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.

Submitted by Maicon Juliano Schmidt (maicons) on 2015-06-16T13:56:09Z No. of bitstreams: 1 Minéia Frezza.pdf: 1758793 bytes, checksum: 506bdf85c94ed952d8aa63d7ca579de0 (MD5) / Made available in DSpace on 2015-06-16T13:56:09Z (GMT). No. of bitstreams: 1 Minéia Frezza.pdf: 1758793 bytes, checksum: 506bdf85c94ed952d8aa63d7ca579de0 (MD5) Previous issue date: 2015-02-27 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Esta dissertação de mestrado consiste em um subprojeto de um estudo maior (Uma mulher, um feto, e uma má notícia: a entrega de diagnósticos de síndromes e de malformações fetais – em busca de uma melhor compreensão do que está por vir e do que pode ser feito, OSTERMANN, 2013) e tem como objetivo descrever a entrega de notícias por um geneticista a gestantes ou puérperas e seus/suas acompanhantes durante aconselhamentos genéticos gravados em áudio, em um hospital materno infantil do Sistema Único de Saúde (SUS), localizado na região sul do Brasil. Depois de transcrever os 54 aconselhamentos genéticos gravados, selecionamos apenas os 21 aconselhamentos que lidam com a comunicação de resultados de exames e os investigamos por meio da Análise da Conversa (SACKS; SCHEGLOFF; JEFFERSON, 1974) para descrever as ações envolvidas na fase das consultas em que ocorre uma sequência de entrega de boas e de más notícias. A análise de dados revelou que o geneticista em questão entrega as notícias seguindo uma sequência didática composta pelos seguintes elementos: (1) pré-anúncio da notícia, (2) retomada dos resultados de exames anteriores que indicavam a realização de exames mais especializados, (3) série(s) de apresentação de perspectiva (MAYNARD, 1992) nos casos de más notícias, (4) anúncio da notícia em si e, (5) apresentação de algo potencialmente “positivo” dentro de cada quadro, quando as notícias tratam de um diagnóstico “ruim”. Outra tendência evidenciada nos dados refere-se ao processo de alocação da categoria de porta-voz da notícia ao médico, à equipe de medicina fetal e à própria instituição quando a notícia é boa. Quando a notícia a ser entregue é ruim, há um processo de distanciamento da pessoa que a entrega, uma vez que essa categoria é alocada ao exame. Assim, por ser colocado na posição de agente dos verbos que montam a notícia, o exame acaba sendo apresentado como “o responsável” pelo porte e entrega das más notícias. Esse processo de “agentivização do exame” está ligado ao processo de “despessoalização da doença”, que acontece devido à falta de referentes pronominais e/ou nominais que categorizem o feto como portador da doença e dos sintomas apresentados durante a sequência de entrega de notícias. A análise linguístico-interacional da entrega de notícias neste contexto de pesquisa revela práticas recorrentes no evento aconselhamento genético. A partir dessas recorrências, o geneticista apresenta formas para lidar com o sofrimento de pacientes e de seus/suas acompanhantes que podem ser disseminadas na formação de profissionais de saúde em áreas em que a entrega de diagnósticos é prática do dia-a-dia. / This master’s dissertation consists of a subproject of a larger study (Uma mulher, um feto, e uma má notícia: a entrega de diagnósticos de síndromes e de malformações fetais – em busca de uma melhor compreensão do que está por vir e do que pode ser feito, OSTERMANN, 2013) and aims at describing the news delivery made by a geneticist to pregnant or puerperal women and their companion during audio recorded genetic counselings held in a mother and child hospital of the Sistema Único de Saúde (SUS), located in southern Brazil. After transcribing the 54 audiorecorded genetic counselings, we selected only the 21 counseling sessions which dealt with the communication of tests results. By taking a conversation analytical perspective (SACKS; SCHEGLOFF; JEFFERSON, 1974), the interactions were analyzed so as to describe the actions involved within the phase of the consultations in which the sequence of good and bad news delivery occurs. The data analysis reveals that the delivery of the news follows a didactic sequence composed by the following elements: (1) a news preannouncement, (2) a retake of the previous exams results which indicated the realization of more specialized exams, (3) a/some perspective-display series (MAYNARD, 1992) in case of bad news, (4) a news announcement itself, and when the news consists of a “bad” diagnosis, (5) a display of something potentially “positive” within each case. Another tendency revealed in the data refers to the process of placing the category of spokesperson to the doctor, to the staff of fetal medicine and to the institution itself when the news is good. When the news to be delivered is bad, on the other hand, there is a process of distancing of the person who delivers it and this category is alocated to the exam, which is then put in the position of the “agent” of the verbs that announce the news and, as a consequence, ends up being “the responsible one” for bearing it. This process of agentivization of the exam is linked to the process of “depersonalization of the disease”, which happens due to the lack of nominal and/or pronominal referents that categorize the fetus as the bearer of the disease and the symptoms presented throughout the news delivery sequence. The linguistic-interactional analysis of the news delivery in this research study shows recurring practices in the event genetic counseling. By these recurrences, the geneticist presents ways to deal with the patients and their companions’ distress, and these ways can be spread to the health professionals’ education in areas in which diagnosis delivery is a daily practice.