responseto the recommendationboth challengesand allowsforfurtherunpackagingof thegloss thatchemotherapyis no longeruseful.Dr.T statesthatitis hardto getbetterwhenthere is no effectivecancer treatment,but that

palliativetreatmentand infectionpreven- tionare possible.David appearsto receive the news stoically and resignedly. As Maynard(1996) argues,suchstoicism,more

than a psychological disposition,is

muchan interactionalproduct.The stoic responsemayreflectthe matter-of-factor "reporting"fashion(Drew 1984)bywhicha physiciandeliversbad newsand avoidsstat- ingthe upshot.In addition,however,stoic responsivenessandgazingawaydo notelicit furtherunpackagingofthegloss.

very

Excerpt3a

JOHN:EXTENSIVE, BUT ALLUSIVE, UNPACKAGING OF THE GLOSS

Johnhas brain cancer and has been undertreatmentfora numberof years.His symptomsrecentlybecameso severethathe was hospitalized,and thehospitalstaffhas sincedeterminedthathisbraintumoris now untreatable.As in the interviewinvolving Robert,we willsee a progressivequestion- ingstrategyby Dr. T in whichhe worksto providean auspiciousenvironmentforthe discussionofthe"dreadedissue"ofdying. Dr.T openstheinterviewbyaskingJohn howhe is feelingandifthepainhe has been sufferingrecentlyhas subsided;thisis fol- lowedbya discussionofJohn'sfeelingsabout hispainmedication.Excerpt3a immediately followsthisdiscussionof pain medication:

Dr. T solicitsJohn'sperspectiveon leaving thehospitaland returninghome.Thisis the topic elicitationtactic(Perakyla 1995), in whicha possiblydistressingissueisbroached.

127 Uhm(.) and(.) I thinkwe weretalkingaboutyougoinghome

128 towardtheendofthis:,wee:k.=

Dr:

129 =mmhm.

J:

130 Do yous-do yousee: thatas (.) a- a- realisticgoal:?=

131 do youthinkyou'llf:eeluptoIgoinghome?(.) bytheendof

132 theweek?

133 (0.8)

134

135

136 =1would very Inmuchliketogo homethisweek.=

137 Dr:

138 (0.4)

139 =And(0.8) as again(2.6) it'sonlyduetothat(0.9) to

140 (0.2) lettingus (0.6) .hhnottakea lottadrugs,just

141 uh(2.1) under(1.2) yersupervision

Dr:

J:

Dr:

J:

J:

I knowI would.= =>uh huh.<=

=Oalrighto

Johnrespondsenthusiasticallyto thepossi- bilityofreturninghome(lines134 and 136) and initiatesa secondforayintothetopicof pain medications(lines 139-41;furthertalk on medicationsis omitted(lines142-62).Dr. T reassuresJohnthathismedicationneeds willbe metbythehospitalstaff.In Excerpt

3b, line 163, he thensuggestsa returnto John'sassessmentofhissituatiolibyposing a perspectivedisplayinvitationconcerning how he thinkshe will"manage" at home. This is a second step,whichretrievesthe

"goinghome"issue(Perakyla1995:262).

Excerpt3b

163 Dr:

164 (2.8)

Howdo youthinkyou'llmanagewhenyougetho:me.

334

SOCIAL PSYCHOLOGY

QUARTERLY

165

J:

Inwhatway.

166

(0.5)

167

Dr:

Uhm.(0.3) tchhDo youthinkit'sgonnabe (0.2) difficultfor

168 you?

169 (0.2)

170

171 this:as youknow=

172 Dr:

173 (0.9)

174 J:

175 expe:rience inthis(1.3) typeof(0.3) problemI won'thave

Anduh(2.8) andas Daphneknows,it'sjust(2.0) from my

J:

NO. (0.2) No I don't hhhI've

=mmhm

hadwaytoomuchexperiencein

176 anyproblem(.) takingcareofit.

177 (1.4)

Notice how Johnrespondsat line 165: He asks the doctor"In whatway,"whichsug-

gestsa lack of specificityin theperspective thathis perspectiveon the illness is well

displayinvitation.The requestforspecificity known to Dr. T ("you," line 171) and to

as a reasonwhyhe won'thavedifficultiesat home (lines 170-71).Johnfurthersuggests

obtainsa "hypotheticalquestion"(Perakyla 1995:271)fromthephysician,whichposes a

"difficult"homesituation(line167)forJohn

to consider. In his two queries, withthe glosses"managingat home" (line 163) and "it's gonna be difficult"(line 167), Dr. T invites"unpackaging"talkthatcould open the topics of cancer and dying. But in response(line 170) to Dr. T's secondquery, Johnproducesan emphatic"NO"; thenhe repeats the rejection ("No I don't") and citeshis"experience"in dealingwith"this"

John'swife,Daphne (line174),whoareboth

awareofhis"experienceinthistypeofprob-

lem"andin"takingcareofit"(lines176;our

emphasis). So far, then, physician and patienthave produced generaland vague referencesto "managing,""difficulty,""this," "problem,"and"it." ImmediatelyafterExcerpt3b,in lines

178-82(Excerpt3c),Dr.T introducesanoth- er'query;he nowrefersto the"melanoma," the "illness,"and "how it's affecting"his patient.

Excerpt3c

178 Do youhavea senseof(0.6) wh:at'shappeningwith

179 the(.) melanoma?

Dr:

180 (0.2)

181 Whattheillnessis do:ing:r-rightnow,howit's

182 affectingyou?

183 (2.6)

184 Yeah,I havea senseofitferSURE=

185 Dr:

186 (0.6)

187 J:

188 (0.4)

189 Uh::. (0.2) Doesn'tmakeitanyeasier

190 (0.2)

191 Dr:

192 (0.6)

193 Butitgivesmea senseofkno:wingwhat'sgoingon.

194 (1.0)

195 Dr:

196 (1.0)

197 ?Uh?which:is: VERyimportanttoIme=

198 =?Uhuh?kno[wi]ng=

199 J:

Dr:

J:

=mmhm

Absolutely.

Mhmm

J:

J:

?Mmhm.okay.'

[uh]

J:

Dr:

BAD NEWS IN ONCOLOGY

335

200

Dr:

=what'sgoingon=

201

J:

=knowingwhat'sgoingon.an-((clearsthroat)).tchhI think

202

that'sextREMelyimportant.

203

(-)

By line 179 the earlier,vague references becomeavailable,at leastretrospectively,as possibleeuphemismsthatallude to "what's happeningwiththemelanoma,"althougha

termsuch as melanoma may stillbe cautious

in itselfbecause it is more technicalthan "cancer," for example (Coombs and Goldman 1973). Although Dr. T refers explicitlyto melanoma,his uses of "what's happening,""whattheillnessis doing,"and "how it's affecting"his patientcan all be glossingand euphemizingthedyingprocess, andmayalludetoitcollectivelyas well. These phrasesare partof a turnat talk thatcomprisesa three-partlist.As Jefferson (1990:79-81) argues,speakerscan employ three-partliststo accomplisha varietyof interactionaltasks,such as movingfroma priortopic to an event thatis of "focal" importanceto a speaker,or introducing,in thethirdpositionon thelist,a matterthat might"offend"a co-participant.Noticehow Dr. T's listprogressesfrom(1) "what'shap-

peningwiththemelanoma"to (2) "whatthe illnessis doing" to (3) "how it's affecting you."Parts(2) and (3) are producedaftera clearpointof turntransition(line 180) and

otherpossibleopportunitiesforturntransi-

tion(afterthe stretched"do:ing"and after

"rightnow"(line181).Accordinglythelistis

assembled interactively:Dr. T moves cau-

tiouslyfromreferencingtheillnessas spec- tacle,to formulatingitsdisembodiedoffen- sive activity,to mentioningJohnas a direct objectof thatactivity,and thelastitemis a potentiallymoreindelicateformulationthan thefirsttwo.The progressioninvolvesfor- mulationsthatplace theillnesscloserto the patient,movingin a directionthatpotential- ly formsan auspicious environmentfor unpackagingtheseglosses. In response,however,Johncontinuesto be euphemistic.At line184he claimshe has a "senseofit"(ouremphasis).In typicalcon- versation,"tying"an utteranceto a preced- ingone throughtheuse of"pro-terms"such as itis a regularwayofprovidingcoherence in the talk (Sacks 1992:150-68). In this

instance,thepriortalkcontainsseveralpos-

sible referents of "it," including each euphemisticsegmentof the three-partlist, thelistas a whole,and/ortheallusiverefer- entofthelist.Hence we arguethattheuse ofa tyingterm(suchas "it"or"that"),when the candidatereferentsto whichthe term tiesare euphemisticand allusivein thefirst place,is a resourceforspeaking(or continu- ingtospeak)euphemisticallyandallusively. In otherwords,a clinician'sperspective displayinvitations,particularlywhenthey are progressively "coercive" (Perakyla 1995:285-86),can elicita replythatis specif-

ic enoughto createan auspiciousenviron- mentforthe clinician,in the thirdturnof the series,to furtherdesignatethe clinical view of diagnosisor prognosisand further name "whatis goingon" (Maynard1991).9 Suchan environmentis notactualizedhere, however.At line 187 Johnemphasizeshis claimof understanding("Absolutely")and then produces the "it" termtwice again:

whenformulatinga complaintabouthisdif- ficulty(line189) and whenproducinga con- trasting,"brightside" characterization(line 193). If Dr. T is usingeuphemismand allu- sion to approach the topic of death and

9A patientcan respondexplicitlyand specifically to a perspectivedisplayquery,as can be seen in this patient'snarrativeabout receivingthe news of her cancer. We have numbered the three parts of the perspectivedisplayseries:

He [the doctor] let me get dressed,thenhe sat me down,heldmyhand,and (1) asked me what I thoughtwas wrong.When (2) I said "cancer," (3) he said thatI was rightbutthatI shouldn't feeltoo worriedas thelumpwas verysmalland there wasn't any lumpiness under my arms, whichis a good sign. (Fallowfield1991:44;our emphasis)

Afterthe doctor asked her "what" she thought was "wrong,"thepatientsaid "cancer."In thepresent data, Dr. T has already broached the cancer term ("melanoma"). The issue he poses is what the melanoma is doing to John,who claims to have a "sense" of"it"butdoes notsay or demonstratewhat

his sense is.

336

SOCIAL PSYCHOLOGY

QUARTERLY

dyingcautiously,and to obtainspecifictalk fromJohnabouthisillness,he has notsuc- ceeded. Instead of explicitlydiscussinghis sense of the cancer,how it is progressing, and whathe anticipates,Johnhas made his ownuse ofeuphemismandallusion.

the organizationof the perspectivedisplay series (wherein news is provided aftera recipient'sanswerto theoriginalquery),the conversationalenvironment,evenifitis not auspiciousin thesense thatthepatienthas unpackagedDr. T's allusionto dying,impli-

(Excerpt3d,lines204-207)byformulatinghis

At thispoint(line 195),Dr. T

acknowl-

catesan informingbyDr.T.

edges John'sclaim of having"a

sense of

As Dr. T delivershisnews,he and John

knowingwhat'sgoingon,"afterwhichJohn emphasizesthe importanceof thisknowl- edge(line197).Dr.T thenproducesa clarifi- cation request (lines 198,200), repeating

alignto theidea thatthecancerpotentially could worsenafterhe leaves the hospital. Noticebelow how Dr. T startsthedelivery

John'sphraseas a candidatehearingofwhat is "important."Johnconfirmsthis with another emphasized repetition at lines

taskin termsthatJohnhasjustused,thereby proposingto affirmtherelevanceofhisown forthcomingtalk. Dr. T thenreviewsthe

201-202.Johnhas now "answered"Dr. T's

"facts"ofJohn'scase,characterizinghiscur-

originalquery(lines181-82):Thatanswering

is accomplishedinteractionallyby Dr. T's producingcontinuers(lines 185,191,195) and silencesthatinvitefurthertalk.Given

Excerpt3e

renthospitalizationas moreseriousthanearli-

er ones (lines209-11and 213-14);Johnpro-

videscontinuationtokens(lines212and216).

204

Dr:

Mmhm.(0.6) Alright.(0.5) .hhhwellonethingI wantedtodo:

205

(.) toda:yis tamakesureyouknowwhat'sgoingon= I knowwe

206

onlymeta fewda:ysago (.) bu:t.tchI feelit's important

207

thatyouhave>ya know<all ofthefa:cts.

208

(0.9)

209

Dr:

.tchhUhm.(0.2)1 think(.) pro:bablythis:um(1.5) ifyou

210

haven'tspenta lo.toftimeinthehospitalexceptforyour-

211

your-yourtreatments.=

212

J:

=Mmhm.

213

Dr:

Thisis thefirsttimeI thinkthat(.) you've(0.2) comein

214

justbecau:seoftheillnesscausingsomesymptoms4-foryou.

215

(0.4)

216

J:

Mmhm?

217

(0.4)

218

Dr:

?Alright?.hhhhAndwhatmyconcernis is that(0.9) uhas time

219

goes byL(.) thattheremaybe mo:re(0.4) problemsthatthe

220

melanomacauses,moresymptoms(0.7) orthatitmightaffect

221

your-yourbodymorethanit'sdoingevenno:w.

222

(1.8)

223

J:

Mmhm?(1.1) I agreewiththat

Dr. T subsequentlystateshis own concern thatJohn'shealthmaycontinueto deterio- rateevenbeyondhiscurrentcondition(lines 218-21).At line223Johnproducesa delayed response, which claims agreement and enablesDr.T toforgeahead.

In Excerpt3e below,Dr. T goes on to informJohnthatthedoctorscan no longer treatthe cancer effectively;theycan only

treathissymptoms(lines224-233).

Excerpt3e

224 Dr:

225 s-someofthemare(.) v:e:rystateofthea:r:t.

.hhhI knowthatyou'vehada lotof(.) differenttreatments=

BAD NEWS IN ONCOLOGY

337

226 (0.9)

227 Umbutitsee:msnowthat(0.3) we mighthavetos:w:itch

228 gears(0.2) and(0.4) workontreatments:(0.4) that(0.3)

229 helprelieve(0.4) or(0.6) improvethecomplicationsofthe

230 cancerlikepai:noranyothersymptomsthatitmightcau::JIse

231 .hhhbecau:seit'sveryhardforme:ordoctorterrieto

232 identifyanytreatmentinpar:(.)ticulartoattackthecancer

233 directly.=

234 J:

235 (1.3)

Dr:

=Mmhm.

236 Thatmaybe somethingthatyouwerea- awareofbefo:re.

237 ((nodding))=

238 J:

239 (1.4)

240 ?Um?(0.3) andI thinkwe cando a goodjo: of(0.3) keeping

241 youprettypainfree:orifthereareanyothersymptomsthat

242 themelanomacau:sesorrelieving-((Jshiftsposition))

243 relievingthatmakeyoufeelbe:tter

244 (-)

245 J:

246 Bu:t(0.7) tchhuhmm(0.6) we haveaftera lotofthought

247 we haven'tcomeupwithany(.) trea:tmentforthemelanoma

248 its:e:1[f]

249 J:

250 (2.4)

251 I unfortunatelyamquiteawareofthatmyself.

252 (0.6)

253 Dr:

Dr:

=Mmhm.

Dr:

?Mm?

Dr:

[r]ight

J:

Mmhm.

Dr. T accountsforhis decisionby implying thatJohn's"stateoftheart"treatmentshave been unsuccessful(lines224-25),and impli- cates anotheroncologistin the decisionto stop treatment(lines 231-33) (Anspach 1988).In response,Johnprovidesa minimal acknowledgment(line234). Dr. T (line236) offersan interpretationof thisacknowledg- ment,suggestingthatit mightindicate a priorawareness,whichJohnconfirms(line 238).NextDr.T reformulateshisdeliveryof

thenews(240-43),suggestingthatthey"can

do a goodj" ofpaincontrol.AfterJohn's quietacknowledgment(line245),Dr.T pro- duces anotherversionof the messagethat theycannot treatthe "melanoma its:e:lf" (lines 246-48). Again,Johndisplaysagree- ment(line249) and stateshis"unfortunate" awareness"of that"(line 251). Notice that both times,Johndisplaysagreementwith Dr. T and does not furtherexplicate or expandtopically.Thus the overallmessage hereis one aboutstoppingthecancertreat- mentandstartingpaintreatment.

In the above segments,across Dr. T's invitationsandqueriestoJohn,we cantrack

a particulartopicaltrajectoryof thephysi-

cian. He moves fromqueries thatdo not markedlypose any problem(Excerpt 3a, lines127-28and 130-32),to a markedquery thatproposes the possibilityof difficulty (Excerpt3b,lines167-8),to an explicitmen- tionof"melanoma"and"theillness"andits "affecting"John(Excerpt3c). At thispoint he also producesa euphemisticthree-part listthatmayalludetoJohn'sdying. Although retrospectively it can be appreciatedthatDr.T is pursuinga particu- lar agenda,theseinvitationsand queriesare producedin real time.Thus,a recipientcan orientto themas independentof anyagen- da. When John answers these queries (Excerpt3a, lines134,136;Excerpt3b,lines 170-71,174-76;Excerpt3c, lines 184,187; etc.),he appearsto deal onlywiththepre- cedingquestions.Thisappearancemaybe a feature of a more general strategyfor euphemisticand allusivetalk;it is possible thatJohnperceivesthetrajectorythatDr. T

338

SOCIAL PSYCHOLOGY QUARTERLY

pursuesbutdoes notrevealthatunderstand- lyzed in the precedingexcerpts,Dr. T can

ing throughhis talk. His agreementwith proposals about cancer versuspain treat- ment suggestsextinguishingratherthan expandingthetopicor otherwiseunpackag- ingpreviousglosses. BywayofthePDS, thenewshereis pre- sentedina cautiousandaffiliativeway.Dr.T initiallyengagesqueriesthateuphemistically solicitexpressionsof anticipateddifficulties andpainfulsymptomsdue to a now-untreat- able cancer. Although John is also euphemisticin his replies,he nevertheless providesopportunitiesforDr. T to move forwardwithmoreexplicitreportsaboutthe stateof thedisease,the effectsit willhave, and the shiftfromcurative to palliative treatment.That is,the physicianbecomes progressivelyless allusiveand moreexplicit as Johnprovidesdisplaysof understanding; these displays,althoughalso euphemistic, permitDr. T's stepwise movement.As a result,thedoctorandthepatientseemmore attunedto one anotherthanin eitherofthe otherinterviewsto thenewsthatthecancer canno longerbe treated. Once again,our analysisis consistent withDr.T's subsequentcomments:

I thinkveryofteninwhateverwaypossible there'sa lot ofnonverbalcommunication betweenphysicianswho'vegottento know theirpatientswelland thepatientsthem- selves.So thatsometimesI thinkthatwhenI comein and talkto thepatientaboutone

thingtheyactuallyunderstandthatI'm talk- ingto themaboutsomethingelse.And so that,butsomehowthemessagegetsthrough veryoftenpatientsand theirfamilies knowexactlywhat'sgoingto happen,or
almostknowexactly,yetthere'ssomevalida-

tion whenthe physiciantells themthat again.Sometimesit's a sense of relief,or some sense of confirmation.I metwith John'swifetoday,andthat'sexactlywhatshe said to me.She said,"Wellwe knewthat that'swhatyouweregoingtosay,butwestill neededtohearyousayit,"whenI wastalk- ingto herabouthowlonghe mightliveor whatwasgoingtohappennext.So that'sone thingI've observedis thatoftenthepatients knowwhattoexpectbutstilltheyneedtoor

theywanttohearyousayitas thephysician.

In short,becauseofa tacitunderstandingof the practiceswe have identifiedand ana-

vernacularlycharacterizehow his"message gets through"as part of the "nonverbal" communicationbetween physicians and patients.

DISCUSSION

Whereaspreviousresearchon deathand dyingfocusedon individualperceptionsand

abstractionsaboutpatient-practitionercom-

munication,we examinethe actualinterac- tionin whicha physicianattemptsto inform patientsoftheirprognoses.We findthatthe conversationaltrajectoriesin our data are highlycontingenton the activitiesof the physicians,the patients,and the patients' familymembers.Across conversations,the physicianin our data exhibitsinteractive

cautionin discussingdeath and dyingwith thepatient.Throughtheuse of a PDS, and througha progressivequestioningstrategy thatcan providean auspiciousenvironment

forpatients'talkabouta dreadedfuture,Dr.

T attemptsto solicitpatients'perspectives

about theirsituationsbeforeprovidinghis

own assessment.He does not succeedfully

in overcominghis patients'resistance,but

once patients give their opinions, Dr. T works to fithis clinical perspectivewith thoseassessments. The patients'responsesstronglyaffect the course of the news delivery.Although Dr. T beginstheconversationswithglosses about thepatients'situations,the extentto whichtheglossesare unpackagedis contin- gent on conversational practices that impedeor facilitatethe the deliveryof the news.Robert and Katherine,forexample,

byintroducingcompetingtopicsofconver-

sation, declining invitations to provide moredetailedinformation,and beingsilent

at particularjunctures,eventuallyderailthe

doctor'seffortsto topicalizeRobert'snon-

recovery.David,whoappearsstoicthrough-

out his interaction with the physician, avoids discussingpalliativecare but never- thelessenablesthedoctorto unpackagethe gloss and deliverthe news thathe willno longer receive chemotherapy.Johnand Daphne respondto Dr. T in a waythatper- mitsunpackaging"what's happeningwith the melanoma," although this is done througheuphemisticand allusive talk. In

BAD NEWS IN ONCOLOGY

339

each of these instances, the recipients' responses to the physician's cautious approachesenterintothe trajectoryof the conversationand help to shape just what informationis conveyedbyaffectinghowit is delivered. In his extensive ethnographicstudy, Sudnow (1967:63-64) suggeststhat,even whendeathmaybe imminent,"dying"does notstandas a properanswerto a patient's question"what'swrongwithme?" Disease categories and descriptionsof symptoms may,and do, servein theplace of"dying," even though the notion of a patient's "dying"furnishesmedicalproviderswitha schema forcaringforthatperson.In

data,althoughthedoctorpresentedas a fact to the researcherthat the threepatients werein thelast stagesof theircancersand were dying,he did not say this to the patientsstraightforwardly.Insteadhe talked

about goinghome,hospice,not continuing tiesthatare profoundlysocialin theirorga-

chemotherapy,relievingpain,and the like. In circumstancesthatare not,once and for all,biologicallydefinitive,we can see a fun-

damentalsocial componentto talk about "dying" and "death." This component residesintheinteractionaland collaborative assessments made between doctor and patient,whichare somedistancefromthese moregraphicterms. Accordingly,a physician'sconveyance of newsto a patientaboutdyingand death may lack direct reference to a putative organic state. Instead, it may comprise sequencesof talkthatbroachan unpackag- ingof thenews.How farthatunpackaging can go depends stronglyon the patient's responsesto thephysician'sinitiatives.And evenwhenthepatientfacilitatesratherthan resiststhe unpackaging,both partiesmay retainallusive and euphemisticstancesin whichdyingand death are not mentioned explicitly.It is notonlythatdyingand death are everyone'sindividualinevitability,then; these"states"enterintoactionsand activi-

nizationas patientsand theirfamilies,along withtheprofessionalswhoservethem,come to"realize"thebad news(Maynard1996).

our

Appendix.Transcribingconventions(FromGail Jefferson,"ErrorCorrectionas an Interactional Resource,"Language inSociety2:181-199,1974)

1.

Overlappingspeech

Lefthandbracketsmarka pointofoverlap,while

A: Oh youdo? R[eally

righthandbracketsindicatewhereoverlappingtalk

B:

[Umhmmm]

ends.

2.

Silences

Numbersinparenthesesindicateelapsedtimein

A:

I'm notuse tathat.

tenthsofseconds.

(1.4)

B: Yeahmeneither.

3. Missingspeech

A: Arethey?

Ellipsesindicatewherepartofanutteranceis left outofthetranscript.

B:

Yes because

4.

Soundstretching

Colon(s)indicatethepriorsoundis prolonged.

B:

I didoka::y.

Morecolons,morestretching.

5.

Volume

Capitallettersindicateincreasedvolume.

A: That'swhereI REALLY wanttogo.

6. Emphasis

A: I do notwantit.

7. Breathing

A: You didn'thavetoworryabouthavingthe.hh hhhcurtainsclosed.

8. Laughtokens

A: Tha(h)twasreallyneat.

9. Explanatorymaterial

A: Well((cough))I don'tknow

10. Candidatehearing

B: (Is thatright?)( )

Underlineindicatesincreasedemphasis.

The"h"indicatesaudiblebreathing.Themore "h's"thelongerthebreath.A periodplacedbefore itindicatesinbreath;noperiodindicatesoutbreath.

The"h"withina wordorsoundindicatesexplo- siveaspirations;e.g.,laughter,breathlessness,etc. Materialsindoubleparenthesesindicateaudible phenomenaotherthanactualverbalization.

Materialsinsingleparenthesesindicatethattran-

scriberswerenotsureaboutspokenwords.Ifno

wordsareinparentheses,thetalkwasindecipher-

able.

340

SOCIAL PSYCHOLOGY QUARTERLY

11. Intonation.

A: Itwasunbelievable.I Thada threepointsix? I 4Ithink. B: You did.

12. Soundcutoff

A: This-thisis true

13. Softvolume

A: 'Yes.' That'strue.

14. Latching

A: I amabsolutelysure.=

B: =You are. A: Thisis onething[thatI=

B:

A: =reallywanttodo.

[Yes?

15. Speechpacing

A: Whatis it? B: >1 ain'ttellin<you

A periodindicatesfallintone,a commaindicates continuingintonation,a questionmarkindicates increasedtone.Up arrows(t) ordownarrows(41)

indicatemarkedrisingandfallingshiftsinintona-

tionimmediatelypriortotheriseorfall. Dashesindicatean abruptcutoffofsound.

Materialbetweendegreesignsis spokenmorequi- etlythansurroundingtalk. Equal signsindicatewherethereis nogaporinter- valbetweenadjacentutterances. Equal signsalso linkdifferentpartsofa speaker's utterancewhenthatutterancecarriesoverto anothertranscriptline.

Partofanutterancedeliveredata pace fasterthan surroundingtalkis enclosedbetween"greater than"and"lessthan"signs.

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KarenLutfeyis a doctoralcandidateintheDepartmentofSociologyand a predoctoralfellow intheNIMH TrainingPrograminSocial PsychologyatIndianaUniversity,Bloomington.Her researchinterestsincludemedicalsociology,sociologyof mentalhealth,and languageand interaction.Sheis currentlyresearchingpatientcompliancewithdiabetestreatmentregimens.

Douglas Maynardis ProfessorofSociologyatIndianaUniversity,Bloomington.He currently researchesbothbad newsand good newsin conversationand thedeliveryofdiagnosticnews inmedicalsettings.He also is workingcollaborativelyon interactioninthesurveyinterview.