REVISITING THE ONTOLOGY OF SHARED DECISION-MAKING IN PALLIATIVE CARE USING CRITICAL DISCURSIVE PSYCHOLOGY

Purpose: In the field of palliative care, there is a scarcity of studies exploring how clinical conversations and interactions frame the decision-making process. The aim of this paper is to propose an ontology of shared decision-making (SDM) that differs from mainstream empirical measurements, and a methodological approach that would explicitly address the role of language use in constructing participation in decision-making about palliative care options.

Method: A narrative synthesis of different theoretical and methodological traditions of discourse analysis was produced with a critical assessment of their pertinence to the study of SDM in palliative care. A brief outline of social theory is presented to explore the critical and linguistic turns that enabled the development of discourse analysis and their impact on the ontology and epistemology of SDM. The approaches to discourse analysis reviewed include conversation analysis, critical discourse analysis, and discursive psychology.

Result: Conversation analysis focuses on talk-in-interaction and the architecture of naturally-occurring conversations, and could empirically demonstrate how the sequential order of the interaction shapes patient participation. Critical discourse analysis addresses on the way power relations are sustained through discourse and would explicitly promote social change by exposing the linguistic features of talk that hinder patient involvement and control. The aim of discursive psychology is to problematise the taken-for-granted internal dispositions of psychology and to explore the consequences of talk in justifying social practices. Discursive psychology (Wetherell, 1998) offers a synthetic approach with both technical aspects of conversation analysis and the study of larger social discourses. Adopting a critical and constructivist ontology, discursive psychology could answer broader questions than conversation analysis about the presence and absence of discourses, and address the social and political consequences of the discursive activities constructing patient participation without imposing an explicit political agenda like critical discourse analysis.

Conclusion: Rather than viewing patient preferences for participation as stable internal dispositions, a critical discursive psychology of SDM in palliative care would conceive of patient participation as a process constructed through talk in social interactions. It can contribute to address broader issues such as the respective involvement of patients and health care providers when talking about options that shape the end of life.