Family resistance to end-of-life prognosis in hospice care: A conversation analytic single case analysis

OBJECTIVES: Some clinicians lack confidence providing prognostic information to families, particularly when they do not accept a short prognosis. This paper aims to understand the communication practices used when the family of a dying patient resist the provision and acceptance of prognostic information, and how a doctor responds to this. METHODS: Naturally occurring conversations between senior hospice clinicians and families of patients at the end of life were audio-recorded. We present a single-case of a consultation between a doctor and the family of an imminently dying patient. Using conversation analysis, we examine the ways in which prognostic information is resisted by the family and pursued by the doctor. Our analysis contrasts this with practices identified in previously analysed cases where prognostic information was accepted. RESULTS: Three practices for resisting prognosis were identified: passive resistance (minimal acknowledgement of prognostic statements), questioning the clinician's account for the prognosis and their certainty, and providing disaligning responses that do not engage with the prognostic statement. We demonstrate how in response, the doctor pursued prognostic talk, making increasingly explicit prognostic statements. The clinician balanced expressions of certainty that the patient was dying, with honesty about their uncertainty regarding timing. The doctor's statements more clearly resembled 'bad news delivery' than other cases in the dataset. CONCLUSIONS: The analysis demonstrates how families can resist the provision and acceptance of prognostic information at the end of life. It shows an obligation for doctors to disclose this information and possible strategies to respond to resistance. PRACTICE IMPLICATIONS: When delivering prognostic information at the end of life, doctors can look for signs of resistance from the family and use strategies to respond, such as expressing certainty where possible while acknowledging uncertainty. These insights may be particularly valuable in acute settings, where prognostic awareness among families may be limited.