Date of Award

1987

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

First Advisor

Alan C. Acock

Abstract

A grounded theory approach guides the interpretation of observational, semi-structured interviews, content analysis, and taped discourse data collected from a 48 bed oncology unit with 288 study patients. Data are presented to explicate generated concepts of regressive intervention and the dying role. Data indicate that when physicians no longer perceive their goals of cure achievable, they distance themselves from patients. Physicians use certain devices to facilitate this gradual or abrupt, but purposeful, withdrawal from patients' curative regimens. These devices are specified in discourse transcripts as use of the medical record, silence, and alternative interactions (family members). Physician-authority, cautious optimistic conversational strategies, and patient role investment are peripheral factors related to regressive interventionary action. Accompanying physicians' efforts to disengage are expectations upon dying patients. Patients are not expected to remain dependent upon physicians, who have already, in the process of diagnosing a fatal illness, transferred them from the sick to the dying role. Having done so, doctors no longer hold a position of primary importance in patient care although they may oversee supportive and palliative treatments. This rite of passage invites and forbids independent identity at the same moment. Dying patients are expected to limit their claim on others for attention, imposing as little burden as possible, are encouraged not to verbalize certain complaints, use a minimum of medication, and rely on themselves to the extent possible. The dying person has the right to be taken care of, but the family is expected to fill these needs. The physician's and nurse's roles are reserved for more important restorative functions. The obligation of staff to maintain certain humane standards of treatment for patients presents problems in the face of institutional efficiency. In conclusion, data are presented that demonstrate specific features of biomedical interaction that display a responsiveness to patients' attempts to construct meaningful accounts of their problems and, further, to encourage the development of non-coercive discourse. These features are argued to improve the quality of care and to make physician purposeful withdrawal a decision based on norms of reciprocity rather than on authority-subordination.

Pages

306

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