Abstract
In a wide diversity of workplaces time and temporality are an omnirelevant feature of the praxeological and material environment, as observable by the pervasiveness of chrono-metrical and chronological technologies and artifacts, and by workers’ orientation to matters of punctuality, productivity and other aspects of task dispatch and managerial organization. Professionals’ orientation to time takes an additional complexity in healthcare settings, given the multiple temporalities involved – biological, institutional, social – and the implications of timely professional intervention in the progression of patients’ health. In palliative care, we argue, a practical concern with time and temporality is a constitutive feature of the work of professionals and teams, visible in and built in their interactions. Furthermore, such orientation to time is related to the collective production of justifications for actions. Drawing on conversation analysis of a corpus of audio recordings, we examine how, in team meetings and interactions with other healthcare staff, palliative care professionals make sense of patients’ end of life trajectories in a situated and joint manner, grounding their proposals for action in terms of timeliness – or lack thereof – concerning patients’ current situation and prognoses on their more-or-less foreseeable unfolding, accomplishing a valid rationale for palliative intervention.
Introduction
The present study examines how, in team meetings and interactions with other healthcare staff, palliative care professionals make sense of patients’ terminal situation in a situated and joint manner, grounding their proposals for action in terms of timeliness – or lack thereof – concerning patients’ current situation and prognoses on their more-or-less foreseeable unfolding, accomplishing a valid rationale for palliative intervention. Following the suggestion that “understanding decision processes can provide a meaningful framework for ameliorating or facilitating decision-making in practice” (Patel et al., 2002: 52), previous studies have examined interprofessional decision-making in end-of-life care (see Arber, 2008; Ho et al., 2016) and the organization of end-of-life conversations between professionals and patients or their relatives (see Binet et al., 2023; Brás and Martins, 2021; Martins et al., 2021; Monteiro and Brás, 2020; Anderson et al., 2020; Pino and Parry, 2019). However, except for Parry (2013), professionals’ production of justifications in team meetings remains understudied, and this is where our article intends to contribute, by conducting conversation analysis of their interactions with a focus on time-oriented decision-making.
Social organization as temporal organization in healthcare settings
Time is a fundamental dimension of social life, experience, and action (see Bergmann, 1992; Élias, 1999). In its double aspect of chronos, that is, measurable, mechanical time, and kairos, that is, the subjective experience of its passage in retrospect and the prospective projection of what will follow (see Heidegger, 1996 [1927]), constitutes a central concern throughout the lives of individuals, and in the interactions they engage in within groups and institutions. Social organization is, to a considerable extent, temporal organization. Actions and decisions are an integral part of the same social order to the extent that we can observe and describe their temporal coordination. Fundamental to the situated and contingent production of action, time and temporality play a central role in social interaction (Deppermann and Gunthner, 2015), grounding participants’ ability to reflexively make sense of prior interactional events and act upon them, constantly answering and accounting for the omnipresent question of “why that now?” (Schegloff and Sacks, 1973). In addition, there is a wide-ranging diversity of social activities in which participants mobilize time and temporality, in their diverse aspects and multiple scales of magnitude, as a conversational topic (Button, 1990; Raymond and White, 2017) and treat them as relevant for locally accomplishing social action. Researchers studying participants’ orientation to time have examined the interactional organization of instructing on an embodied action to be performed immediately (Mondada, 2017), updating on recent events (Beach, 2001; Clark and Rendle-Short, 2016; Searles, 2019), bringing a conversation to an end (Schegloff and Sacks, 1973), postponing an institutional procedure to a future interaction (Mondada et al., 2015), treating an encounter at hand as a “conversation-in-a-series” (Button, 1991), or using reference to age as a resource for categorizing self and others (Monteiro, 2017; Charalambidou, 2019).
In a wide diversity of workplace settings, time and temporality are treated as an omnirelevant feature of the praxeological and material environment, as observable by the pervasiveness of chronometrical and chronological technologies and artifacts, e.g., clocks, calendars, timetables and agendas, records (Dohrn-Van Rossum, 1996 [1992]; Zerubavel, 1981), and by workers’ orientation to matters of punctuality, productivity and other aspects of task dispatch and managerial organization. Professionals’ orientation to time takes an additional complexity in healthcare settings (Moreira, 2007; Zerubavel, 1979), given the multiple temporalities of biological processes, patients’ hospital careers, cumulative management of a large number of cases, and the implications of timely professional intervention in the progression of patients’ clinical situations (see Light, 2000; May et al., 2006). That is, health professionals constantly coordinate the “biological temporalities” as expressed in patients’ symptoms, disease progression, treatment interventions and healing processes, with the “institutional temporalities” such as expressed in vacancies’ management, work organization, technical conditionings and coordination with other institutions, and with “social temporalities” such as the ones manifest in family dynamics, and wider social institutions involved in support to healthcare, as well as in policies, norms, conceptions, and values.
In palliative care, a multiprofessional healthcare domain specialized in assisting patients with terminal illnesses, a practical concern with time and temporality is a constitutive feature of the work of professionals and teams. Previous research on workplace practices organized around the professional management of “critical moments” occurring within patients’ end-of-life trajectories (Glaser and Strauss, 1968) informs that palliative care professionals’ work of composing and commonalizing medically-defined dying trajectories (Martins, 2015, 2018) involves a constant work of measuring the estimated life expectancy of patients with terminal illnesses and accordingly deciding on the most relevant way of promoting their quality of life. Moreover, time and temporality are treated as relevant from early on within intervention with patients and relatives, since early discussions of end-of-life concerns (Walczak et al., 2017) and early referrals to palliative assistance (Santos and Reis-Pina, 2019) to planning for an uncertain future (Borgstrom, 2015), responding to patients’ questions about life expectancy (Pino and Parry, 2019) and appeasing relatives’ uncertainty in prognostic conversations (Anderson et al., 2020).
Rather than being exclusive to interactions with patients and relatives, the challenge of talking about time is a pervasive feature of end-of-life care, given the complex unfolding of patients’ clinical situation and its consequences for professional intervention, managed jointly within multiprofessional teams (Arber, 2008). Socio-interactional research on team meetings informs that decision-making is a local, situated accomplishment of team members (Housley, 1999; Raclaw and Ford, 2015; Svennevig, 2012) which, in diverse healthcare settings (see Sarangi, 2016; Thurston et al., 2016), involves the participation of professionals from different professions and/or specialities, for example, nurse and physician (Sterie, 2017), rehabilitation team (Izumi, 2014), emergency room (Seuren et al., 2019), hospice (Eagle and de Vries, 2005), as well as discharge meetings including the participation of the patient (Keel and Schoeb, 2017). Examining interprofessional team meetings in the domain of palliative care, Arber (2008) has identified some of the linguistic strategies mobilized by palliative care professionals for achieving the team’s agenda and managing boundaries around the display of specialized knowledge and professional expertise. We further these studies by conducting conversation analysis focused on time-oriented interactional decision-making in the meetings of multiprofessional palliative care teams.
Materials and methods
This study is based on a corpus of audio recordings of nine weekly team meetings (14 hours approximately), collected during ethnographic fieldwork in one in-hospital Palliative Care team in Portugal, and a corpus of audio recordings of two weekly meetings in a Palliative Care hospice (6 hours approximately), which are part of a larger multi-corpus consisting of 55 interviews with palliative care professionals, 22 audio recordings of phone calls between professionals and patients’ relatives, and ethnographic notes on observed workplace activities of the in-hospital palliative care team, which took place between September and December 2019, within the scope of Project ETIC Managing end-of-lie trajectories in palliative care: a study on the work of healthcare professionals (PTDC/SOC-SOC/30092/2017), funded by Fundação para a Ciência e Tecnologia, Portugal. The institutions’ Ethical Committees authorized this study, and participants gave their written and oral informed consent. In compliance with ethical procedures for data protection, all the names of the participants and other confidential information were duly anonymized. The conversational data used in the present study was transcribed in order to preserve the sequential and temporal organization of participants’ talk (see Jefferson, 2004; Mondada, 2012).
The organization of Palliative Care (henceforth, PC) intervention in Portugal proceeds along the interplay between three distinct types of service: 1) in-hospital PC (including out-patient appointments at the hospital); 2) home-based PC; 3) hospice-based PC units. Palliative care teams are multi-professional with variable configurations. The in-hospital team was composed of physician, nurse, social worker, psychologist, and administrative, while the hospice team also included physiotherapist, occupational therapist, and spiritual assistant. Within the Palliative Care teams, each of its members has knowledge about patients’ cases, the temporal evolution of their clinical progression and current situation, as well as on the availability of resources, according to the information they gather through their expertise and interaction with patients, families and other professionals involved. Although each professional produces normative understandings of what is to be done on the basis of such information and their ability to predict expectable outcomes of professional intervention, it is within the team meetings that professionals share and jointly update available information on a patient’s current situation, proposing and collectively ratifying plans for future action in a concerted manner.
Analysis
The analysis investigates the discursive and interactional practices of PC professionals in team meetings for making sense of patients’ specific situations and planning palliative intervention, with a focus on professionals’ orientation to the relevance of time and temporality concerning concurrent therapeutic approaches (e.g., curative and palliative) and the timeliness of palliative intervention (e.g., referral to admission or discharge from specific PC modalities). A first extract shows how, during a team meeting at the palliative care hospice, the discussion of an issue calling for professionals’ decision occasioned an orientation to the temporality of decision and to the current “moment” as critical for acting: Extract 1 (UCP_26.2.2020, 2.09.41)
In line 1, the nurse addresses the possibility of the patient leaving the hospital to spend the weekend at home with her daughter. After topicalizing the issue, treating it as problematic, the nurse asks the other members of the team for their opinion, framing the decision as constrained by an expectable, critical event whose temporal occurrence is unpredictable (“we are getting to a moment of,” line 2). The delicate nature of referring to this event is conveyed tacitly, as the nurse leaves the sentence unfinished, then providing an alternative (“or still,” line 3). Prefacing her response to the nurse’s question by framing it as her own opinion (“i think,” line 4) and by treating the proposed solution as tentative (“perhaps,” line 4), the team’s physiotherapist proposes that the patient organizes to spend the weekend at her daughter’s home. Supporting the physiotherapist’s proposed course of action, the social worker treats it as an opportunity for understanding the patient’s difficulties in living outside of the hospital (line 6), providing a justification for the decision under discussion.
In this extract, we observe how a team’s decision about a patient is presented as potentially problematic concerning its timeliness, and how this is done by referring to events situated within different orders and magnitudes of temporal organization. The weekend, a shorter, calendar-based event constantly co-constructed, ratified and mobilized in social life, is associated with specific expectations of a greater availability of the daughter to care for the patient, according to the weekly-based micro temporal double morphology described by Mauss (1989). Wider ranges of biological time are also implied and considered, whose length can only be guessed at, limited by an expectable but unpredictable fatal event, and clinical aspects of the patient’s “end-of-life trajectory” and hospital career, namely temporary discharge from the hospice facilities. Moreover, it shows that professionals treat such decisions as calling for the opinion of other team members about a proposed course of action and how, when provided, they framed it as personal and tentative using markers of uncertainty, eventually supported by other team members (see Arber, 2008). Still, the physiotherapist’s proposal leaves the problematic issue – that is, the timeliness of the decision vis-a-vis the critical, unpredictable event – unaddressed, focusing on “where” the patient should go to rather than “when.” This extract also shows how professionals proceed by weighing the different ways in which their decision may benefit the patient, and how an initial focus on a relational perspective (i.e., giving the patient an opportunity to spend time with her daughter) gives place to a concern with its relevance from a wider care delivery viewpoint, that is, exploiting this as an opportunity to identify the patient’s difficulties justifying the potential decision within a care rationale. We would also like to show, in this excerpt, how time is an expressive resource (Binet et al., 2023) and a decision-making resource within the interaction. When the professional leaves a sentence unfinished and a silence follows or when the end of a word in an unfinished sentence is prolonged (see line 3), the professional is using time in the interaction to convey doubt and uncertainty but also to question others and open to their inputs. Additionally, time within the interaction is a resource to decision-making, when, by suspending content, professionals “give” time to the decision-making process.
Making sense of multiple (concurrent) therapeutic approaches
In PC, professionals routinely produce clinical narratives in which they situate the patients’ current condition, justifying decisions for action by orienting to timeliness as to the progression of the patient’s situation toward an expectable event/stage within their end-of-life trajectory. Such can be observed in Extract 2, where the in-hospital PC team’s nurse updates on a patient’s current situation: as the team’s psychologist inquires on the relevance of a suspended treatment, the nurse produces a justification for the rationale of this clinical decision, then frames its relevance (or lack thereof) in prognostic terms: Extract 2 (EIH_2.10.2019, 04.05)
In line 1, the nurse announces that the team will continue following the patient, who is to remain at the hospital (line 2). After referring that the patient is currently taking antibiotics, the nurse retrospectively reports on the evolution of his illness (lines 2–3) and, referring to the radiotherapy treatment, informing the other members of the team that it was suspended (line 4). After a stretch of silence, the nurse projects a conclusion (“and so,” line 4), but leaves the turn incomplete when, in overlap, the psychologist ambiguously problematizes whether there is “indication to do” (line 6). As the nurse problematizes her colleague’s previous question, the psychologist identifies radiotherapy as her object of concern (and not the antibiotics treatment), hinting that it might not be useful to proceed given the patient’s situation. The nurse explains why the treatment was suspended (lines 11–14), disconfirming that it was ever stopped (line 16). Resuming the conclusion she had previously projected, the nurse expresses lack of knowledge and doubt and produces a series of predictions of how, in the present moment, she envisions the future unfolding of the patient’s situation. Prefaced by an expression of prospective-oriented, subjective envisioning (“i see,” line 17), she refers to the patient’s current and future situation, addressing different issues: his clinical evolution (line 19), his current situation of being “in a very advanced phase” toward an inevitable, fatal event (line 20), and an expected outcome of his hospital career (lines 21–22). After the doctor ratifies (line 24), the nurse elliptically brings her conclusion to a close, again formulating her prognosis as prospective, subjective envisioning.
This extract illustrates some of the discursive practices mobilized by PC professionals for presenting and making sense of patients’ end-of-life trajectories, as well as challenges and opportunities for intervention. This involves their orientation to a complex intertwinement of considerations about the temporality of patients’ progression and its clinical significance, accomplished by:
retrospectively presenting the patient’s situation until the present moment, describing the temporal progression of past and/or ongoing significant events and processes (e.g., antibiotics, radiotherapy, infection), and reporting a present situation or concern calling for action.
identifying a proposal or decision (e.g., keeping a patient under palliative assistance; administration of antibiotic therapy) and accounting for its prospective relevance and timeliness on the basis of a (pessimistic/optimistic/neutral) prognosis on the patient’s clinical situation, namely concerning the relevance of palliative intervention, other types of medical intervention, and/or likeliness for the patient’s permanence or discharge from the hospital.
expressing a personal, subjective understanding of how the patient’s situation may be expected to evolve, while treating the care action as resulting from a collective decision involving the team (e.g., “we will continue to accompany”). This points at a sort of social cognition to the extent that responsibility and accountability – the ability and duty to answer for the rational fundaments of a decision – are not only attributed to individual speakers. Indeed, the team meeting is the interactional framework producing a collective enunciator (Lorda and Zabalbeascoa, 2012), by intersubjective ratification, active and passive, of meeting-situation-statements (Malinowski, 2002 [1935]: 246).
Professionals’ orientation to the temporality of patients’ situation can also be observed upon the scheduling of a first PC consultation. Extract 3 shows how the members of the in-hospital PC team make plans for a new patient who is being followed in another medical speciality: Extract 3 (EIH_11.12, 0.22.11)
The doctor’s suggestion to schedule the patient’s first palliative consultation for the same day as his next consultation with the oncologist at that hospital (lines 1–4) is rebutted by the nurse, who claims that the patient is “also” being followed by another medical speciality in another hospital (lines 6–7). In response, the doctor presents the patient’s situation and hospital career, taking a retro- and prospective orientation to its temporal progression: prognosticating a “likely” tumor in the lung which has “not yet” evolved into a main tumor nor it has “many” metastases (lines 10–12), the doctor suggests that the exams indicate a specific condition (13), then informs that the tumor has not been identified “at this moment” (line 14). After the nurse acknowledges this information (line 15), the doctor operates a conclusion (via “portanto”/“so,” line 16) on the relevance of the specialized pulmonological intervention in the other hospital (lines 16–17), expressing an expectation that it will allow the identification of the patient’s specific condition (line 19). Then, after a stretch of silence, the doctor sums up the patient’s situation by positioning it at the “beginning” stage of an “advanced” illness (lines 20–21), orienting to the relevance of making sense of where the patient stands within the progression of the illness and end-of-life trajectory.
In making prognosis about a patient’s situation, the way in which it is presented to the team orients to the temporal progression of his illness evolution (as suggested by available medical exams, which the doctor presents as evidence supporting a low degree of uncertainty) and of his hospital career of illness (Martins, 2015), for example, admission into different medical specialities, examination, and pursuit of specialized diagnosis. While the doctor’s prospective projection of a series of medical events conducing to a concrete diagnosis orients to a prognosis of “an illness which is already in a very advanced state,” hence granting the relevance of the PC intervention under planning, the professional modulates his epistemic stance, conveying a degree of uncertainty concerning the specific situation and how it will unfold.
Deciding on referrals to palliative support
Palliative care professionals engage in pondering the temporal progression of patients’ situations both in quantitative and qualitative terms, weighing costs and benefits according to available information and resources, and intertwining biomedical and moral reasonings in justifying care decisions. Such can be observed in Extract 4 as, in a phone call to the team’s nurse, an oncologist informally refers a patient to the in-hospital PC team, justifying her decision as clinically relevant but not urgent and leaving the temporality of the process open for the team to decide on: Extract 4 (EIH, 2.10.2019, 1.02.51)
After reporting on the patients’ current situation, the oncologist takes a prospective orientation to communicate her prevision that no further treatment is possible (lines 6–7), tacitly treating palliative intervention as the alternative, relevant solution. Then, shifting to a retrospective orientation, the doctor reinforces this idea by justifying her postponing of the patient’s PC referral, invoking previous difficulties in obtaining his adhesion to talking about end-of-life support (lines 7–8). Operating another shift in temporal reference so to resituate her presentation of the case within the moment of the interaction and addressing the team as a whole instead of only referring to her co-participant, the doctor expresses a concern that, “sooner or later,” the patient will need support (9–10). Such vague reference to the temporal progression of the patient’s illness displays the oncologist’s orientation to a tension between uncertainty and inevitability; predicting how the patient’s situation – and expectable need for palliative support – will progress, the oncologist operates a contrast with the patient’s situation in the present (“at this moment he does not need anything”), justifying her decision of leaving it to the team to schedule an appointment to whenever they find suitable, and suggesting that it takes place in the same day the patient goes to her consultation (lines 10–11). Shifting between retro- and prospective orientations to the temporal unfolding of a patient’s situation, professionals refer to past events and predictions for the future so to justify present decisions. Addressing the timeliness of referring the patient to PC, the oncologist displays a tension between managing his resistance to “end-of-line talk” on her own before requesting assistance from the PC team, making an early referral so to maximally benefit the patient, and adjust to the schedule of the PC team. Moreover, it shows how the professional produces temporal reference in a vague manner referring to the patient’s clinical progression and in a precise manner concerning her decision for his referral, soliciting admission to the services of the PC team. Justifying the solution to this practical problem, the oncologist treats both the patient and the team as beneficiaries (see Clayman and Heritage, 2014), addressing the patient’s current lack of need for PC support, as well as the team’s convenience.
Professionals’ production of justifications for postponing intervention, that is, giving reasons for doing something at some other time (see Parry, 2013) can likewise be observed in a next extract, where the in-hospital PC team’s nurse presents the case of a patient who had been indicated for palliative consultation, proposing the postponing of her admission to PC: Extract 5 (EIH_21.11, 0.04.42)
The palliative nurse announces that a doctor from the hospital made a request for referral and informs that the team (referred to via plural “we will evaluate again,” line 7) will evaluate the patient in one month. Explicitly accounting for this decision, the nurse treats it as the opinion of the team (again referred to in a collective manner, via plural “we think,” line 8) that the patient does not need “anything” in the present moment, justifying a delay of the team’s intervention.
PC professionals’ and teams’ decisions on initial intervention involves a constant concern with patients’ current situation as well as with previews for how it will evolve, making sense of the relevance of palliative intervention at a given time concerning the patient’s needs. Displaying retrospective orientation to previous events and the relevance of present and future intervention, the team’s coordinator and nurse informs that the team will continue keeping the case under scrutiny, referring to the progression of the patient’s illness (i.e., how it has progressed to “an advanced stadium” and keeps “aggravating” beyond it) as well as of the previous request from the doctor. Then, shifting to prospective orientation, and treating the PC team’s action as resulting from collective decision, she informs that the patient’s first palliative consultation will be postponed for one month, accounting for this decision in terms of how the patient does not need palliative intervention. Similarly, time-oriented justifications are produced by team members when communicating proposals for cancelling impending referrals to other PC services. In the next extract, we join the action as, responding to the in-hospital team nurse’s prompt, the doctor presents the patient’s case, reporting on his current situation on which he grounds a proposal for (non-)action: Extract 6 (EIH_11.12.2019, 0.39.44)
Responding to the team nurse’s prompt (line 1), the doctor identifies the patient by name and age, then describing his primary illness and its state of progression and, subsequently, reporting a comorbid cardiac condition for which he went to the hospital (lines 4–5). The doctor then narrates how the patient’s internment at the hospital has resulted in a significant improvement of his clinical situation (lines 5–13), treating the patient’s weight loss as a turning point to recovery and a series of subsequent evidence exhibited by the patient at the functional level as supporting his discharge from the hospital (lines 13–16). Operating a temporal disjunction in the progression of the narrative (line 17), the doctor informs the team on the patient’s current situation (line 18). Establishing a causal nexus between the patient’s current situation and its consequence in terms of medical action (“and so,” line 18), and topicalizing the impending referral of the patient to a PC unit (line 19), the doctor justifies his personal opinion (“i think,” line 19) that the patient’s terminal situation makes it “not worthy” (line 20) to proceed with the transfer.
In sum, this extract shows how the doctor presents a proposal to the team by narrating prior events as progressively build-up toward an optimistic projection for the patient’s recovery, in support of discharging him from the hospital, then operating a sudden contrast with the patient’s current agonic situation, on which he justifies the cancelling of plans for referral to another PC service. The doctor does not treat this sudden change in the patient’s condition as a reason to question previous decisions which might threaten his recognition as a competent doctor. Rather, here we see the irrefutability of an uncertain diagnosis and how a weak modalization protects the professional against failed predictions and corresponding decisions. Indeed, when the course of a disease deviates significantly from a prediction professionals do not emically treat it as a proof of incompetence, nor do they take it as a basis to annul or question the rationality of previous decisions, because they consider there were good reasons justifying them. Admitting the existence of uncontrolled variables and controllable ones creates a protective context of professional competence and epistemic authority of professionals faced with the failure of their predictions.
Conclusion
In this paper we examined how the interprofessional planning of PC intervention routinely involves professionals’ orientation to time for justifying clinical decisions, their constant orientation to pose and answer the question “why that now?” (Schegloff and Sacks, 1973). The “now” is relative to a sequential position in the unfolding of an interaction (Binet et al., 2023), but also to the sequential position of each meeting in the professionals’ work timeline. In meetings of the PC team, professionals present patients’ current situation, situating it within a wider macro-temporal continuity (comprised within the scope of a patient’s end-of-life trajectory), justifying the worth of a specific action, whether it is already in course (e.g. treatment) or still being decided (e.g. admission into in-hospital PC or referral to another modality of palliative assistance). While palliative professionals work with both retrospective and prospective time lines, the different possibilities of such trajectories that they need to consider prospectively complexifies time’s sequence, which appears anything but linear. Nevertheless, the data under study shows that, recurringly, professionals topicalize time in relative terms, situating patients’ current condition within the boundaries of illness progression / end-of-life trajectory – that is, on a path toward death (Martins, 2015). Palliative professionals mainly work in Gell’s (1992) “A-series time,” by looking at the relative situation of a patient vis-a-vis the anticipated event of death; it is not their goal to establish “B-series time” claims, that is, claims that are true at all moments, like the date of death. For this they use diverse linguistic practices, such as referring to time spans (e.g., “state,” “stadium”), categorizing situations of illness (e.g., “early,” “advanced,” or “terminal”) or topicalizing the timeliness of intervention (e.g., “still,” “not yet”). Such practices of referring to patients’ life expectancy, mobilized in interactions between professionals, contrast with the professionals’ use of “absolute categorical time estimates,” in terms of days or hours, when solicited by patients’ relatives (Anderson et al., 2020). One reason for this contrast may reside in that, whereas professionals’ provision of estimates to patients is oriented by an imperative of cautiousness (Pino and Parry, 2019) given the delicate nature of end-of-life talk and the relevance of tactful communication (Brás and Martins, 2021; Martins et al., 2021; Monteiro and Brás, 2020 see also Breviglieri, 2008), interprofessional talk about patients’ time is especially oriented to the relevance of action, so that informing other professionals on patients’ situation fundamentally serves as an imperative for organizing collective decision, planning and implementing actions aiming at its optimal benefit for the patients.
The concept of “anticipatory discourses” (Scollon and Scollon, 2000) is relevant to illuminate this work. Indeed, palliative professionals constantly refer to future events and we can situate their stances in the bidimensional matrix relating the epistemic with the agentive axis of anticipatory discourses. In the oracular end of the epistemic axis the future is what it is and may be known, or the future is what it is but we can not know how it will be; in the agnostic end of the epistemic axis the future cannot be fixed and cannot be known, it depends on current actions; in between the two there is an intermediate point, the probabilistic, in which the future is neither entirely fixed neither entirely open, although some results are more probable than others (idem). In the agency axis, we find the agentive end, where humans are able to have effects on the future, while in the fatalist end humans cannot do anything to change the future (idem).
Regarding the death of the patient, palliative professionals situate on the oracular end of the epistemic axis and the fatalistic end of the agency axis. They focus their work on a less knowable and more actable aspect: patients’ quality of life until death. Regarding the patients’ quality of life, we can situate palliative professionals’ epistemic stance as probabilistic – since they possess incomplete knowledge about disease progression, patients’ actions, patients’ families actions, institutional responses – and their agency stance tends toward agentive. This complex equilibrium is constantly played in professionals’ conversations when taking decisions, as we hope to have demonstrated.
Finally, we want to further emphasize the role this work on time has in justifying the palliative care actions, in answering the ever-present question “Why that now?”. By justifying the worth of acting at a specific time, in relation to a patient’s current and prospective situation, on grounds of its timeliness (Harder and Chu, 2020), for example, whether action is opportune, premature or overdue, PC professionals establish a nexus between the “current moment” as a temporary, actable upon standpoint, a prognosed temporal progression of the patient’s illness, and the prospective relevance of (temporally situated) action. Professionals’ prognoses involve the explicit expression of epistemic stance, organized around a tension between subjective uncertainty and shareable evidence (e.g., exam results, reports of observable situations, reference to previous events, time-based categorizations of “state” within the scope of illness progression), providing ground for producing predictions on patients’ clinical progression and expectable relevance of action (or lack thereof). In the process they co-produce the team as a collective enunciator. Talk-in-interaction plays a central role in the organization of professionals’ time-oriented presentation and discussion of cases at hand, a process which, simultaneously, shows the intersubjective validation, co-responsibilization and co-production of the team as a collective enunciator. This interactional process converts everyone into a speaker for the team but also for the diseased body, for the patient and for his/her family. In the meetings, professionals’ ratification of this collective voice may be active – by speaking –, or passive – by silence. Three aspects are worth noting: i) in the hospital, although the team worked interdisciplinarily, with the inputs of all professionals, there were differences in speaking time and power, which we cannot explore here due to space limitations; ii) in these processes, some of the professionals’ specific attributions remain distinct, but boundaries are also frequently blurred, sometimes positively, sometimes problematically; iii) palliative care decisions are permanently under revision, and so the professionals constantly produce the collective voice of the team, based on new information and perceptions coming from any of them. Nevertheless, the team’s production of its own collective voice is an essential regular feature of daily work. This is the more relevant as other authors have been showing the extremely important role that collective decision has in health care. Frith’s (2009) work on a fertility clinic has shown how health professionals consider collective deliberation as a guarantee of ethical decisions. Hernandez-Marrero et al. (2016) have shown that for palliative care professionals taking ethical decisions interprofessionally promotes a sense of shared-decision and team-based empowerment and is a protective factor against burnout.
By taking a detailed look into how professionals report patients’ current situation, it becomes possible to examine situated practices organized around professional orientation to salient states and/or events, their temporal and sequential progression, and their relevance for professional action within a wider retro- and prospective orientation to patients’ trajectories. This study contributes to an understanding of PC intervention as an interactional, temporally situated accomplishment, acknowledging its interprofessional, collective production and the centrality of time and temporality as professionals’ concerns for accomplishing concerted and justified medical actions.
Footnotes
Acknowledgements
We are grateful to all participants in the study for their openness and welcome during fieldwork. We would also like to thank all colleagues of ETIC team for the fruitful collaboration and Fundação para a Ciência e Tecnologia, Portugal, for the funding.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research received funding from national funds through the Fundação para a Ciência e Tecnologia, Portugal, in the framework of project ETIC (PTDC/SOC-SOC/30092/2017). The funding source had no role in the study design, the collection, analysis and interpretation of data, the writing of the report, nor in the decision to submit the article for publication.
Data availability statement
The data that support the findings of this study are available on request from the corresponding author, ORB. The data are not publicly available due to their containing information that could compromise the privacy of research participants.