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Bad News in Oncology: How Physician and Patient Talk About Death and Dying Without Using

Those Words
Author(s): Karen Lutfey and Douglas W. Maynard
Source: Social Psychology Quarterly, Vol. 61, No. 4 (Dec., 1998), pp. 321-341
Published by: American Sociological Association
Stable URL: http://www.jstor.org/stable/2787033 .
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Social PsychologyQuarterly
1998,Vol. 61,No. 4,321-341

Bad News in Oncology:How Physicianand PatientTalk


about Death and DyingwithoutUsingThose Words*
KAREN LUTFEY
DOUGLAS W. MAYNARD
Indiana University

Wefocuson thesocializationofpatientstotheprocessofdeathanddyingbyexamin-
ingactualinteractionsamongmedicalpractitioners, and theirfamilymem-
patients,
bers.Ourdataconsistofthreemedicalinterviews. In eachone,theoncologistdelivers
thenewsthatthepatient'scanceris no longertreatable. Althoughnotstated,the
impliedmessageis thatthepatientwillsoon die.Because,in theseepisodes,
thesame
doctoris attemptingto conveya similarmessageto threedifferent we can
patients,
comparethewaysin whichthepatientsrespondto themessageand thusaffect the
deliveryof thenews.In variouspracticalways,bothphysicianand patientexhibit
cautionindiscussing
interactional deathanddying.

Social psychological approaches to nal experiencesof individualswho confront


deathand dyinghave been preoccupiedwith mortalor chronicillness.
individuals'perceptionsof theirillnesstra- In theirreviewof themedicalliterature
jectories.In her classicworkOn Death and on breaking bad news, Ptacek and
Dying (1969), for example, Elisabeth Eberhardt (1996:496) identifya need for
Ktibler-Rossarticulatesa series of psycho- more empirical work, suggesting that
logical stages throughwhich people pass "research should begin with the simple
whenconfronted withdeath,suchas denial, question of whetherhow thenews is con-
isolation,anger,bargaining, depression,and veyedaccountsforvariancein adjustment
acceptance.Otherresearchon chronicand beforemovingintomore specificquestions
terminalillnessproposesthe importanceof about whichaspectsof conveyingbad news
awareness contexts (Glaser and Strauss are most beneficial" (our emphasis). We
1965),identity levels (Charmaz1987,1991), want to change the emphasis of existing
and viewsof self(Corbinand Strauss1987; work and to examine the role of talk and
Kutner1987;Yoshida 1993) as theyrelateto interactionas embedded in processes of
processesof normalization (Robinson1993) death and dying.This strategy is attunedto
and adaptation(Davis [1963]1991).Previous Longhofer's(1980) neglectedargumentthat
research,in short,emphasizesabstract,inter- dyingis a socialprocessbetterunderstoodin
the contextof interactionand communica-
*We wish to thank Prof.Richard M. Frankel for tionthanas theinternaland inherently pro-
thisstudyin manyways.We also grateful- gressivestagesdescribedbyKubler-Ross.
facilitating
ly acknowledge insightfulcomments we received Previous research on terminalillness
fromBill Corsaro,JeremyFreese, and VirginiaGill.
also reliesheavilyon typifications and gen-
We are extremely grateful to the physician who
allowed himselfto be taped while discussingvery eralizations.Glaser and Strauss(1965), for
difficulttopics withhis patientsand who took time example,discuss various typesof medical
froma busy clinicalschedule to be interviewed.Not work including machine,clinical, safety,
least, we thankthe patientsand theirpartnerswho comfort, and information
sentimental, work.
participated in the study. From the Indiana
UniversityCollege of Arts and Sciences,the second
In another, more interactionistapproach to
authorreceiveda grantthatsupportedthisresearch. these researchers
issues, work to make gen-
Finally,our gratitudegoes to the anonymous SPQ eral assertionsbased on detailedanalysesof
reviewerswho gave us helpfulsuggestionsand com- actualinteractions.Perakyla(1991) uses spe-
mentary. Correspondence to: Karen Lutfey
(klutfey@indiana.edu) at the Department of
cific examples from his fieldnotes to illus-
Sociology, Indiana University, Bloomington IN trate physicians'controlover situationsand
47405. their specificationof identities.Sudnow
321
322 SOCIAL PSYCHOLOGY QUARTERLY
(1967), who is orientedto hospitalemploy- The interactionalprocess wherebythe
ees' everydaypractices,discussestheirtypi- doctorin ourdata attempts to generateopen
cal reactionsto situationsand their"main awarenessand realizationis organizationally
strategies"fordealingwithproblems. similarto theconversation analyticphenom-
Our approachis relatedmostcloselyto enon thatJefferson (1986) terms"unpackag-
Sudnow's (1967) Passing On, whichexam- ing of a 'gloss."'A "gloss"refersto an inac-
ines death and dyingas sociallyorganized curate,incomplete, or maskedconversation-
processes.Sudnowfindsthattheseprocesses al generalization of "whatreallyhappened"
are defined and managed collaboratively (Jefferson 1985:436).Thata piece oftalkis a
throughtheinteractions and mundaneprac- gloss is not available in its firsttelling,but
tices of hospital staffmembers,including emergesas a consequenceof the recipient's
doctors,nurses,aides, orderlies,chaplains, activities; recipientsmayor maynotprovide
and others.We also approach death and an auspiciousenvironment forthe unpack-
dyingas socially organized interactional agingprocess.Insofaras an auspiciousenvi-
phenomena,butconcentrate on communica- ronmentexists and the gloss is actually
tions that Sudnow (1967) explicitlymini- unpackaged,the talk will be producedin a
mized,involvingdirecttalk betweendoctor way thatis sensitiveto the ongoinginterac-
and patient(and families)and the attempt tionratherthanby one speakerunilaterally
to socializepatientsto the dyingand death announcing "what really happened" or
process. More recently,Bor and Miller "whatone reallymeans."When a recipient
(1988) and Perakyla(1995) have examined does not provide an appropriateenviron-
how,in counseling, professionalsand clients ment,the potential unpackagingmay not
addressdeathand dyingas "dreadedissues" occur.
thatrequirepreparationof an appropriate We use detailed,turn-by-turn analyses
or auspiciousinteractionalenvironment. A of threeepisodes of doctor-patient interac-
difference betweenthesemore recentstud- tion to examinethe interactive, contingent
ies and oursis thatcounselingoftenseeksto natureof awarenesscontextsand how they
get clients or patientsto discuss dreaded are shaped throughconversation. We assert
issues, whereas the physicianin our data that physicians'attemptsto achieve open
solicits specific kinds of talk from his awarenessand realizationvaryin significant
patientsbutalso seeksto inform themabout ways accordingto the contingenciesof the
theirillnesstrajectories. patients'responses.Specifically,we examine
More specifically,
we examinethe ways thewaysin whichthephysician, thepatient,
in whicha physiciancan conveyto a patient, and thepatient'sfamilymemberscautiously
and how the patientreceives,the news that approachthe delicatetopic of the patient's
his canceris no longertreatable,thathe is terminalillness;the interactionalresources
close to dying, and thatthephysicianis shift- thatare available to physiciansforbroach-
inghis treatment focusfromcuringthecan- ing the topic of death and dying;and the
cer to managingpain symptoms.Maynard resources available to the recipients to
(1996), followingcharacterizations thatsub- deflect,divert,avoid,or euphemizethemat-
jects providein theirnarratives of bad news ter.
experience, argues that the problem for
recipientsis one of "realization."In medical DATA AND METHODS
settings, forexample,patientsface the task
of comingto understandthat a featureof The secondauthorcollectedthedata for
theirlifeworld-the presumptionof their this studyat a hospital associated with a
body'sown relatively good healthor,in the medical school in an eastern state. The
cases examined here, theirtrajectoryfor physician,a participantin a largerstudyof
recovery-hasbeen alteredsignificantly. The the hospital'soncologyclinic,coincidentally
physicianmust deliver the bad news and had threemale patientswithdifferent forms
elicittherealizationfrompatientsand fami- of terminal cancer. Two of the patients,
ly membersthatthepatients'conditionsare "Robert"and "John,"were recuperating in
nowterminal and thattheyare dying. the hospital from unsuccessful surgical
BAD NEWS IN ONCOLOGY 323
attemptsat treatingtheircancers.The third the effortto elucidate and describe the
patient,"David," was visitingthe oncology structureof a coherent,naturally
bounded
clinic as an outpatient.Because, in these phenomenonor domainof phenomenain
episodes,the same doctoris attempting to interaction,how it is organized,and the
conveya verysimilarmessageto threedif- practices
bywhichitis produced.(p. 101)
ferentpatients,we can comparethe varied In the second "mode of data analysis,"
ways in whichthe patientsrespondto the suggeststhat
Schegloff
message and therebyaffectthe deliveryof
thenews. theresourcesof past
[i]na sortof exercise,
The second author videotaped in the workon a rangeofphenomenaand organi-
zationaldomainsin talk-in-interactionare
hospitalroomsof theadmittedpatientsand,
broughtto bear on theanalyticexplication
forthe outpatient, in an examinationroom of a single fragment of talk. (p. 101; our
thatwas partof a clinicattachedto thehos- emphasis)
pital.In each case he obtainedthe permis-
sion of the oncologist,the patient,and the Our analysistakesthelatterform,although
patient'spartner.(John'sand David's wives we examinethreemedicalinterviews rather
werepresent, as was Robert's"girlfriend,"
to thana singleoccasionoftalk.Because single
use histerm.) episodesare the"locusoforder"'(Schegloff
In an interview withthe secondauthor, 1987:102),we analyze each of our doctor-
the oncologistin the data volunteeredthat patient interviewsas an entityin its own
he "feltawkward"when he was talkingto right.At the same time,we can draw from
Robert: existingconversationanalyticresearchon
interaction
patient-practitioner to linkthese
I don'tthinkit had anything
to do withthe episodes to other,similaroccurrences.Our
factthatI was beingobserved.It was more
analysis is also comparative:The conver-
withthe factthatsometimeswhen I say
I'm trying genceamongthesethreeepisodesin person-
topatients,
things to cuethem.Im
tryingto get themto ask me some questions,
nel,disease category, and typeof informing
or to findoutwhattheyknowabouttheill- makes it possible to investigatesimilarities
ness.How severeitis,or whether
theyknow and differencesin the organizationof the
thattheymightdie,or whethertheythink interviews. We also draw on ethnographic
that'simminent.
But whenI talkedto himI interviews thatthesecondauthorconducted
didn't get any of the responses that I to supplementour primaryconcernswith
would've like to get that would help me to the recordedinteractional material(Kinnell
buildon things. and Maynard1996;Maynard1989).
In two of our episodes,the analysisis
This accountis important to our analy- framedin termsof the perspectivedisplay
ses, and we will elaborate on it later. In series(PDS). This"device... operatesin an
termsof data collection,however,thephysi- interactionallyorganized manner to co-
cian's commentssuggestthat,fromhis per- implicatethe recipient'sperspectivein the
spective,the presence of a video recorder presentation of diagnoses" (Maynard
and observerdid not influencethe interac- 1983:333),althoughin the presentdata the
tion.The firstauthortranscribedthe data physicianpresentsa prognosisratherthana
usingJeffersonian conventions
transcription diagnosis.The PDS allows a physicianto
(Atkinson and Heritage 1984:x-xvi; see deliver news cautiously by solicitingthe
appendix). recipient'sopinionbeforeproviding his own
Althoughmuchof conversation analysis assessment,and then,throughsuggesting
is based on collectionsof sequential phe- clinical agreementwith that opinion, co-
nomena frommultiple conversations,we
workherealongthelinesof the"single-case
analysis." Schegloff(1987) organizes the 'Conversationanalysisoperateswiththeassump-
tionthateveryinteractionhas locallygenerated
conversation analytic enterpriseinto (at suchthatevensingleepisodesoftalkare
orderliness,
least) two typesof analyses.He describes coherentand meaningful
interactionally forpartici-
thefirsttypeas oftheirbackground
pantsregardless characteristics.
324 SOCIAL PSYCHOLOGY QUARTERLY
implicating therecipientin thefinalpresen- proceed withextremecaution, to discuss
tationof the news.Further,this approach euphemismand allusion as possibilitiesin
helpsthephysicianto forecastdiagnosticor the talk, and to draw on other resources
prognostic newsforpatientsinsteadofdeliv- (such as post hoc interview material)beside
ering it in a blunt or forcefulway,which theinteraction itself.
impedes realizationand adaptationto the
news(Maynard1996). ROBERT: MINIMAL UNPACKAGING
Allusive talk is a phenomenonin our OF THE GLOSS
analysis.Like Schegloff(1996:181),we use
the termsallude and allusion (as well as Roberthas been underyear-longtreat-
euphemism)broadly.Our workdiffers from mentforcancerof thegall bladder.He is in
Schegloff's,however,in thatwe address a the hospitalrecoveringfroman operation
relatedbutessentially differentinteractional duringwhichthe surgeondeterminedthat
phenomenon.Schegloff(1996) analyzes a the cancer was too far advanced to permit
sequencein whichone partyto conversation any further removalof damagedcells.Now
"plants" somethingin the talk that is not Dr. T mustconveythe information thatthe
said "in so manywords"or is notsaid expli- cancer can no longerbe treated,although
citly.Then a recipientof thistalkformulates pain management is possible.The encounter
an explicitunderstanding of theinexplicitor we examineinvolvesa seriesofexchangesin
allusiveutterance. The originalspeakernext which Dr. T approaches the topic of
repeatsthat"explication," therebyconfirm- Robert's dyingin a progressivefashion,
ing both the recipient'sunderstanding and along the lines of a stepwise questioning
that the originalutterancewas indeed an strategythat Perakyla (1995) identified.
allusion.In our data, when the partiestalk
Robertand his girlfriend Katherine,howev-
allusively,no suchexplicitunderstandings or
er,resisteach stepwisemove.
confirmations occur.
Dr. T opens the interviewby asking
The methodologicaladvantage of the
Robert how he is feeling;Robert responds
phenomenon explicated by Schegloff
(1996:192)is a "data-internal verification"
of that he has improved.Dr. T thensays that
whattheparticipants understandas an allu- the surgeons are happy withhis recovery
sive conveyance.Because our data contain and broaches the topicofhis dischargefrom
"candidate"allusionsthatare notnecessari- the hospital (Excerpt la, lines64-70). After
ly explicitlyunpackagedor confirmed in the a 1.2 second silence elapses without a
interaction,theyoffera special challenge response from Robert or Katherine (line
(Schegloff1996:191);thisderivesfromana- 69), Dr. T comments that Robert'sfamilyis
lyticallyproposingwhatparticipants are say- also thinkingabout the patient'sdischarge,
ing whentheyseem to be purposefully not and produces,a question: "Has Tanybody
sayingitin so manywords.Here our analytic had the opportunity to talk to you abou:t"
strategy forexplicating theallusivetalkis to (lines70-72).

Excerpt Ja

64 Dr: Now (0.3) I knowthatthe:surgicaldoctorshavebeenpretty


65 ha:ppywithhowquicklyyou'verecover:ed:(0.4) fromthe
66 su rgery=Iwasjustlookingatthehospitalchart.That's
67 whattheirnotes:notessa::y.I knowthey'rethinking abou:t
68 planningfer:whenyoucan getoutofthehospitaltoo:.
69 (1.2)
70 Dr: uhm>1 knowyourfamily<is thinking (.) aboutthattoo:.
71 (0.4)
72 Dr: Has lanybodyhadtheopportunity totalktoyouabou:t
73 (0.8)
74 ((R pointsto K, Dr lookstoher))
BAD NEWS IN ONCOLOGY 325

75 Dr: Ouho=
76 K: =yes.Mis [sus] Parker
77 P: [she]
78 (0.4)
79 Dr: Abou:t.((Dr looksbacktoR))
80 (0.3)
81 K: [yeah]
82 R: [Sh-s]herelatesto what-whatwenton:
83 (0.2)
84 Dr: Oh
85 (0.5)
86 R: Whowasthatlady[ Is-]
87 K: [Miss]us Parker.
88 (0.5)
89 Dr: Did shetalkto youabou:t=
90 R: =Ya.
91 Dr: theprogram calledHo:spic:e?

Althoughthisquestionis notgrammatically topic associated with death and dying.


completeand is followedby a silence (line Indeed, Dr. T later remarked about this
73), Robertrespondsby nonverbally select- interview:
ingKatherineto speak (line 74). She replies
SometimesI use the discussionof hospice
affirmatively and namesa Mrs.Parker(line not so muchbecause it's important to me
76). Dr. T then solicits a more elaborate thatthepatientaccepta homehospicepro-
responseabout the contentof the interac- gram,butit's a wayof introducing themto
tion by usingan "abou:t" component(linse theidea thatthey're-ofhowsicktheyare,
79), as he had in his earlierquery.Robert really.So I was tryingto use it moreas a
nowverballyindicatesthatDr. T is to speak platform ... that'ssometimes a goodidea to
to Katherinebecause "she relatesto what- get theconversation reallydirectedwhere
whatwenton:" (line 82). Afterreceivingthis you wantit to go, whichis on death and
indicationwithan "oh" or "change-of-state dyingissues.
token"(Heritage 1984), and afterRobert's
queryabouttheirvisitor'sidentity (lines86), In the AIDS counseling discourse that
Dr. T (line 89-91) asks his questiona third Perakyla (1995:262-63) examined, the
time,tying(Sacks 1992:150-68)thisversion deviceofretrieving a themeabsentfromthe
to the previous two by elongating and client's previous reply can occasion talk
emphasizing "abou:t"whenhe asks explicit- about a fearor worrythatsubsequentlyis
lyiftheydiscussedhospice. pursued.Robertand Katherine, however,do
As Perakyla(1995:241)has observedin notrespondto the"deathand dying"aspect
the contextof AIDS counseling,counselors ofDr. T's questionabouthospice.
who attemptto address "dreaded issues" Indeed, Katherine's responses (lines
withtheirclientsoftenstartwithan "elicita- 93-94,97-98 in Excerptlb) to Dr. T's ques-
tion" such as Dr. T uses here. When that tions about hospice and Mrs.Parkerocca-
does notinducethepatientto volunteerany siontalkthatmovesawayfromhospicecare
descriptionof a future"hostileworld,"the and hencefromthedyingprocess.
counselorsemploya questionthatspecifies
a theme that is absent fromthe previous
answer or narrows the relevant issues 2In her work on Candidate Answers,Pomerantz
(Perakyla1995:254-61).Here,byprofferring (1988:367) suggests that "offering a Candidate
Answer is functional whenever a speaker has a
a CandidateAnswer2(Pomerantz1988:365) reason to guide a co-participantto respondin a par-
about hospice,the physicianintroducesa ticularway."
326 SOCIAL PSYCHOLOGY QUARTERLY
Excerptlb

91 Dr: theprogram calledho:spic:e?((Dr looksto K)) Is- is that


92 whatMissusPar[ker- ]
93 K: [No.]>she askedabouta nursing homefor'im
94 an< (0.4) he referred himselftotheParkVie:w
95 (0.4)
96 Dr: I see= ((Dr looksbacktoR))
97 K: =Andthenshetoldhimaboutlif:e(0.4) uh ((Dr looksto K))
98 support [>youknow<]
99 Dr: [Uhhuh ]
100 K: ifhe wantedthat(0.4) I've gotthepapersan I'll giveitto
101 himto sgn.= ((Dr lookstoR))
102 Dr: =1 see (0.4) 1 see. (1.2) 1 see. (0.8) SOUndslikeshewas
103 prettystraightFORward withall thedetai:l[s:?huh ]=
104 K: [OH yeah]shegives
105 hima lotof(.) in[ formati ]on.
106 Dr: [?alright?]
107 (0.6)
108 Dr: Ookayo=
109 R: =Verygood
110 (1.6)
111 Dr: WHERE do youthinkyou'llbe hea:dingafteryouleavethe(.)
112 ho:spital.

InitiallyKatherinerespondsto Dr. T's candi- of beingasked outright. Togetherwiththe"I


date answerabouthospicewitha "No" (line sfee"sand the silences,thismy-sidetelling
93). Then she indicates that Mrs. Parker "fishes"formore informationabout their
inquiredabouta "nursinghome"forRobert meetingwithMrs.Parkerwithoutthe need
(line 93-94).The emphasison "nursing"sug- to ask themdirectlyabout the "details."3
gests this as a contrastwith the hospice Katherine and Robert, however,provide
topic.Dr. T respondsin a delayed fashion responses that implicate topic closure:
with"I see" (lines 96). Subsequently(lines Katherine produces an agreeing,general
97-98) Katherineclaims that Mrs. Parker gloss of the conversation(line 104-105),
also discussed "lif:e support" with them, while Robert (line 109) aligns with her
whichfurther displayscontraststressingand assessment.
marksa difference betweenher interpreta- Afterthisexchange,Dr. T asks Robert
tion of the conversationwithMrs. Parker abouthisplansforleavingthehospital(lines
and the topic (hospice) that Dr. T has 111-12). BeforeExcerptlc, in an exchange
offeredwithhislineofquestioning. Goingto notshownhere(lines113-78),Robertstates
a nursinghome also can suggesta less seri- thathe would like to returnto the nursing
ous prognosisforRobertthandoes hospice. home where he lived before enteringthe
Nevertheless,Katherine's talk about "life hospital.Despite thisresponse,Dr. T sug-
support"preservesthe generaltopic of the geststhatRobertmightconsiderjoiningthe
illness trajectorywhile shiftingthe focus hospice programbecause it is a good pro-
awayfromhospicecarespecifically. gramforpatientswho have had cancer;this
In response,at line 102 Dr. T says "I shiftfromdiscussing thenursing hometo the
see," waits,says it again,waits,repeatsit a hospice program reintroduces a topicrelated
thirdtime,and waitsyet again beforepro-
ducinga "my-sidetelling"(Pomerantz1980) 3Also note how Dr. T raises his intonationon
and attaches"huh"to theendofhisutter-
"details"
(lines 102-103).In thisformof information ance. These actionsstronglyinvitean expansive
seeking, the recipient is interactionally responseto hiscandidateinterpretation oftheearli-
encouragedto volunteerinformation in lieu erdiscussion.
BAD NEWS IN ONCOLOGY 327
to death and dying,therebyalludingto the thedoctor'spreviousqueryaboutwherethe
topicof Robert'sterminalillnesstrajectory. couple plans forRobertto go afterleaving
Robert,however,rejectsthe optionof hos- the hospital(Excerpt lb, lines 111-12), he
pice,claimingthathe would have to spend tacitly solicited their perspective on
his nightsalone and thatit is inconvenient Robert'slong-term healthneeds and illness
forhisfamily. in thisquestion(lines179,181) he
Then,at line 179 (Excerptlc), trajectory;
Dr. T poses an unmarkedperspectivedis- asksmoreovertlyfortheirassessmentofthe
play invitation4 by asking about what future.
Robertsees "as happeningin thefuture." In
Excerpt Ic

179 Dr: wh-What do yousee: as (0.8) as the-happening in thefu:tur:e.


180 (1.4)
181 Dr: Areyouhopingthatyou'llg-getbetter:?
182 (0.5)
183 R: OH yes:doc[tor oh yes sure
184 K: [ohgoodlor:d(that'strue)]
185 (1.1)
186 Dr: Do youthinkthere'sa possibility that(1.5) youmightno:t?
187 (0.2) getbetter?
188 (1.1)
189 R: I've hadthoses::econdthoughts.
190 Dr: Uh huh
191 (1.1)
192 R: WhatI wentthrough yesterday?
193 (0.2)
194 Dr: Mm hmm.=
195 R: =and thedaybefore.
196 Dr: Mm hmm.
197 (0.2)
198 R: You go through
those
199 (0.4)
200 Dr: right
201 (0.4)
202 R: seriesofwhatever.

Aftera 1.4 secondsilence(line 180),thedoc- accountsfortheirstrongalignmentat this


torreformulates his question:Usinga candi- pointin theconversation.
date answer,he asksifRobertis "hopingthat The doctor then offersa contrastive
(he'll) get better" (line 181). Robert and assessment,askingif Roberthas considered
Katherineprovideresoundingly positivereac- the possibilitythathe "mightno:t (0.5) get
tions(lines 183-84),thusexhibiting a strong better"(lines 186-87).5This is similarto the
orientationto a desiredrecoveryscenario. "hypothetical questions" that Perakyla
(Recall thatat lines 64-65,Dr. T character- (1995:264-71) analyzes: When the patient
ized the surgeonsas pleased withRobert's has not namedany objectsof fearor worry,
recovery.)Now,in line 181, by offeringan as here, the physicianoffersa candidate
optimisticcandidateanswerto his previous "hostileworld."
question about Robert's future,Dr. T may
have invitedRobertand Katherineto adopt 5Noticethe use of the litotes(suggestingan affir-
mative-getting worse-by negatingits contrary-
an optimisticoutlook,whichthereby partially "not gettingbetter"), which Bergmann (1992:150)
argues is a method of alluding to delicate subjects.
4Maynard(1991:170) refersto perspectivedisplay This formulationdisplays a tacit orientationto the
invitationsas "unmarked"or "marked,"accordingto possibility of dying; if the topic were formulated
whethera queryis statedin a neutralway or favorsa more overtly (as "dying") it could be perceptibly
particularresponse. more harsh.
328 SOCIAL PSYCHOLOGY QUARTERLY
Althoughsuch a questioncan elicitan mize their importance or seriousness.
answerthatdeals withthehypothetical situ- Therefore,in a varietyof ways,the patient's
ation,Robertresiststhe premise(Perakyla talk here is consistent with the cultural
1995:315-21).He respondsthathe has had expectationsdescribed by Parsons (1951)
such "second thoughts"in previous days withrespectto the "patientrole,"in which
(lines 189,192,195), therebyproposingthat one of the social responsibilitiesof a sick
these"second" thoughtsare less significant personis to desireto recoverand to make
or less validthanhisideas aboutgetting bet- everyeffortto do so.
ter. Furthermore,Robert's generalized Nevertheless,Dr. T pursues this topic
"you" (line 198) can referto otherpeople's and produces a third component of the
also havingthese typesof thoughtswhen PDS-an announcement of the clinicalper-
dealing with serious illness, and thereby spectivein lines214-15 of Excerptld-in a
exhibitshis own reactionas relativelytypi- cautious, somewhat circuitous way. He
cal.6This is consistentwithSacks's (1984) assertshis own concernabout "that,"which
notionof"doingbeingordinary," whichsug- we take as tyingto hispreviousreferenceto
geststhatinterpreting a situationas normal "not gettingbetter,"tellingthemthathe is
and ordinary, as opposedto extraordinary or personally concerned (lines 205-206).
catastrophic,is a regularresponseto experi- Further, by reaching for and holding
ence. In Jefferson's(1984) terms,Robert Robert's hand duringthis utterance(i.e.,
may be displaying"troubles resistance." offering supportor comfort), thedoctormay
Finally,by colloquially characterizinghis demonstratenonverballythathe is broach-
thoughtsabout nonrecovery as a "series of inga serioustopic.
whatever"(line 202), Robertoffersto mini-

ExcerptId

203 Dr: Oright?


204 (3.7)
205 Dr: Cause that'ssomething thatI've been((Dr reachesto holds
206 R's hand))kindofconc-cemedabou:t.
207 (0.7)
208 Dr: I mean(0.3) I don-can'tcounttheda:ys,but(.) you'vebeen
209 in thehos:?pital
likequitea- whatthree:wee:ks:ya know
210 (1.5)
211 Dr: kinda(0.7) letsyoukno:wthat(1.0) you'rehavingsome
212 pro:blemswhenyou'reherethatlo:ng.
213 (1.1)
214 Dr: ?But?(.) I'm concemedthat(.) >you know<there'sa
215 possibilitythatthingsmightnotgo so: well:foryou:
216 (0.8)
217 Dr: So I wanttomakesurethat,I can anticipate anynee:ds
218 ((R shakeshead)) thatyoumighthaveafteryouleavethe
219 ho:.spital.
220 R: That'swonderful.
221 (2.2)
222 R: You'reso muchconcern:ed.
223 (2.1)
224 R: I reallyappreciate that.
225 (1.8)
226 R: Can'tthankyouenough.

6Also see also Kinnelland Maynard(1995) fora discussionof the use of "you" in HIV testcounseling.
BAD NEWS IN ONCOLOGY 329
By reminding themofthelengthofRobert's bluntlyinforming Robert of his condition
hospitalstay (lines 208-209), Dr. T impli- and moregently"forecasting" thenewsand
cates Robert's and Katherine's common- helping him to "calculate the news in
sense knowledge,suggestingthatsuch long advance of its finalpresentation" (Maynard
stays generallyindicate serious problems 1996:109).
(lines 211-12).7Robertmeanwhileremains When Robert and Katherine remain
silent. silent(line213),Dr.T proposesan upshotor
The doctor'stalk in thisinstancefunc- completionof the syllogismby once more
tionsas something similarto an incomplete usinglitotesand tellingthecouplehe is con-
syllogism(Gill and Maynard1995); such a cernedthat"there'sa possibility thatthings
turnorganizationoccurs frequentlyin the mightnot go so well" for Robert (lines
deliveryof diagnoses,to parents,about their 214-15). Again,the doctorcautiouslyshifts
developmentally disabledchildren. Clinicians fromallusiveto moreexplicittalkabout the
providethefirsttwocomponents ofthesyllo- futureas Robert and Katherine'ssilences
gism,suggesting, forexample,that(1) people disaffiliatewiththe delicatetopic of death
withmentalretardation exhibitsymptoms x, and dying.
y,and z and (2) the parents'child exhibits Afterthisseries of turnsand silences,
symptoms x,y,andz. Clinicianstherebyinvite the doctorshiftsthe focusof his talk from
parentsto completethe syllogismby infer- thepossibility of nonrecovery to theimpor-
ringthattheirchildhas mentalretardation. tanceof palliativetreatment, allusivelyindi-
In the presentcase, the doctorsets up the catingthathe wantsto be surehe can "antic-
firsttwopartsof thesyllogism bynotingthat ipate any needs" (line 217) Robert might
(1) Roberthas been hospitalizedforthree have after he leaves the hospital (lines
weeks(lines208-209),and that(2) suchlong 218-19).Also,in contrastto thelongsilences
hospitalizationsgenerallyindicate serious following thedoctor'stalkin thefourprevi-
problems(lines 211-12). Formally,Robert ous utterances,Robert now takes several
may be invitedto completethe syllogism, turnsof talk, respondingto the doctor's
withoutits beingstated,by concludingthat
statementof concernby fashioning a series
he has serioushealthproblems.
ofgratuities (lines220,222,224,226).
An ambiguitymay be present here,
Our analysisofthisdoctor-patient inter-
however.The extentto whichthe seriesof
view is consistentwith Dr. T's own later
"you"s in lines211-12 refersto the general
reflections.Recall fromourdiscussionofthe
population ("lets one know one is having
data and methodsthatDr. T had feltawk-
problems ... ") as opposed to Robert specif-
ward duringthe interview.In addition,he
ically ("lets us know you're havingprob-
remarkedthathe was "trying"to findout
lems . . . ") is unexplicated. Insofar as Dr. T
uses "you" in a generalizedfashion,he may what Robertknewabouthisillness:
be employinga syllogistic construction. On But Robert,he sortof had his ownagenda
the otherhand,insofaras Dr. T is referring insteadand almostat timeswe weretalking
to Robert in particular,he accomplishes about different things.Whichin partmay
something that is more direct than an have been because he wantedto avoidtalk-
incompletesyllogism.Withthis utterance, ingaboutwhatI wantedto talkabout.So it's
Dr. T appears to walk a fineline between not thatunusualthatthingsare awkward.
BecauseI don'tthinkit'sveryeasyto talkto
7An ironic parallel exists between Robert's and people aboutdyinganyhow, and neverwill
Dr. T's rhetorical arguments in this conversation be. But in thatcase it was probablya little
(lines 189-99 and 206-10, respectively).Whereas Dr. MORE awkward thanusualbecauseI really
T cites commonsenseevidence consistentwithnon- didn'tsee thatI wasgetting anywhere.
recovery,Robert (lines 189-99) provides common-
sense evidence for recovery.Althoughhe admitsto Our analysisdemonstrates how Dr. T could
havinghad transitory thoughtsabout not recovering, have sensed that the patient "wanted to
he casts these ideas as typical for someone in his
position. Each participant uses "you" as a way of
avoid" talkingabout his illness trajectory
invokingwhat any competentactor could know or and thattheywere "talkingabout different
believe. The doctorattributes
things." the avoidance
330 SOCIAL PSYCHOLOGY QUARTERLY

of the topic of impending death to the suffersfromleukemiaand, withhis wife,is


patient,but our analysissuggeststhatsuch visitingtheclinicas an outpatient.
Although
resistanceto delicatetopicsis also achieved David respondsto Dr. T's proposalsabout
interactionally.Dr. T employeda succession discontinuing treatmentby remainingstoic
ofquestionsthatprogressively can moveto a and largelysilentduringthe conversation,
fullerdiscussionof the "dreaded issue" of Dr. T neverthelessmeetswithmodestsuc-
death and dying (Perakyla 1995). cessin deliveringthenewsas he worksto co-
Nevertheless, in theirrepliesto Dr. T's ques- implicateDavid in thedecisionto discontin-
tions,the patientand his partnerglossed, ue thechemotherapy.
shifted,and movedto close the topic.In the The beginningof the encounteris occu-
end,Dr. T also alludedto butdid notformu- pied withconcernsabout David's shortness
late explicitly
a concernwithRobert'sdying ofbreathand anemia.Dr. T marksan impor-
and death. tanttopicshiftwithhis use of "well" (line 1
of Excerpt2a) (Sacks 1992:773)to introduce
DAVID: LIMITED UNPACKAGING OF hisown"known-in-advance" agenda(Button
THE GLOSS and Casey 1984).
The patientin thisconversation,
David,

Excerpt 2a

1 Dr: Well.(0.3) I'm gladyoucamein causeI didwanna(0.4) ((Dr


2 nods))talk-talktoyouaboutuh,a- fewthings::
3 (1.2) ((D nods))
4 Dr: I knowwhenyouwerein theho:spitalwe wereon thefence
5 aboutwhether to: (1.0) considersomemore((D nods))
6 chemothe:rapy .hhhhhhapd hhhhI thought itwas worthwhile
to
7 see howyoudidatho::meandhowyoufel::t.
8 (0.2) ((D nodsslightly, gazes in tohislap))
9 Dr: .hhhhhum(2.0) Myfeelingis: that(0.9) at Ithispoint
10 Tprobably thechemotherapy ((Dr nods))wouldn'tdo (0.6) you
11 muchgood.
12 (0.6)
13 D: >it won't?<
Dr. T proceedsto reviewa previousconver- ment(lines3 and 8) precedingDr.T's assess-
sationwithDavid concerning hischemother- mentdisplays"receptiveness" (Heath 1984)
apy treatment(lines 4-7, 9-11), and offers to David's participation and is consistent
his own assessmentthatthe chemotherapy with the cautiousness demonstrated in typi-
"wouldn'tdo muchgood" (lines10-11). cal PDS series.Furthermore, David's non-
This episode differs
fromthe othertwo verbal responses (head nods) in lines3 and 8
we consider(Robertand John)in thatDr. T demonstrate that he is tracking and respond-
offershis own assessmentof thechemother- ing to the doctor's extended turnof talk.
Afterprovidinga second opportunityfor
apy withoutofferinga perspectivedisplay
David to respond(line 8), thedoctormoves
invitationto the patient.Some elementsof
into his own assessmentof the prognosis,
the conversation,however,are consistent
whichimpliesthat the treatmentat home
with the PDS organization,For example, has notworkedwell.
although Dr. T does not explicitlysolicit At lines9-11,Dr. T proposesa courseof
David's assessmentof chemotherapy treat- action.Notice thathe characterizes the rec-
ment,his talkbeforelines9-11 is grounded ommendationas a "feeling,"a subjective
largelyin topicsthathe claimshe discussed evaluation,ratherthanas an objectiveclini-
previouslywithDavid. Further, theseriesof cal fact.He further mitigatestheforceofhis
"transition relevance places" (Sacks, recommendation withthreequalifiers:"at
Schegloff,and Jefferson 1974) in this seg- Ithis point,"" probably"and "muchgood"
BAD NEWS IN ONCOLOGY 331
(lines 9-11). He also nods in an affirmative Aftera silence(line 12), David produces
way.Finally, thesuggestion thatchemothera- a requestforconfirmation. The querying into-
pywouldbe undesirableis placedat thevery nationof "it won't?"(line 13) possiblyindi-
end oftheutterancein a "dispreferred" fash- catessurprise,
andmayoccasiontherelevance
ion, displayingthe caution withwhichthe of a justification fortherecommendation. Dr.
news is being broached (Pomerantz1984). T respondsto David's questionby suggesting
By noddingwhilehe deliversthisnews(line thatcontinuedchemotherapy actuallycould
10), Dr. T may be solicitingan accepting harmhimbecauseoftroublesome sideeffects
responsefromDavid. (lines14-15,17-21inExcerpt2b).
Excerpt2b

14 Dr: .hhNo ((Dr shakinghead)) I don'tthinkso=I thinkitcould


15 possiblydo yousomeha.rm((Dr nodding, D nodsslightly))
16 (0.2)
17 Dr: .hh?um?becauseit-itdoes havesi:deeffects thatwe've
18 ta:lkeda?bou:t?.hhh((D looksawayfromDr)) and(0.6) >I
19 thinkit< (.) ((D returns
gaze toDr)) m:ightbe a goodidea:
20 N:OT ta (.) presson withthechemotherapy treatment.
21 ((D looksawayfromDr))
22 (2.7)
23 D: 'How can youkeep-sp-?(0.4) how((D motionstohimself))
24 can yougetbetter then.
25 (0.2)
Again,Dr.T mitigates hisassertionbyclaim- press on") (lines 18-20); afterthis,David
ingthathe does not"think"thechemothera- turnshis gaze away again,remainingsilent
pywillhelp. for2.7 seconds(line22).
Through his talk, Dr. T works to co- When he speaks (lines 23-24), David
implicateDavid in thetreatment decisionin returnsto the earliertopicof discontinuing
twoimportant ways.First,he uses theinclu- the treatment.By askinghow he will "get
sive "we" whentalkingabout beingon the better"ifthechemotherapy is discontinued,
fence(line 4 in Excerpt2a) and havingdis- David may be challengingDr. T's recom-
cussed side effects(line 17 in Excerpt2b). mendation on the basis of commonsense
Second,insofaras the decisionto discontin- assumptionsthatpropermedicaltreatment
ue chemotherapy is based partially on focuseson a cure,and solicitinga forthright
knowledgethathe purportedly shareswith prognostic assessment.
the doctor about harmful side effects In a way thatis organizationallysimilar
(Excerpt 2b, lines 17-18), David is being to a perspective display series, Dr. T
asked to act in his own best interestby responds by using the issue David raises
avoidingtheseside effects.Dr. T nowrecom- about "gettingbetter"to help formulate his
mendsa discontinuation of thechemothera- newsdeliverythatthereis no effective treat-
py (note the litotes formulation,"not to mentforthecancer.

Excerpt 2c

26 Dr: We:ll:it-it's-it'sha:rdto-itis hardtogetbetter when


27 (0.6) youdon'thavea treatment that'seffective againstthe
28 Ica:ncer .hhhmbu:t
29 ((D gazes awayfromDr))
30 (0.2)
31 Dr: um(1.0) I would(0.4)
32 ((D returns gaze to Dr))
33 Dr: trytowork(0.3) on otherthingslike(.) yournutri:tio:n (.)
34 andmakingsureyou'regetting plentyofflu:ids:and
35 preventing infections:becausetruthfully (0.5) I don'tfeel
36 likethe(0.3) chemotherapy wouldmakemuchofan impa:ct
332 SOCIAL PSYCHOLOGY QUARTERLY
37 (0.6)
38 ((D nodsslightly))
39 Dr: on things
40 D: Uh huh
41 Dr: Make be-makethingshe-ter.
42 (1.1)

Dr.T placesthenewsthatthereis no effective mentof chemotherapy (lines 35-36), which


treatment forthecancerbehind"we:ll:,"sev- David receivesbynodding(line38).
eral repetitionsof "it's,"and "it's ha:rdto" Afterthisexchange,in talk not repro-
(lines26-28),whichagainindicatethedispre- duced here,Dr. T reiteratesthebasis forhis
recommendation. David intermittently nods
ferredstatusofthisnews.Afterthis,a contrast
and gazes awayor intohislap.Shortlythere-
marker("mbut,"line28) helpsprovidea tran-
after,he asks about "the blood transfusion"
sition to what the doctor can "try,"and (lines54-55 below),whichhe and Dr. T had
changesthe focusto palliationand the pre- discussed earlier in the interview(before
ventionoffurther problemssuchas infections Excerpt2a) as a temporary meansof allevi-
(lines33-35).Next,Dr. T reverts to hisassess- atingDavid's symptoms.

Excerpt2d

54 D: Do youthinkthebloodtransfusion ((D motionstohimself))


55 willbringitback?a little.
56 (0.5)
57 Dr: I thinkthebloodtransfusion willmakeyou.hh((Dr nodding))
58 fee:lbetteratleasttemporarily it'llgiveyoumore
59 (0.5) erbreathing spaceLtterally you'll [feel(comfor-)]
60 D: [That's(why-)]
61 That'snoteasybreathing ((D gazingawayfromDr))
62 Dr: 'Right.'
63 (0.4)
64 Dr: Um itcan'tdo anything (0.2) to:: (.) affectthe
65 leukemiadirectly butitwou:ldmakeyoufee:lbette:r. ((Dr
66 nodding))
67 (1.0) ((D gazes awayfromDr))
68 Dr: That'sprobablysomething that(0.4) is (.) worthus
69 co:ncentrating on now.Makingsurethatyou'reas
70 comfortable as possiblein-in everywaypossible.

As in his previousquestion about "getting him more "breathingspace" (line 61)8 he


better"(Excerpt 2b, lines 23-24), David's again disaffiliates
by lookingaway afterthe
queryhere (Excerpt2d, lines 54-55) ques- doctorrejectsthepossibility
of a transfusion
tionsDr. T's assertionthatthereis no effec- as a curativemeasure (line 67) (Goodwin
tive treatmentforthe cancer (Excerpt 2c, 1980). His gaze away continuesthrougha
lines 27-28), and does not acknowledgethe longperiodwhileDr. T summarizes hisposi-
preventive planDr. T had proposed(Excerpt
8David is having difficultybreathing not only
2c, lines 33-35). Dr. T respondsto David's
because the leukemiahas affectedhis lungs,but also
questionby formulating thepalliativeeffects because he is anemic;thusit is more difficultforhis
of theplan (lines57-59),dismissing thecura- blood to deliveroxygento variouspartsof his body.
tivepossibilities(lines64-65),and repeating Althoughhe is currently usingoxygen(and carriesa
portable supply),David is aware thatblood transfu-
the"feelbetter"consequences(line65).
sionsare one wayof alleviatingtheproblem.Thispar-
AlthoughDavid is receptiveto the doc- tiallyexplainshis suggestionof a transfusionin lines
tor's suggestionthata transfusion will give 54-55 and his enthusiastic
responsein lines60-61.
BAD NEWS IN ONCOLOGY 333
tionby reiterating the importanceof pallia- JOHN:EXTENSIVE, BUT ALLUSIVE,
tivecare (lines68-70). UNPACKAGING OF THE GLOSS
In thisinterview,then,Dr. T informs the
patientabouttheimminenceofhis dyingby Johnhas brain cancer and has been
recommending a discontinuation of undertreatment fora numberof years.His
chemotherapy. David's initialreactionques- symptoms recentlybecameso severethathe
tionsthe doctor'sposition;his responseto was hospitalized,and the hospitalstaffhas
the recommendationboth challenges and sincedetermined thathisbraintumoris now
allows forfurther unpackagingof the gloss untreatable.As in the interviewinvolving
thatchemotherapy is no longeruseful.Dr. T Robert,we will see a progressivequestion-
statesthatitis hardto getbetterwhenthere ing strategyby Dr. T in whichhe worksto
is no effectivecancer treatment,but that providean auspiciousenvironment forthe
palliativetreatmentand infectionpreven- discussionofthe"dreadedissue"ofdying.
tion are possible.David appears to receive Dr. T openstheinterview byaskingJohn
the news stoically and resignedly. As howhe is feelingand ifthepain he has been
Maynard(1996) argues,such stoicism, more suffering recentlyhas subsided;thisis fol-
than a psychological disposition,is very lowedbya discussionofJohn'sfeelingsabout
much an interactionalproduct.The stoic his pain medication.Excerpt3a immediately
responsemay reflectthe matter-of-fact or followsthisdiscussionof pain medication:
"reporting" fashion(Drew 1984) bywhicha Dr. T solicitsJohn'sperspectiveon leaving
physiciandeliversbad newsand avoidsstat- the hospitaland returning home.This is the
ing the upshot.In addition,however,stoic topic elicitationtactic (Perakyla 1995), in
responsiveness and gazingawaydo notelicit whicha possiblydistressing issueis broached.
furtherunpackaging ofthegloss.
Excerpt 3a

127 Dr: Uhm(.) and(.) I thinkwe weretalkingaboutyougoinghome


128 towardtheendofthis:,wee:k.=
129 J: =mmhm.
130 Dr: Do yous- do yousee: thatas (.) a- a- realisticgoal:?=
131 do youthinkyou'llf:eelup to Igoing home?(.) bytheendof
132 theweek?
133 (0.8)
134 J: I knowI would.=
135 Dr: =>uh huh.<=
136 J: =1 wouldveryInmuch liketogo homethisweek.=
137 Dr: =Oalrighto
138 (0.4)
139 J: =And (0.8) as again(2.6) it'sonlydue to that(0.9) to
140 us (0.6) .hhnottakea lottadrugs,just
(0.2) letting
141 uh (2.1) under(1.2) yersupervision

Johnrespondsenthusiastically to the possi- 3b, line 163, he then suggestsa returnto


bilityof returninghome (lines 134 and 136) John'sassessmentof his situatioliby posing
and initiatesa secondforayintothetopicof a perspectivedisplayinvitationconcerning
pain medications(lines 139-41;further talk how he thinkshe will "manage" at home.
on medicationsis omitted(lines142-62).Dr. This is a second step,whichretrievesthe
T reassuresJohnthathis medicationneeds "goinghome"issue(Perakyla1995:262).
willbe metby the hospitalstaff.In Excerpt

Excerpt3b

163 Dr: How do youthinkyou'llmanagewhenyougetho:me.


164 (2.8)
334 SOCIAL PSYCHOLOGY QUARTERLY
165 J: In whatway.
166 (0.5)
167 Dr: Uhm.(0.3) tchhDo youthinkit'sgonnabe (0.2) difficult for
168 you?
169 (0.2)
170 J: NO. (0.2) No I don't..hhhI've hadwaytoomuchexperience in
171 this:as youknow=
172 Dr: =mmhm
173 (0.9)
174 J: Anduh (2.8) andas Daphneknows,it'sjust(2.0) frommy
175 expe:riencein this(1.3) typeof(0.3) problemI won'thave
176 anyproblem(.) takingcareofit.
177 (1.4)

Notice how Johnrespondsat line 165: He as a reasonwhyhe won'thave difficulties at


asks the doctor"In what way,"whichsug- home (lines 170-71).Johnfurthersuggests
gestsa lack of specificity
in the perspective that his perspectiveon the illness is well
The requestforspecificity known to Dr. T ("you," line 171) and to
displayinvitation.
obtainsa "hypothetical question"(Perakyla John'swife,Daphne (line 174),whoare both
1995:271)fromthephysician, whichposes a awareofhis"experiencein thistypeofprob-
"difficult"homesituation(line 167) forJohn lem"and in "takingcare of it"(lines176;our
to consider. In his two queries, with the emphasis). So far, then, physician and
glosses"managingat home" (line 163) and patienthave produced general and vague
"it's gonna be difficult"(line 167), Dr. T references to "managing,""difficulty,"
"this,"
invites"unpackaging"talk thatcould open "problem,"and "it."
the topics of cancer and dying. But in ImmediatelyafterExcerpt3b, in lines
response(line 170) to Dr. T's secondquery, 178-82(Excerpt3c), Dr. T introducesanoth-
Johnproducesan emphatic"NO"; thenhe er'query;he now refersto the "melanoma,"
repeats the rejection ("No I don't") and the "illness," and "how it's affecting"his
citeshis "experience"in dealingwith"this" patient.

Excerpt3c

178 Dr: Do youhavea senseof(0.6) wh:at'shappening with


179 the(.) melanoma?
180 (0.2)
181 Dr: Whattheillnessis do:ing:r-right
now,howit's
182 affecting you?
183 (2.6)
184 J: Yeah,I havea senseofitferSURE=
185 Dr: =mmhm
186 (0.6)
187 J: Absolutely.
188 (0.4)
189 J: Uh::. (0.2) Doesn'tmakeitanyeasier
190 (0.2)
191 Dr: Mhmm
192 (0.6)
193 J: Butitgivesme a senseofkno:wingwhat'sgoingon.
194 (1.0)
195 Dr: ?Mmhm.okay.'
196 (1.0)
197 J: ?Uh?which:is: VERy important to Ime=
198 Dr: =?Uhuh?kno[wi]ng=
199 J: [uh]
BAD NEWS IN ONCOLOGY 335

200 Dr: =what'sgoingon=


201 J: =knowingwhat'sgoingon. an-((clearsthroat)).tchhI think
202 that'sextREMelyimportant.
203 (-)

By line 179 the earlier,vague references instance,thepriortalkcontainsseveralpos-


become available,at least retrospectively,
as sible referents of "it," including each
possibleeuphemismsthatallude to "what's euphemisticsegmentof the three-partlist,
happeningwiththe melanoma,"althougha thelistas a whole,and/ortheallusiverefer-
termsuch as melanoma may stillbe cautious ent of the list.Hence we arguethatthe use
in itselfbecause it is more technicalthan ofa tyingterm(suchas "it"or "that"),when
"cancer," for example (Coombs and the candidate referentsto whichthe term
Goldman 1973). Although Dr. T refers ties are euphemistic and allusivein thefirst
explicitlyto melanoma,his uses of "what's place,is a resourceforspeaking(or continu-
happening," "whatthe illnessis doing,"and ingto speak) euphemistically and allusively.
"how it's affecting"his patientcan all be In otherwords,a clinician'sperspective
glossingand euphemizing thedyingprocess, displayinvitations, particularlywhen they
and mayalludeto itcollectively as well. are progressively "coercive" (Perakyla
These phrasesare partof a turnat talk 1995:285-86),can elicita replythatis specif-
thatcomprisesa three-part list.As Jefferson ic enoughto create an auspiciousenviron-
(1990:79-81) argues,speakers can employ mentforthe clinician,in the thirdturnof
three-partlists to accomplisha varietyof the series,to furtherdesignatethe clinical
interactionaltasks,such as movingfroma view of diagnosisor prognosisand further
prior topic to an event that is of "focal" name "whatis goingon" (Maynard1991).9
importanceto a speaker,or introducing, in Such an environment is not actualizedhere,
the thirdpositionon the list,a matterthat however.At line 187 Johnemphasizeshis
might"offend"a co-participant. Noticehow claim of understanding ("Absolutely")and
Dr. T's listprogressesfrom(1) "what'shap- then produces the "it" termtwice again:
peningwiththemelanoma"to (2) "whatthe whenformulating a complaintabout his dif-
illness is doing" to (3) "how it's affecting ficulty(line 189) and whenproducinga con-
you."Parts(2) and (3) are producedaftera trasting, "brightside" characterization (line
clear pointof turntransition (line 180) and 193). If Dr. T is usingeuphemismand allu-
otherpossibleopportunities forturntransi- sion to
approach the topic of death and
tion (afterthe stretched"do:ing"and after
"rightnow"(line 181).Accordingly thelistis
assembled interactively:Dr. T moves cau- 9A patientcan respondexplicitlyand specifically
tiouslyfromreferencing the illnessas spec- to a perspectivedisplayquery,as can be seen in this
tacle,to formulating its disembodiedoffen- patient'snarrativeabout receivingthe news of her
sive activity,
to mentioning Johnas a direct cancer. We have numbered the three parts of the
perspectivedisplayseries:
objectof thatactivity,and the last itemis a
potentially moreindelicateformulation than He [the doctor]let me get dressed,thenhe sat
the firsttwo.The progressioninvolvesfor- me down,held myhand,and (1) asked me what
mulationsthatplace theillnesscloserto the I thoughtwas wrong.When (2) I said "cancer,"
(3) he said thatI was rightbut thatI shouldn't
patient,movingin a directionthatpotential- feel too worriedas thelump was verysmall and
ly formsan auspicious environmentfor there wasn't any lumpiness under my arms,
unpackaging theseglosses. whichis a good sign. (Fallowfield1991:44;our
In response,however,Johncontinuesto emphasis)
be euphemistic. At line 184 he claimshe has After the doctor asked her "what" she thought
a "senseofit"(our emphasis).In typicalcon- was "wrong,"thepatientsaid "cancer."In thepresent
versation,"tying"an utteranceto a preced- data, Dr. T has already broached the cancer term
("melanoma"). The issue he poses is what the
ingone throughtheuse of"pro-terms" such
melanoma is doing to John,who claims to have a
as itis a regularwayofprovidingcoherence "sense" of "it" but does not say or demonstratewhat
in the talk (Sacks 1992:150-68). In this his sense is.
336 SOCIAL PSYCHOLOGY QUARTERLY
dyingcautiously, and to obtainspecifictalk the organizationof the perspectivedisplay
fromJohnabout his illness,he has not suc- series (wherein news is provided after a
ceeded. Instead of explicitlydiscussinghis recipient'sanswerto theoriginalquery),the
sense of the cancer,how it is progressing, conversational environment,even ifit is not
and whathe anticipates, Johnhas made his auspiciousin the sense thatthe patienthas
ownuse ofeuphemismand allusion. unpackagedDr. T's allusionto dying,impli-
At thispoint(line 195),Dr. T acknowl- catesan informing byDr.T.
edges John'sclaim of having "a sense of As Dr. T delivershis news,he and John
knowingwhat'sgoingon,"afterwhichJohn alignto the idea thatthe cancerpotentially
emphasizesthe importanceof thisknowl- could worsenafterhe leaves the hospital.
edge (line 197).Dr.T thenproducesa clarifi- Notice below how Dr. T startsthe delivery
cation request (lines 198, 200), repeating (Excerpt3d,lines204-207)byformulating his
John'sphraseas a candidatehearingofwhat taskin termsthatJohnhas justused,thereby
is "important." John confirmsthis with proposingto affirm therelevanceof his own
another emphasized repetition at lines forthcomingtalk. Dr. T then reviews the
201-202.Johnhas now "answered"Dr. T's "facts"of John'scase,characterizing
his cur-
originalquery(lines181-82):Thatanswering as moreseriousthanearli-
renthospitalization
is accomplishedinteractionallyby Dr. T's er ones (lines209-11and 213-14);Johnpro-
producingcontinuers(lines 185, 191, 195) videscontinuationtokens(lines212and216).
and silencesthatinvitefurthertalk.Given
Excerpt 3e

204 Dr: Mm hm.(0.6) Alright. (0.5) .hhhwellone thingI wantedtodo:


205 (.) toda:yis ta makesureyouknowwhat'sgoingon = I knowwe
206 onlymeta fewda:ysago (.) bu:t.tchI feelit'simportant
207 thatyouhave>ya know<all ofthefa:cts.
208 (0.9)
209 Dr: .tchhUhm.(0.2) 1 think(.) pro:bablythis:um(1.5) ifyou
210 haven'tspenta lo.toftimein thehospitalexceptforyour-
211 your-yourtreatments.=
212 J: =Mm hm.
213 Dr: Thisis thefirst timeI thinkthat(.) you've(0.2) comein
214 justbecau:seoftheillnesscausingsomesymptoms 4-foryou.
215 (0.4)
216 J: Mm hm?
217 (0.4)
218 Dr: ?Alright? .hhhh Andwhatmyconcernis is that(0.9) uh as time
219 goes byL(.) thattheremaybe mo:re(0.4) problemsthatthe
220 melanomacauses,moresymptoms (0.7) orthatitmightaffect
221 your-yourbodymorethanit'sdoingevenno:w.
222 (1.8)
223 J: Mmhm?(1.1) I agreewiththat

Dr. T subsequentlystateshis own concern In Excerpt 3e below,Dr. T goes on to


thatJohn'shealthmay continueto deterio- informJohnthatthe doctorscan no longer
rateevenbeyondhiscurrent theycan only
condition(lines treatthe cancer effectively;
218-21).At line223 Johnproducesa delayed treathissymptoms (lines224-233).
response, which claims agreement and
enablesDr. T to forgeahead.

Excerpt 3e

224 Dr: .hhhI knowthatyou'vehad a lotof(.) different


treatments=
225 s- someofthemare(.) v:e:rystateofthea:r:t.
BAD NEWS IN ONCOLOGY 337
226 (0.9)
227 Dr: Um butitsee:msnowthat(0.3) we mighthaveto s:w:itch
228 gears(0.2) and(0.4) workon treatments: (0.4) that(0.3)
229 helprelieve(0.4) or(0.6) improvethecomplications ofthe
230 cancerlikepai:noranyothersymptoms thatitmightcau::JIse
231 .hhhbecau:seit'sveryhardforme: ordoctorterrieto
232 identify anytreatmentin par:(.)ticular
to attackthecancer
233 directly.=
234 J: =Mm hm.
235 (1.3)
236 Dr: Thatmaybe something thatyouwerea- awareofbefo:re.
237 ((nodding))=
238 J: =Mm hm.
239 (1.4)
240 Dr: ?Um?(0.3) andI thinkwe can do a goodjo: of(0.3) keeping
241 youpretty painfree:orifthereareanyothersymptoms that
242 themelanomacau:sesorrelieving- ((Jshiftsposition))
243 relieving thatmakeyoufeelbe:tter
244 (-)
245 J: ?Mm?
246 Dr: Bu:t (0.7) tchhuhmm(0.6) we haveaftera lotofthought
247 we haven'tcomeup withany(.) trea:tment forthemelanoma
248 its:e:1[f]
249 J: [r]ight
250 (2.4)
251 J: I unfortunately am quiteawareofthatmyself.
252 (0.6)
253 Dr: Mmhm.

Dr. T accountsforhis decisionby implying In the above segments,across Dr. T's


thatJohn's"stateoftheart"treatments have invitations and queriesto John,we can track
been unsuccessful (lines224-25),and impli- a particulartopicaltrajectory of the physi-
cates anotheroncologistin the decisionto cian. He moves fromqueries that do not
stop treatment(lines 231-33) (Anspach markedlypose any problem (Excerpt 3a,
1988).In response,Johnprovidesa minimal lines127-28and 130-32),to a markedquery
acknowledgment (line 234). Dr. T (line 236) that proposes the possibilityof difficulty
offersan interpretation of thisacknowledg- (Excerpt3b,lines167-8),to an explicitmen-
ment,suggestingthat it mightindicate a tionof"melanoma"and "theillness"and its
priorawareness,whichJohnconfirms(line "affecting" John(Excerpt3c). At thispoint
he also produces a euphemisticthree-part
238). NextDr. T reformulates his deliveryof
listthatmayalludeto John'sdying.
thenews(240-43),suggesting thatthey"can
Although retrospectively it can be
do a good j" of pain control.AfterJohn's
appreciatedthatDr. T is pursuinga particu-
quietacknowledgment (line 245),Dr. T pro- lar agenda,theseinvitations and queriesare
duces anotherversionof the message that producedin real time.Thus,a recipientcan
theycannot treat the "melanoma its:e:lf" orientto themas independentof any agen-
(lines 246-48). Again,Johndisplaysagree- da. When John answers these queries
ment(line 249) and stateshis"unfortunate" (Excerpt3a, lines134,136;Excerpt3b,lines
awareness"of that"(line 251). Notice that 170-71, 174-76; Excerpt3c, lines 184, 187;
both times,Johndisplaysagreementwith etc.),he appears to deal onlywiththe pre-
Dr. T and does not furtherexplicate or cedingquestions.This appearancemaybe a
expand topically.Thus the overallmessage feature of a more general strategy for
hereis one about stoppingthe cancertreat- euphemisticand allusivetalk;it is possible
mentand starting paintreatment. thatJohnperceivesthetrajectory thatDr. T
338 SOCIAL PSYCHOLOGY QUARTERLY
pursuesbutdoes notrevealthatunderstand- lyzed in the precedingexcerpts,Dr. T can
ing throughhis talk. His agreementwith vernacularly characterizehow his "message
proposals about cancer versus pain treat- gets through"as part of the "nonverbal"
ment suggests extinguishingrather than communication between physicians and
expandingthe topicor otherwiseunpackag- patients.
ingpreviousglosses.
By wayofthePDS, thenewshereis pre- DISCUSSION
sentedin a cautiousand affiliative way.Dr. T
engagesqueriesthateuphemistically
initially Whereaspreviousresearchon deathand
solicitexpressionsof anticipateddifficulties dying focusedon individualperceptionsand
and painfulsymptoms due to a now-untreat- abstractions about patient-practitioner com-
able cancer. Although John is also munication, we examine the actual interac-
euphemisticin his replies,he nevertheless tionin whicha physicianattemptsto inform
provides opportunitiesfor Dr. T to move patientsof theirprognoses.We findthatthe
forwardwithmoreexplicitreportsaboutthe conversationaltrajectoriesin our data are
stateof the disease,the effectsit will have, highlycontingenton the activitiesof the
and the shiftfromcurative to palliative physicians,the patients,and the patients'
treatment.That is, the physicianbecomes familymembers.Across conversations, the
progressively less allusiveand moreexplicit physician in our data exhibits interactive
as Johnprovidesdisplaysof understanding; cautionin discussingdeath and dyingwith
these displays,althoughalso euphemistic, the patient.Throughthe use of a PDS, and
permitDr. T's stepwise movement.As a througha progressivequestioningstrategy
result,thedoctorand thepatientseemmore thatcan providean auspiciousenvironment
attunedto one anotherthanin eitherof the forpatients'talkabouta dreadedfuture, Dr.
otherinterviews to thenewsthatthecancer T attempts to solicitpatients' perspectives
can no longerbe treated. about theirsituationsbeforeprovidinghis
Once again, our analysis is consistent own assessment.He does not succeed fully
withDr. T's subsequentcomments: in overcoming his patients'resistance,but
once patients give their opinions, Dr. T
I thinkveryoftenin whatever waypossible works to fithis clinical perspective with
there'sa lot of nonverbalcommunication thoseassessments.
betweenphysicians who'vegottento know The patients'responsesstronglyaffect
theirpatientswell and the patientsthem- the course of the news
delivery.Although
selves.So thatsometimes I thinkthatwhenI
Dr. T beginsthe conversations withglosses
come in and talkto thepatientabout one
thingtheyactuallyunderstand thatI'm talk- about the patients' situations,the extentto
ingto themabout something else. And so which the glosses are unpackaged is contin-
that,butsomehowthemessagegetsthrough gent on conversational practices that
... veryoftenpatientsand theirfamilies impede or facilitatethe the delivery of the
knowexactlywhat'sgoingto happen,or news.Robert and Katherine,forexample,
almostknowexactly, yetthere'ssomevalida- by introducing competingtopicsof conver-
tion when the physiciantells themthat sation, declining invitations to provide
again. Sometimesit's a sense of relief,or moredetailedinformation, and beingsilent
some sense of confirmation.I met with at particularjunctures, eventuallyderailthe
John'swifetoday, andthat'sexactly whatshe doctor'seffortsto topicalizeRobert'snon-
said to me. She said, "Well we knewthat recovery. David, who appearsstoicthrough-
that'swhatyouweregoingto say,butwe still out his interaction with the physician,
neededto hearyousayit,"whenI was talk- avoids discussingpalliativecare but never-
ingto herabouthowlonghe mightlive or thelessenables thedoctorto unpackagethe
whatwasgoingto happennext.So that'sone
gloss and deliverthe news thathe will no
thingI've observedis thatoftenthepatients
longer receive chemotherapy.John and
knowwhatto expectbutstilltheyneedto or
theywanttohearyousayitas thephysician. Daphne respondto Dr. T in a waythatper-
mitsunpackaging"what's happeningwith
In short,because of a tacitunderstanding of the melanoma," although this is done
the practiceswe have identifiedand ana- througheuphemisticand allusive talk. In
BAD NEWS IN ONCOLOGY 339
each of these instances, the recipients' damental social componentto talk about
responses to the physician's cautious "dying" and "death." This component
approachesenterinto the trajectory of the residesin theinteractional and collaborative
conversationand help to shape just what assessments made between doctor and
information is conveyedby affecting how it patient,whichare some distancefromthese
is delivered. moregraphicterms.
In his extensive ethnographicstudy, Accordingly, a physician'sconveyance
Sudnow (1967:63-64) suggeststhat,even of newsto a patientabout dyingand death
whendeathmaybe imminent, "dying"does may lack direct reference to a putative
not standas a properanswerto a patient's organic state. Instead, it may comprise
question"what'swrongwithme?" Disease sequencesof talkthatbroachan unpackag-
categories and descriptionsof symptoms ing of the news.How farthatunpackaging
may,and do, serve in the place of "dying," can go depends stronglyon the patient's
even though the notion of a patient's responsesto the physician'sinitiatives. And
"dying"furnishesmedicalproviderswitha even whenthepatientfacilitates ratherthan
schema for caringfor that person. In our resiststhe unpackaging,both parties may
data,althoughthedoctorpresentedas a fact retainallusive and euphemisticstances in
to the researcherthat the three patients whichdyingand death are not mentioned
were in the last stagesof theircancersand It is notonlythatdyingand death
explicitly.
were dying, he did not say this to the are everyone'sindividualinevitability, then;
patientsstraightforwardly.Insteadhe talked these"states"enterinto actionsand activi-
about goinghome,hospice,not continuing tiesthatare profoundly social in theirorga-
chemotherapy, relievingpain, and the like. nizationas patientsand theirfamilies, along
In circumstances thatare not,once and for withtheprofessionals whoservethem,come
we can see a fun-
all,biologicallydefinitive, to "realize"thebad news(Maynard1996).

Appendix.Transcribing conventions(From Gail Jefferson,"ErrorCorrectionas an Interactional


Resource,"Language in Society2:181-199,1974)
1. Overlapping speech Lefthandbrackets marka pointofoverlap,while
A: Oh youdo? R[eally righthandbrackets indicatewhereoverlapping talk
B: [Umhmmm] ends.
2. Silences Numbersin parentheses indicateelapsedtimein
A: I'm notuse ta that. tenths ofseconds.
(1.4)
B: Yeahme neither.
3. Missingspeech Ellipsesindicatewherepartofan utterance is left
A: Arethey? outofthetranscript.
B: Yes because...
4. Soundstretching Colon(s)indicatethepriorsoundis prolonged.
B: I didoka::y. Morecolons,morestretching.
5. Volume indicateincreasedvolume.
Capitalletters
A: That'swhereI REALLY wanttogo.
6. Emphasis Underline indicatesincreasedemphasis.
A: I do notwantit.
7. Breathing The "h" indicatesaudiblebreathing. The more
A: You didn'thaveto worryabouthavingthe.hh "h's" thelongerthebreath. A periodplacedbefore
hhhcurtainsclosed. itindicatesinbreath; no periodindicatesoutbreath.
8. Laughtokens The "h" withina wordor soundindicatesexplo-
A: Tha(h)twas reallyneat. siveaspirations;
e.g.,laughter,breathlessness,etc.
9. Explanatory material Materialsin doubleparentheses indicateaudible
A: Well((cough))I don'tknow phenomena otherthanactualverbalization.
10. Candidatehearing Materialsin singleparentheses indicatethattran-
B: (Is thatright?)( ) scribers werenotsureaboutspokenwords.If no
wordsareinparentheses, thetalkwas indecipher-
able.
340 SOCIAL PSYCHOLOGY QUARTERLY
11. Intonation. A periodindicatesfallin tone,a commaindicates
I Thada threepointsix?
A: It was unbelievable. continuingintonation,a questionmarkindicates
I 4Ithink. increasedtone.Up arrows(t) ordownarrows(41)
B: You did. indicatemarkedrisingandfallingshifts in intona-
tionimmediately priortotheriseorfall.
12. Soundcutoff Dashes indicatean abruptcutoff ofsound.
A: This-thisis true
13. Softvolume Materialbetweendegreesignsis spokenmorequi-
A: 'Yes.' That'strue. etlythansurrounding talk.
14. Latching Equal signsindicatewherethereis no gap orinter-
A: I am absolutely sure.= val betweenadjacentutterances.
B: =You are. Equal signsalso linkdifferent
partsofa speaker's
A: Thisis one thing[thatI= utterancewhenthatutterance carriesoverto
B: [Yes? another transcriptline.
A: =reallywanttodo.
15. Speechpacing Partofan utterance deliveredat a pace fasterthan
A: Whatis it? surroundingtalkis enclosedbetween"greater
B: >1 ain'ttellin<you than"and"less than"signs.

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Karen Lutfeyis a doctoralcandidatein theDepartment ofSociologyand a predoctoral


fellow
in theNIMH Training Programin Social Psychologyat Indiana University,
Bloomington.Her
researchinterestsincludemedicalsociology,sociologyof mentalhealth,and languageand
interaction.
She is currently
researchingpatientcompliancewithdiabetestreatment
regimens.

Douglas Maynardis ProfessorofSociologyat Indiana University,


Bloomington. He currently
researchesbothbad newsand good newsin conversation and thedeliveryof diagnosticnews
in medicalsettings.
He also is working
collaboratively
on interaction
in thesurveyinterview.