How the more life discourse constrains end-of-life conversations in the primary care of medically frail older adults: A critical ethnography
There is growing emphasis for primary care clinicians to initiate and engage in end-of-life (EOL) conversations with medically frail older adults. However, EOL conversations happen most often when death is imminent or are avoided altogether. The objective of this study was to understand the socio-po...
| Main Authors: | , , , |
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| Format: | Article |
| Language: | English |
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Elsevier
2022-12-01
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| Series: | SSM: Qualitative Research in Health |
| Subjects: | |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S2667321522001366 |
| _version_ | 1811199191543709696 |
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| author | Celina Carter Shan Mohammed Ross Upshur Pia Kontos |
| author_facet | Celina Carter Shan Mohammed Ross Upshur Pia Kontos |
| author_sort | Celina Carter |
| collection | DOAJ |
| description | There is growing emphasis for primary care clinicians to initiate and engage in end-of-life (EOL) conversations with medically frail older adults. However, EOL conversations happen most often when death is imminent or are avoided altogether. The objective of this study was to understand the socio-political forces shaping EOL conversations between clinicians, medically frail older adults and/or their care partners within an urban primary care setting, a Family Health Team in Ontario, Canada. We conducted an eight-month critical ethnography in 2019 involving observations and interviews of clinicians, patients, and care partners (n = 35). Analyzing this data for discourses and power-knowledge systems we found that two discourses, frailty and more life shape EOL conversations in this setting. More life discourse disrupts EOL conversations by making it more difficult to talk about decline and dying as well as personal goals. Biomedicine and clinical practice guidelines comprised the two major power-knowledge systems that increase the influence of more life in this setting as well as the norm of seeking longevity. Improving EOL conversations is complex and requires addressing the power-knowledge systems that perpetuate more life as well as a discursive shift towards prioritizing relationships and people's life worlds. Primary care as a specialty can critically reflect on the ways it is entrenched in a culture of care that valorizes more life and (re)create clinical practice guidelines and evaluations to align with person-centredness more meaningfully. Future research should involve patients, care-partners, and interprofessional clinicians to co-create approaches to care that can better accommodate frailty talk. |
| first_indexed | 2024-04-12T01:43:51Z |
| format | Article |
| id | doaj.art-4be8c70fe689499d97d74a1c436158d3 |
| institution | Directory Open Access Journal |
| issn | 2667-3215 |
| language | English |
| last_indexed | 2024-04-12T01:43:51Z |
| publishDate | 2022-12-01 |
| publisher | Elsevier |
| record_format | Article |
| series | SSM: Qualitative Research in Health |
| spelling | doaj.art-4be8c70fe689499d97d74a1c436158d32022-12-22T03:53:07ZengElsevierSSM: Qualitative Research in Health2667-32152022-12-012100174How the more life discourse constrains end-of-life conversations in the primary care of medically frail older adults: A critical ethnographyCelina Carter0Shan Mohammed1Ross Upshur2Pia Kontos3Dalla Lana School of Public Health, University of Toronto, 550 College St, Toronto, ON, M6G 1B1, Canada; Corresponding author.Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, CanadaDalla Lana School of Public Health, University of Toronto, 550 College St, Toronto, ON, M6G 1B1, CanadaDalla Lana School of Public Health, University of Toronto, 550 College St, Toronto, ON, M6G 1B1, Canada; KITE-Toronto Rehabilitation Institute, University Health Network, Dalla Lana School of Public Health, University of Toronto, CanadaThere is growing emphasis for primary care clinicians to initiate and engage in end-of-life (EOL) conversations with medically frail older adults. However, EOL conversations happen most often when death is imminent or are avoided altogether. The objective of this study was to understand the socio-political forces shaping EOL conversations between clinicians, medically frail older adults and/or their care partners within an urban primary care setting, a Family Health Team in Ontario, Canada. We conducted an eight-month critical ethnography in 2019 involving observations and interviews of clinicians, patients, and care partners (n = 35). Analyzing this data for discourses and power-knowledge systems we found that two discourses, frailty and more life shape EOL conversations in this setting. More life discourse disrupts EOL conversations by making it more difficult to talk about decline and dying as well as personal goals. Biomedicine and clinical practice guidelines comprised the two major power-knowledge systems that increase the influence of more life in this setting as well as the norm of seeking longevity. Improving EOL conversations is complex and requires addressing the power-knowledge systems that perpetuate more life as well as a discursive shift towards prioritizing relationships and people's life worlds. Primary care as a specialty can critically reflect on the ways it is entrenched in a culture of care that valorizes more life and (re)create clinical practice guidelines and evaluations to align with person-centredness more meaningfully. Future research should involve patients, care-partners, and interprofessional clinicians to co-create approaches to care that can better accommodate frailty talk.http://www.sciencedirect.com/science/article/pii/S2667321522001366BiomedicalizationFrailtyDiscoursePrimary careEnd-of-life conversationsAdvance care planning |
| spellingShingle | Celina Carter Shan Mohammed Ross Upshur Pia Kontos How the more life discourse constrains end-of-life conversations in the primary care of medically frail older adults: A critical ethnography SSM: Qualitative Research in Health Biomedicalization Frailty Discourse Primary care End-of-life conversations Advance care planning |
| title | How the more life discourse constrains end-of-life conversations in the primary care of medically frail older adults: A critical ethnography |
| title_full | How the more life discourse constrains end-of-life conversations in the primary care of medically frail older adults: A critical ethnography |
| title_fullStr | How the more life discourse constrains end-of-life conversations in the primary care of medically frail older adults: A critical ethnography |
| title_full_unstemmed | How the more life discourse constrains end-of-life conversations in the primary care of medically frail older adults: A critical ethnography |
| title_short | How the more life discourse constrains end-of-life conversations in the primary care of medically frail older adults: A critical ethnography |
| title_sort | how the more life discourse constrains end of life conversations in the primary care of medically frail older adults a critical ethnography |
| topic | Biomedicalization Frailty Discourse Primary care End-of-life conversations Advance care planning |
| url | http://www.sciencedirect.com/science/article/pii/S2667321522001366 |
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