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This thesis analyses doctors empathising with patients in palliative care interactions. Historically, palliative care has treated not only patients physical pain but their emotional pain, as well. Although the importance of empathy (defined for the purposes of this thesis as The doctor s expressed understanding of the patient s emotional experience ) has been emphasised in this environment, however, there has been no prior research showing how palliative care doctors actually empathise with their patients in practice. Drawing upon 37 recordings of doctor-patient consultations collected in a UK hospice, this thesis addresses this omission by using conversation analysis (CA) to analyse several facets of empathy in this environment. The analysis begins in chapter four by considering the ways in which doctors can empathise with patients. It shows how doctors can empathise semantically, either by reworking what the patient has themselves said or by showing understanding on a normative basis. It also considers non-semantic ways of displaying empathy (e.g. response cries), showing how these are fundamentally different to the semantic type of empathic display. Overall, this chapter shows that empathy is not restricted to particular formats but, rather, is dependent upon the content of the doctor s turn. The analysis then moves on consider the wider context of doctors empathic responses. Chapter five, first of all, analyses cases where patients emotions become the topic of the interaction, either because the doctor asks about them directly or because the patient raises an emotionally-implicative topic. The emphasis here is on how palliative care doctors can talk to patients about, and empathise with, their emotions without necessarily having to do anything about those emotions. Chapter six then focuses on cases where patients emotions are discussed alongside the more task-driven aspects of the consultation, either because the patient s physical condition has had an emotional impact on them or because their presenting problem is inherently emotional. In contrast to chapter five, then, the source of the patient s emotions here can be treated by the doctor without the emotions being topicalised. The final two chapters of the analysis focus on doctors empathising with patients not in response to something that the patient has said but in the service of some task. Chapter seven shows how doctors can empathically bridge the gap between their medical and the patient s experiential perspectives at moments where it becomes clear that there is a disparity between the two. These include moments where the patient expresses expectations that go beyond what can realistically be provided, moments where the patient might take offence at the doctor s advice and moments where the doctor must reassure patients about their symptoms without seeming to criticise their emotional responses to those symptoms. Chapter eight, meanwhile, shows how doctors can empathically demonstrate that their practice is being driven by a due consideration of the patient s feelings. Specifically, it shows how doctors can draw upon patients feelings in helping them come to a decision about a treatment, cite those feelings when accounting for a treatment that they have recommended and frame a difficult topic as an outgrowth of sentiments that the patient has already expressed. In conclusion, this thesis shows how empathy is not clearly demarcated in palliative care. While there are cases where patients emotions are discussed and empathised with for the sake of discussing and empathising with them, more commonly, empathy and emotion are interwoven alongside and into the task-driven aspects of consultations. This thesis thus shows the interactional manifestation of palliative care s underlying philosophy, with patients emotional pain addressed alongside their physical pain in an integrated, holistic way.

This thesis examined the delivery of medical bad news as a situational dilemma. When physicians have to convey distressing information, they must apparently choose between two negative communicative alternatives: To convey the diagnosis directly may distress and harm the patient, but to deny the diagnosis, in order to protect the patient and preserve hope, would risk compromising informed decision-making. Following Bavelas’ (1983) and Bavelas, Black, Chovil, and Mullet’s (1990) theory of situational dilemmas, the author predicted that experienced physicians would solve this dilemma by communicating the bad news indirectly (i.e., using honest but mitigated, softened, or hedged language). The experimental test of this prediction compared the language that physicians used when they communicated a diagnosis of metastasized cancer (the bad news condition) vs. a diagnosis of benign hemangiomas (the good news condition). In a within-subjects design, eight physicians with experience in palliative medicine conveyed these two diagnoses to 16 different volunteers who role-played the patients. The physicians and volunteers each had a schematic scenario with the medical background, but they otherwise improvised their interview, which was videotaped in split screen. Microanalysis of the physicians’ language focused on the sections where the physicians presented the good or the bad news for the first time. This analysis reliably assessed whether the physicians used direct or indirect terms in their naming of the diagnosis and in their evaluation of the news; whether they expressed certainty about the diagnosis; how they referred to the receiver of the diagnosis; and who they identified as the bearer of the news. The results of the microanalysis supported the prediction in this thesis: The physicians used indirect terms at a significantly higher rate when the news was bad than when the news was good. These results suggest that indirect language was the solution that these experienced physicians found for the situational dilemma of delivering bad news. In addition, the volunteer patients’ report after the bad news interview indicated that all of the volunteers understood the diagnosis and that virtually all appreciated the way the physician conveyed the bad news. These results provide evidence to support the effectiveness of indirect language in allowing physicians to convey bad news honestly while still being tactful. The findings of this study have direct implications for training physicians on how to break bad news in a manner that is both accurate and humane.

This thesis examined the delivery of medical bad news as a situational dilemma. When physicians have to convey distressing information, they must apparently choose between two negative communicative alternatives: To convey the diagnosis directly may distress and harm the patient, but to deny the diagnosis, in order to protect the patient and preserve hope, would risk compromising informed decision-making. Following Bavelas’ (1983) and Bavelas, Black, Chovil, and Mullet’s (1990) theory of situational dilemmas, the author predicted that experienced physicians would solve this dilemma by communicating the bad news indirectly (i.e., using honest but mitigated, softened, or hedged language). The experimental test of this prediction compared the language that physicians used when they communicated a diagnosis of metastasized cancer (the bad news condition) vs. a diagnosis of benign hemangiomas (the good news condition). In a within-subjects design, eight physicians with experience in palliative medicine conveyed these two diagnoses to 16 different volunteers who role-played the patients. The physicians and volunteers each had a schematic scenario with the medical background, but they otherwise improvised their interview, which was videotaped in split screen. Microanalysis of the physicians’ language focused on the sections where the physicians presented the good or the bad news for the first time. This analysis reliably assessed whether the physicians used direct or indirect terms in their naming of the diagnosis and in their evaluation of the news; whether they expressed certainty about the diagnosis; how they referred to the receiver of the diagnosis; and who they identified as the bearer of the news. The results of the microanalysis supported the prediction in this thesis: The physicians used indirect terms at a significantly higher rate when the news was bad than when the news was good. These results suggest that indirect language was the solution that these experienced physicians found for the situational dilemma of delivering bad news. In addition, the volunteer patients’ report after the bad news interview indicated that all of the volunteers understood the diagnosis and that virtually all appreciated the way the physician conveyed the bad news. These results provide evidence to support the effectiveness of indirect language in allowing physicians to convey bad news honestly while still being tactful. The findings of this study have direct implications for training physicians on how to break bad news in a manner that is both accurate and humane.