Sacred silence in pediatric oncology: A qualitative study of communication during difficult conversations 公开
Rockwell, Sarah (Fall 2020)
Abstract
Background: In pediatric oncology, communication between pediatric oncologists, children and adolescents with high-risk cancer and their families is imperative to facilitate therapeutic alliance. Communication is particularly important during conversations about disease reevaluation, which often necessitate parental decision-making in the context of emotional distress. Silence can be used to create space for emotional and informational processing. We are not aware of prior studies that have investigated the timing, content, and context in which silence engenders a sacred connection between provider and patient/family during bad news conversations for children with high risk cancer.
Objectives: To determine the frequency of sacred silences used by pediatric oncologists during recorded conversations around disease progression for children with high-risk cancer and their families; to explore the nature of statements that precede (i.e., prompt) and follow (i.e., emerge from) moments of sacred silence.
Methods: Serial disease reevaluation conversations between pediatric oncologists, children with high-risk cancer, and their families were recorded across the progressing illness trajectory. Following codebook development, MAXQDA v.2020 software was used to manage audio-recorded medical dialogue and to apply codes. Segments coded as Silence, within Bad News conversations, were further analyzed to identify profound moments surrounding silence, labeled Sacred Silence.
Results: Bad news conversations included 238 coded segments of Silence, almost half fit the definition of Sacred Silence. Qualities of the surrounding conversation identified as creating Sacred Silence included: giving bad news, patient/family questions, provider information, empathic statements, silence, emotion, and provider questions. Empathic statements often prompt silence and the subsequent emotional expression by patient/family. Multiple silences employed within close proximity to each other, creating a series, were identified as Stacked Silences. The majority of Sacred Silence moments occur within a series of Stacked Silence. The repetition of silence at consistent intervals within a series creates a psychological space in which everyone in the room can sit together and process. Each subsequent silence helps to advance the conversation further into difficult choices about decreasing treatment, end of life care, and prognosis.
Discussion: Silence used in close proximity to bad news during disease reevaluation conversations has the opportunity to evoke a sacred moment, which can include the expression of emotion, questions, and empathic statements that connect the provider and patient/family. These data offer opportunities to develop targeted educational communication programs for pediatric oncologists to incorporate silence, specifically multiple silences in close proximity to each other, throughout bad news conversations. Further longitudinal studies are needed to examine how silence impacts therapeutic alliance across the illness course.
Table of Contents
Chapter 1: Introduction ………………………………………………………………………...1
Chapter 2: Literature Review ………………………………………………………………......4
Chapter 3: Methods ……………………………………………………………………………15
Overview
Population and Sample
Research Design and Procedures
Data Collection
Codebook Development
Code Application and Analyses
Instruments
Data Analysis
IRB Approval
Limitations
Chapter 4: Results ……………………………………………………………………………..21
Chapter 5: Discussion and Recommendations……………………………………………….39
References ……………………………………………………………………………………...44
Appendix A: Codebook ………………………………………………………………………..47
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