End-of-life discourse: An analysis of agency, coherence, and questions

In spite of the widely recognized problems surrounding end-of-life communication in the medical setting (SUPPORT Investigators 1995), actual clinical encounters with terminally ill patients have not been analyzed from a linguistic perspective. This ethnographically-based study examines clinical interactions (N = 18) and casual, open-ended interviews surrounding three terminally ill cancer patients throughout a period of approximately three months. Combining analytical tools from narrative analysis, interactional sociolinguistics, and medical communication research, I focus on the linguistic features that display patients' agency and help them construct a sense of coherence in the face of illness and the prospect of dying.; I show how patients display agency vis-a-vis their interlocutors (conversational agency) and vis-a-vis a displaced situation, such as the cancer diagnosis and pain management ( displaced agency). Some examples of discursive strategies examined include topic initiations and the speech acts of request and promise. When the display of agency is impossible due to constraints of illness, the expression of coherence emerges to be crucial in the process of making sense of the illness experience. By looking at linguistic evidence of coherence-making through patients' responses to questions accounts of their spiritual, emotional, and intellectual domains. Finally, I complement the top-down analysis of agency and coherence with a focused, exhaustive investigation of one speech activity throughout the clinical encounters: questioning. I combine qualitative and quantitative analyses of questions and their responses, paying special attention to their temporal orientations.; This study underscores the importance of qualitative discourse analysis of end-of-life medical communication and patient narratives, especially when they pertain to sensitive and legally controversial issues such as the Do-Not-Resuscitate (DNR) order and end-of-life options. In scrutinizing a small number of exchanges in detail, it complements the public health approaches commonly adopted in medical research.