The Dialectics of Care: Communicative Choices at the End of Life

Abstract

Communication at the end of life poses important challenges for patients, families, and caregivers. Previous research on end-of-life communication has concentrated on areas including the provision of bad news and clinical and personal decision making. In this study, we turn our attention to the processes through which caregivers provide comfort in palliative care. Our ethnographic and interview study of spiritual communication among hospice workers and their patients is guided by a dialectical framework. We find a central dialectic in which hospice workers recognize the tension between "leading" and "following" patients and families in discussions of spirituality at the end of life. Our analysis reveals that though some care providers choose one pole of this dialectic, most workers try to manage the dialectic by shifting between leading and following in different situations or different points in time or by transcending the dialectic and addressing the multiple goals of interaction.

Competing Discourses Surrounding Primary Caregivers of Hospice Patients

“…Considine and Miller (2010) found in their study that hospice staff communication to the patients and family was a dialogic of shifting between leading and following the conversations, of leading and being led. It is assumed in hospice work that the PCGs always know more about their situations than the staff does.…”

“…Communicatively, some of the families swing within the competing discourse of prolong it-end it' but with an ever downward spiral toward the end it' discourse. The back and forth within the competing discourse is spiraling inversion according to RDT (Baxter, 2011;Baxter Montgomery, 1996;Considine, & Miller, 2010). The prolong it-end it is a downward spiraling inversion that eventually ends with the death of the patient.…”

“…This study is focused on the latter, the EOL communication in the hospice environment. Most of these studies have focused on such issues as breaking bad news, advanced directives or "do not resuscitate" (DNR) orders, prognosis, and the final conversation of the dying with their families (Considine & Miller, 2010).…”

“…Presence-absence is reflected in the conflict of the past memories of the "true" husband as compared with the current situation. Considine and Miller (2010) used dialectical analysis to investigate spiritual communication among hospice workers and the patient. In their ethnographic study they found three main techniques used by the hospice team for managing competing discourse: (1) they choose to focus on one side of the dialectic, (2) they vacillate between the two poles of the dialectic depending on the situation or topic by either leading a discussion or following the patient's and family's discussion, (3) they transcended a direct leading and following role by asking questions to help the patient and family themselves process the competing discourse.…”

“…Narrative theory has been used to explain how hospice volunteers (Wittenberg-Lyles, 2006) and hospice staff (Considine & Miller, 2010) within a palliative context use narrative to help with communication. The communication of a personal story that connects with palliative patients and families is a powerful way of expressing empathy and gaining trust without feeling one has to be an expert.…”