Three Studies of the Communication Ecology of Advance Care Planning

Abstract

Using an ecological perspective, this dissertation focuses on personal and communicative factors affecting advance care planning. It situates and studies the process of advance care planning within three different contexts: an individual, cognitive context, the familial context, and the clinical context. Study One focused on beliefs and attitudes toward advance care planning using a survey that was completed by patients and their family member healthcare surrogates. The study found differing degrees of concordance for different measures of advance care planning preferences. Concordance ran from fair to good for measures of patient priorities and attitudes toward advance care planning, while concordance was low for decision-making preferences and goals. The study also found that patient perceptions of surrogate openness to talking about death predicts concordance across all but one measure. This finding provides a basis for arguing that interventions targeted exclusively at patients should also focus on surrogates. The study finally connects family communication environment types to concordance scores. Pluralistic family types, which value open communication and free thinking, are associated with improved concordance across two measures.

Study Two uses a qualitative approach to focus on the way family communication environment types can be used to classify family attitudes toward advance care planning conversation and decision-making. The analysis identifies important characteristics of these family communication environments that coordinate with the way patients and surrogates frame the problem of advance care planning, the way they discuss it, and the way they approach decision making in this context. Finally, Study Three uses a mixed-methods approach to analyze secondary data from patient-clinician interactions in a clinical setting, focusing on discursive strategies physicians and patients use during conversation about end-of-life care and decision-making strategies. It highlights a gulf between patients and physicians in terms of the advance care planning content they become more engaged in discussing. Based on ratings from outside observers, the study found that patients are more engaged when talking about surrogate decision-makers in detail, while physicians are more engaged when talking about advance care planning documents.