Death and the treatment imperative: Decision-making in late-stage cancer

Abstract

Care at the end-of-life in the United States has expanded in the past decade in large part due to structural changes such as increased access to hospice care, the integration of palliative care, policy mandates, and financial incentives. Despite these shifts, research shows that appropriate end-of-life care continues to be underutilized. This paper uses conversation analytic (CA) and ethnographic methods to examine doctor-patient interactions among a sample of 14 Stage IV cancer patients and the way decisions unfold about next steps in treatment during a moment that larger policy changes began to take place following passage of the Affordable Care Act. This work reveals that, despite structures designed to better facilitate end-of-life care transitions for patients in late life, doctors continue to demonstrate interactional hesitancy in discussing the possibility of a patient's end-of-life in treatment discussions and an orientation to the treatment imperative. Examining doctor-patient interaction as one key trouble source in end-of-life care implementation shows in situ evidence that the treatment imperative supersedes the structural shifts supporting less medical intervention in late life.

Keywords: Cancer care; Conversation analysis; Death & dying; Decision-making; Treatment imperative.