Shared decision making about palliative chemotherapy: A qualitative observation of talk about patients' preferences

Background: Particularly at the end of life, treatment decisions should be shared and incorporate patients' preferences. This study examines elaboration and preference construction. Aim: To examine the values, appraisals and preferences that patients express, as well as the oncologists' communicative behaviour that facilitates these expressions in consultations on palliative chemotherapy. Design: Verbatim transcripts of audio-recorded consultations (n=60) were analysed in MAXqda10 software. Two independent coders identified and categorised patients' preference-related utterances and oncologists' utterances, preceding and following such expressions. Setting/participants: Cancer patients (n=41) with a median life expectancy <1year and oncologists (n=13) meeting with them in either initial or evaluative follow-up consultations. Results: Most frequent were patients' expressions of treatment preferences (65% of consultations), often the simple wish to have treatment. Expressions of underlying values (48%) and appraisals of treatment aspects (50%) were less common. Most preference-related utterances concerned single statements (59%); in 51% of the consultations, true dialogue was observed. Preference-related utterances were least common in follow-up consultations concerning stable disease or response. Preference-related fragments were patient-initiated (42%), oncologist-facilitated (28%) or oncologist-invited (30%). Oncologist responses likely to trigger more preference-related talk were showing empathy, checking and probe questioning. Likely to reduce space were providing information, personally agreeing and neutral responses. Conclusion: Elaboration and joint preference construction is not standard practice in consultations on palliative chemotherapy. Oncologists may benefit from realising this and training skills that support this key step of shared decision making. Also, repeated shared decision making throughout the course of palliative chemotherapy should be stimulated