Procedural Detailing: A Patient’s Practice for Normalizing Routine Behaviors

ABSTRACT

In palliative care in the UK, occupational and/or physiotherapists consult with patients to assess how they are managing their activities for daily living in light of their life-limiting condition(s), and to identify any activities that might benefit from therapeutic intervention. In this paper we use conversation analysis to describe a patient’s practice in these consultations, which we call “procedural detailing,” whereby they produce a step-by-step description of how they do some everyday activity, such that it is depicted as adequate, stable, and unproblematic. Based on a collection of 15 cases identified in video recordings of consultations in a large English hospice, we demonstrate how patients use this practice to normalize their routine conduct and thereby reject or rule out an actual or anticipated therapeutic recommendation. Our analysis suggests that such descriptions let patients participate in shared decision-making by revealing their preference for routines that preserve their level of independence and dignity.

Life-limiting illnesses expose patients to challenges including breathlessness, pain, fatigue, lymphedema, stress (Bye, 1998), and loss of functional capacity and cognitive acuity (Ostlund et al., 2019). These can limit patients’ participation in meaningful daily activities, leading to occupational deprivation (Keesing & Rosenwax, 2011). Patients’ loss of independence and sense of control over their daily living can be accompanied by the experience of being deprived of previous roles, further affecting their sense of identity (Keesing & Rosenwax, 2011; Maersk et al., 2019). All these aspects can lead patients to loss of dignity (Chochinov, 2002).

An overarching goal of palliative care is helping patients conserve their dignity (Chochinov, 2002; Johnston et al., 2015; Ostlund et al., 2019) by addressing physical, social, psychological, and spiritual needs, by supporting carers (Faull, 2015), and by helping patients affirm remaining life while preparing for death (Bye, 1998). Occupational (OT) and physiotherapy (PT) interventions play an essential part in this agenda by supporting patients’ continued involvement in meaningful activities. Research on this domain of care has been conducted through surveys (Eva & Morgan, 2018; Hammill et al., 2019) and interviews (Bye, 1998; Keesing & Rosenwax, 2011), mostly with occupational therapists and sometimes carers, in European and Australian contexts. Textbooks (e.g., Cooper, 2006) and a thematic review of evidence (Hammill et al., 2014) are also available. OT in palliative care entails a paradigmatic shift away from patients’ rehabilitation and return to independence, and instead emphasizes supporting quality of remaining life while centering patients’ needs and experiences (Bye, 1998).

Therapeutic interventions in palliative care aim to foster a sense of “normality in an otherwise changed reality” (Bye, 1998, p. 12). This is done through help in symptom management including education on handling fatigue and energy levels (Keesing & Rosenwax, 2011), and providing assistive equipment, home modifications, and professional care (Eva & Morgan, 2018). Depending on how they are introduced, interventions can sometimes compromise (rather than preserve) patients’ dignity. For example, patients can experience the introduction of aids and professional care as an intrusion into their privacy and as disruptive of their daily routines, thus exacerbating (rather than alleviating) a sense of loss of control and independence (Ostlund et al., 2019). It has therefore been recommended that interventions be introduced in patient-centered ways – to let patients set their own goals, exercise choice, make decisions, and retain control over their caregiving (Bye, 1998; Hammill et al., 2014). The therapist’s role has been described as providing options while empowering patients in their decisions about desired type and level of support in different aspects of daily living (Bye, 1998).

In this paper, we focus on patients’ activities for daily living, particularly their descriptions of those activities. Such descriptions regularly occur in our data, which are video recordings of hospice patients’ consultations with occupational therapists (OTs) and physiotherapists (PTs) specialized in palliative care. Using conversation analysis, we examine a practice that patients use in these consultations, whereby they describe step-by-step their routine way of doing some everyday activity. We show how patients use this practice as a method for normalizing their own habitual conduct in an area of daily activity, thereby rejecting or ruling out some healthcare recommendation. As such, the practice – which we refer to as procedural detailing—provides for patient participation in shared decision-making.

Decision-making in palliative care

The patient-centered approach to intervention described in the palliative care literature is consistent with the tenets of shared decision-making (SDM; Legare et al., 2014), where mutual agreement is negotiated with patients (and sometimes carers/family/spouse) regarding some course of action based on the best available evidence and patient preference. SDM is best suited to situations involving difficult decisions, like where there’s no clear best course of action (Barry & Edgman Levitan, 2012) or where there’s clinical uncertainty, ambiguity, or insufficient evidence (Blair & Legare, 2015). Attention to patient values and preferences is inherent to therapeutic work in palliative care as described by Bye (1998), who found that therapists commonly work to achieve a “balance of care” (p. 9) taking into consideration patients’ “wishes, abilities, and resources” (p. 9).

The study of SDM in palliative care settings remains relatively underdeveloped, especially research on the concrete practices used in negotiating such decisions (Belanger, 2017; though see, e.g., Pino & Land, 2022). In a systematic review of conversation analytic work relevant to SDM (in a variety of Western healthcare settings), Land et al. (2017) documented a range of communication practices used by patients and professionals leading up to and surrounding the phase in which a patient is invited to make a decision about a treatment recommendation. Overall, they found that patients’ opportunities to influence decision-making were structurally limited by the way such phases are organized. This paper contributes to work on SDM in palliative care contexts by describing one practice by which patients influence decision-making. We show how patients describe their own procedures for everyday activities and what these descriptions accomplish in the context of OT/PT consultations.

Patients in palliative care have been shown to positively value engagement in everyday activities. An integrative review of qualitative (mostly interview-based) studies of SDM in palliative care in Western contexts documented patients’ expressed desires to participate not only in medical decision-making, but also in decisions regarding daily matters related to OT/PT (Kuosmanen et al., 2021). In interview-based research on the occupational priorities of patients in a Scottish hospice, most of the patients’ goals were simple, everyday tasks like washing and dressing independently (Boa et al., 2019). Similarly, a literature review of qualitative studies on palliative care patients’ priorities (von Post & Wagman, 2019) found that several patients wished to continue their occupational patterns so as to retain control of their situation and maintain their own identity. These findings resonate with research showing that patients prioritize carrying out activities of daily living to maintain a level of participation, independence, and normality (Bye, 1998; Hammill et al., 2014).

Occupational therapy and physiotherapy assessment consultations

The everyday tasks, routines, and activities that patients value take center stage during OT and PT assessment consultations. In these clinical interactions, therapists assess patients’ needs, goals, abilities, and resources with respect to managing their life-limiting conditions (Bye, 1998; Cooper, 2006; Eva & Morgan, 2018; Hammill et al., 2014). Therapists elicit descriptions of patients’ daily lives, home configuration, and everyday routines to identify areas that may benefit from OT/PT interventions (e.g., professional care and/or devices to compensate for loss of functional capacity). While professionals may regard such interventions as the best option for managing patients’ life-limiting conditions, patients’ preferences may lie elsewhere. Despite the benefits of something like a wheeled walker, for example, patients may find it embarrassing to use in public and inconsistent with how they view themselves in their illness trajectory (Maersk et al., 2019). Patients are also likely to have developed personal solutions to compensate for diminished functional capacities. While perhaps suboptimal from a clinical point of view, these personal solutions might represent a patient’s best attempt to maintain agency and normality and should thus be validated (Keesing & Rosenwax, 2011; Maersk et al., 2019). In this setting, then, patients’ practical task is to give professionals a sense of how well they are managing daily tasks given their current/projected capacities, whether (and what kind of) assistance might help, and how any proposed interventions would fit into their everyday lives.

This study

This study examines how patients participate in decision-making in OT/PT assessments. Using conversation analysis (CA), we describe a previously undocumented communicative practice whereby patients produce step-by-step descriptions detailing procedures that they routinely follow to tackle practical daily tasks (e.g., cooking, washing, or getting dressed). We investigate the social actions that these descriptions accomplish in specific contexts: after an OT or PT has recommended (or is hearable on the way to recommending) a change to some aspect of the patient’s daily living. In these contexts, patients’ descriptions of daily routines work to decline or resist the recommendation, either by rejecting the assumption of a problem, or by conveying that their existing solutions for an experienced problem are good enough and thus need no altering.

By focusing on the import of patients’ descriptions in these consultations, this paper contributes to research on OT and PT in palliative care. We demonstrate how patients themselves use descriptions of their own routines within OT/PT assessments. This concrete focus on the actual activity of describing one’s routine contrasts with prior research, which has emphasized the importance of such routines in a generic sense – as activities for preserving a sense of self (Johnston et al., 2015), optimizing independence (Eva & Morgan, 2018), and maintaining dignity, agency, and normality (Keesing & Rosenwax, 2011; Maersk et al., 2019; Ostlund et al., 2019). Our study also adds to a growing body of CA research on communication problems, tasks, and practices in OT/PT. Previous studies examined goal setting in physiotherapy (Parry, 2004; Schoeb et al., 2014), as well as manual (Krummheuer, 2015) and verbal (Parry, 2013; Yip & Schoeb, 2020) practices used within physiotherapy sessions. Other work focused on OT consultations in a psychiatric clinic, documenting how OTs provide feedback to patients (Weiste, 2018) and how they respond to patients’ displays of emotions (Weiste, 2016). Our original contribution to this area is twofold: we investigate a hitherto neglected area of OT/PT intervention (decision-making regarding changes to daily routines) and focus on patients’ contributions to decision-making.

Materials and methods

Theoretical approach

Our study of descriptions of ordinary everyday routines is situated within the traditions of CA (Sidnell & Stivers, 2013), ethnomethodology (Heritage, 1984a), and discursive psychology (Edwards & Potter, 1992). Common to these approaches is attention to the practical problems that people manage in their social interactions and the practices they use to navigate them. This perspective bears especially on our understanding of two things: “ordinariness” and descriptions.

We take people’s social actions to embody a concern with presenting themselves as “ordinary;” that is, as people whose conduct can be seen to unproblematically align with common social norms and expectations. This concern is especially evident in cases where people recount events that could be regarded as unusual, but do so in ways that downplay their extraordinariness and ultimately normalize them (Jefferson, 2004a; Sacks, 1984; see also Burdett et al., 2019). It has been argued that in these ways people contribute to reproducing a shared sense of normality, which forms the very fabric of everyday social life, while presenting themselves as the sort of persons who are committed to that reality (Sacks, 1984, 1995). Here we find a strong connection with what the patients in our data are doing when they describe their daily routines. In their descriptions, the patients show that some aspect of their lives (which therapists may assess as evidencing difficulty and thus open to intervention) is adequately under control for the time being. These descriptions, we argue, are partly how palliative care patients work to maintain a sense of control and “normality in an otherwise changed reality” (Bye, 1998, p. 12).

Our study also builds on the study of descriptions as social action. Studies within CA and discursive psychology have shown that people’s descriptions should not be examined in de-contextualized ways and unproblematically taken as reflecting underlying attitudes or states of mind (Edwards & Potter, 1992). Rather, people use descriptions to implement social actions in specific activity contexts (e.g., Drew, 1984). In doing so, they also frame their descriptions as plausible accounts of everyday realities, thus working to come across as unbiased observers (Potter, 1996; see also Smith, 1978). The descriptive practice we examine resembles script formulations, whereby actions and events are described in ways that “make them perfectly normal, what everybody or anybody would do, as routine, not needing any special account” (Edwards, 1994, p. 217). We will show that this feature is key to the operation of patients’ descriptions in our data. Precisely because they present aspects of daily living as adequately under control (and thus in no need of special attention or intervention) they can be understood as declining healthcare measures in contexts where therapists have made a recommendation or are hearable on their way to doing so.

Data and procedure

Our data come from the VERDIS-AHP corpus, a collection of recordings (38 video, and 9 audio, 35+ hours in total) of physiotherapy and/or occupational therapy consultations at a large English hospice. These recordings were collected in 2017 with ethical approval from UK NRES Committee Nottingham 2 (Ref: 17/EM/0037) and with the participants’ consent to record and reproduce pseudonymized transcripts for research purposes. Patients were judged by care staff as having the capacity to consent and not currently experiencing severe distress. We excluded four recordings of acupuncture and Bowen therapy to focus only on consultations featuring therapeutic assessments by OTs and/or PTs specialized in palliative care (n = 43). The participants in these consultations were 43 patients (23 female, 20 male; average age 71; 31 outpatient, 12 inpatient), 20 companions (partners, friends, family members, and one professional carer), five OTs, and three PTs. The patient (and, if present, their companion) would meet with either or both OT and PT for about 45 minutes. The majority (31/43) were meeting with these OT/PT professionals for the first time; in the extracts in the analysis, all participants were meeting for the first time.

All patients were diagnosed with one or more life-limiting condition – various cancers, respiratory diseases, and neurological conditions, to name the most common. The practical management of these served as the reason for their consultations; as one therapist explained to the patient: “We’re gonna be asking you a few questions if that’s okay with you […] just about how you’re getting on, um, at home and the things that we can do to help” (AHP48). In these loosely structured interviews, therapists aimed to discover areas of stress or difficulty in daily life (e.g., getting to bed, using the toilet) for which aides, interventions, and techniques might be recommended.

We approached these recordings using CA (Sidnell & Stivers, 2013), an empirical, inductive, and largely qualitative approach to social interactions that centers on how everyday social encounters are recognizably brought off by the participants involved. Using audio-visual recordings and detailed transcripts thereof (Hepburn & Bolden, 2017), analyses in CA focus on what interactional participants do (e.g., therapists’ recommendations, patients’ subsequent resistance) and how they do it (i.e., through orchestrations of language use, prosody, and bodily conduct). Special attention is given to where this occurs, or its “sequential context” (Schegloff, 2007), which includes how a given action relates to what came before and how it affects what may come afterward. Evidence is also adduced via participants’ demonstrable orientations to the unfolding action (for example, through the way in which they respond to it).

Given that activities for daily living were the remit of these consultations, initial analyses targeted a broader range of statements about patients’ habits and routines. A systematic search resulted in 50 cases of such statements over 34 videos. While analyzing this larger collection in data sessions (Albert & de Ruiter, 2018), a regular practice (Schegloff, 1997) was discovered – that is, a regular way of doing something (what) with some specifiable conduct (how) in some specifiable sequential environment (where). This practice of “procedural detailing” is described below. Fifteen cases were found in eight consultations. These were transcribed following Jefferson (2004b) and analyzed with respect to their sequential emergence, their design, and their uptake by coparticipants.

Results

Central in these consultations are healthcare recommendations that address potential, inferred, or reported problems with activities of daily living, and which entail some modification of the patient’s existing routines. In the context of such a healthcare recommendation (whether actual or anticipated), a patient may use procedural detailing – a step-by-step description of their existing procedure for an everyday activity. This description implies that the healthcare recommendation is unnecessary (because the patient already has procedures in place to manage a/that problem; e.g., Extract 1) or undesirable (because it would disrupt an existing or preferred routine; e.g., Extracts 2 and 4). The OT/PT sometimes acknowledges the patient’s existing procedure (Extract 1) and does not pursue the recommendation further (Extract 1; in 3, the potential recommendation is not produced); in other cases, they pursue their recommendation (Extract 4), sometimes by questioning the patient’s account/detailing (Extract 2). All instances of procedural detailing were produced in the habitual present tense (e.g., “usually what I do is … ”), and regularly (but not uniformly) appeared with minimizers (e.g., just, a bit) and ended by indicating “nothing else to add” (e.g., and that’s all, high terminal prosody). The cases below exemplify different ways in which procedural detailing features in sequences of decision-making in our collection. The first subsection shows practitioners making a recommendation, which the patient resists by using procedural detailing. We then show how a possible recommendation is preempted through procedural detailing. And finally, we illustrate how procedural detailing may be used to correct the practitioner’s presupposition of a problem, thereby precluding the need for a recommendation. In this way, the practice lets patients display their values and preferences – a core component of SDM.

Extract 1. Patient recognizes that his health condition warrants intervention but rejects the therapist’s recommendation with procedural detail.

Transcript of a palliative care consultation between a patient and occupational therapist. The patient makes an explicit admission of difficulty with drying himself after the shower, which occasions two offers of a special type of drying technique. The patient refuses both offers; the second refusal is done with ‘procedural detailing,’ the focal practice of this paper, with which he describes an unproblematic personal technique of drying off after the shower.

Extract 2. Procedural detailing used to account for rejection of healthcare recommendation.

Transcript of a palliative care consultation between a patient and physiotherapist. The patient had admitted to having difficulty in his morning routine, which led to the therapist suggesting that he modify his routine so that it’s split up into smaller chunks. He rejects this suggestion and then accounts for that rejection with procedural detailing, in which he describes an elaborate morning routine of several steps.

Recognizing problem but rejecting recommendation

Over the course of these consultations the participants may mutually recognize some problem in the patient’s activities for daily living. That problem may occasion a healthcare recommendation from the practitioner, creating an environment for SDM. In this subsection we show one trajectory by which procedural detailing is used in this environment as a way to resist that recommendation.

Extract 1 shows how, in the context of a mutually recognized problem, a patient may counter a healthcare recommendation through procedural detailing that depicts a functionally equivalent alternative to the solution advanced by the therapist. This embodies an account that the problem is adequately under control, thus removing or excluding the relevance of the recommendation by implication. Here, the patient meets with an occupational therapist (OT3) to discuss how he’s getting along at home with respect to his advanced chronic obstructive pulmonary disease (COPD). His procedural detailing appears in lines 34–37 (in gray highlight), but we show the build up to it to demonstrate how it appears as one of several instances of resistance to the therapist’s recommendations.

The transcript begins as OT3 asks the patient about drying himself after showering. The patient first claims competence in this task (line 2), but later qualifies that competence by complaining about getting very breathless (line 8) especially when drying my legs and: (.) that sort of thing (lines 11–12). The patient thus recognizes his problem with this task, for which the therapist recommends a toweling dressing gown, which would allow the patient to conserve energy by drying off passively (lines 13–17).

While the patient claims awareness of this technique, he admits to not having tried it personally because he simply hasn’t got to it yet (lines 18–24). In this way, he neither accepts nor rejects her recommendation, but passively resists it. Perhaps because the possibility of adopting the recommendation remains open, the therapist makes a second suggestion of big bath sheets (lines 25–26), which similarly allow drying passively. While OT3 recommends this (lines 26–33), the patient gives several unmarked acknowledgments (Heritage & Sefi, 1992, p. 395). With these, he passes up opportunities to elicit more information about the bath sheets (e.g., with “oh?” or “oh really?”) and thereby treats her explanation as “not news.” The patient thus continues his resistance to OT3’s recommendations.

After this second recommendation we encounter the target practice of this article. The patient’s procedural detailing begins with well-prefacing, which already signals some departure from what may be expected (Heritage, 2015). He then projects an elaboration (Günthner, 2011) of his drying procedure with usually what I do is (line 34). Here, what I do invokes an alternative to the therapist’s recommendation of big bath sheets, treating them both as practices for managing “drying oneself.” This serves as a tacit admission that the task does need management, and thus that the therapist’s recommendation was warranted. The patient then elaborates his procedure for drying in list fashion (Jefferson, 1990): I dry myself a little bit and (.) put my pants on and then: (.) I have a shave (lines 34–35; “pants” in UK English being “underwear” in US English). These details indicate the patient’s preference and account for his personal technique over the therapist’s alternative recommendation. Because he first dries himself partially and then does other activities, he dries himself passively. His practice is therefore functionally equivalent to the big bath sheets, which, by implication, he has no need for. Also note the “no problem” presentation of events. His use of usually suggests competence in the task by claiming regularity and capability, and there is an avoidance of reference to difficulty or distress, despite the patient’s earlier admission of breathlessness (line 8) and the therapist’s treatment of it as troublesome.

In response to procedural detailing, it becomes relevant to draw an appropriate inference. In this instance, the therapist receipts it with o:hkay (line 39), thereby treating it as an informing (Heritage, 1984b). The patient however recompletes his turn with a standalone so (line 40, G. Raymond, 2004), prompting OT3 to draw the “right” inference (Drew, 1984)—that is, that his current practice adequately manages the task, rendering the recommendation unnecessary. The therapist then does so by articulating an upshot of his procedural detailing (line 41). She accepts his claim that things are under control (so you feel you’re coping), but preserves the possibility his practice will one day become inadequate (in between, or “for now”). We thus see a negotiation between professional advice, grounded in technical expertise, and patient experience and preference. This negotiation is key to SDM.

Extract 2 is similar in that there is mutual recognition of a problem, for which the therapist advances some change in the patient’s routine. Here, however, the patient first explicitly rejects the recommendation and then uses procedural detailing to support and account for that rejection. The patient (primary diagnosis of COPD and bronchiectasis) has come with his wife to a consultation with a physiotherapist (PT2). About 13 minutes prior to this exchange, the patient had reported two related problems: i) breathlessness in the morning, for which PT2 had recommended spacing out his activities to conserve energy, and ii) developing phlegm overnight such that after breakfast he would cough to the point of vomiting. The transcript starts as PT2 reintroduces the idea of spacing out his activities to save energy. She evaluates this as quite important (line 4) and may thus be heard as recommending it (Stivers et al., 2018). She later endorses having a think about- (.) m:aybe doing s: things slightly different (lines 5–7).

Evidently anticipating a forthcoming recommendation (and perhaps working to preempt it), the patient enters in recognitional overlap (Jefferson, 1984) to mention a behavioral change that would qualify as doing things slightly different: getting his walking sticks out (line 9). The therapist counters by identifying something else he might change: his morning routine of getting up and going downstairs to take his tablets (lines 15–16). This refers back to earlier in the consultation (data not shown), where the patient had recognized that taking many tablets at breakfast made him feel exhausted, but he also said he was unwilling to change this routine. Before her turn has come to possible completion, however, the patient informs her that I go on the chair (line 18). That is, by taking his chairlift downstairs he already does something that saves him energy, thus showing an effort to address the problem. So far, then, the patient has offered his own ideas about conserving energy, thus tacitly acknowledging a problem in need of management. Moreover, by airing these ideas before the therapist’s turns have come to completion, the patient exhibits some resistance to the therapist’s proposal of a change in routine.

The patient continues this pattern of resistance through the use of procedural detailing, with which he depicts a stable routine that accommodates no modifications. His procedural detailing is positioned after he explicitly rejects PT2”s suggestion that he take his tablets before coming downstairs. In this post-rejection environment, his description will be heard as accounting for that rejection. His procedural detailing draws on several features of the organization of lists (Jefferson, 1990). First, his description begins with I come downstairs (line 24). This is notable because its positioning as temporally first forecloses the possibility of anything preceding it. He thereby already depicts his habitual practice as one that cannot accommodate PT2”s recommendation. Second, in contrast to the normative three-item list (Jefferson, 1990), the patient enumerates nine events in his morning routine (lines 24–37). While he could have produced a relatively simple description (e.g., “I come downstairs and take my pills”), he instead gives a much more granular (Schegloff, 2000) one. By exceeding the normative number of items, the patient paints a picture of a complex but stable ecosystem of events, whose interdependencies have fossilized in their ordering. Indeed, this fixedness is hearable to his wife. Already upon the production of the second item of the list (do my injection), she orients to the list-in-progress (Lerner, 1994) as evidence of the patient’s character. She enters to explain to PT2 that He’s a stickler for routine (line 27), which serves as an account for the patient’s hearable resistance. Finally, the patient closes his description with terminal high prosody and eat p- pills at the same ↑time (lines 36–37). This change in prosodic structure not only signals the ending of the list, but treats the prior list as “array-exhaustive” (Jefferson, 1990, p. 76). It is akin to ending a list with “and that’s ↑it” (see Extract 4) in that it recognizes the possibility of list expansion, but does so by explicitly closing it off to any further addition. Cumulatively, then, his detailing of events accounts for his rejection by depicting a system that is unamenable to modification.

What is relevant after procedural detailing is for the therapist to make an inference based on the details given. Here, PT2 first receipts the patient’s description (Yeah) and then pushes back on what it implicates. She challenges the patient by reminding him of his earlier admission: but sometimes you- you’re sick (line 41). That is, she draws the situationally appropriate inference (that he is proposing that the situation is adequately under control) but does not accept the conclusion. Perhaps because the patient’s description does not clearly offer a solution to his problem – in contrast to the functional equivalence drawn in Extract 1 between the patient’s practice and the therapist’s recommendation – PT2 persists in challenging him.

In the cases in this subsection, there was an agreed-upon problem for which the healthcare professional made some recommendation. In light of this recommendation, the patient’s use of procedural detailing can present their personal routine as normal, adequate, and in need of no modification. We observed two patterns where the patient shared information that bore on decision-making: the practice was used in the first case to propose that an existing routine is in place, which reduced the relevance of the recommendation; and in the second case, procedural detailing supported and accounted for an explicit rejection of the recommendation.

Anticipating problem and preempting recommendation

Another context for SDM is when, in the context of the ongoing assessment of the patient’s daily activities, the patient observably anticipates that the HCP may treat an aspect of the organization of their daily living as problematic, which could then also lead to a recommendation. The patient may then head off its topicalization by detailing the practice that they have developed for dealing with the problem. This can preempt arriving at a decision regarding the anticipated recommendation. We see this in Extract 3.

Extract 3. Patient anticipates topicalization of problem and uses procedural detailing to preempt its emergence.

Transcript of a palliative care consultation between a patient and occupational therapist. The patient mentions that she uses a bedside commode downstairs where she sleeps, which leads to the therapist drawing the conclusion that she doesn’t have a toilet downstairs. The patient confirms that this is so, and then after a short silence, without being prompted by the therapist, she says that she is able to empty the commode by herself. She makes this claim using procedural detailing to describe an under-control process of emptying the commode.

Here the patient (primary diagnosis of COPD and bronchiectasis) is meeting with an occupational therapist (OT2) along with her friend/neighbor (COM), who sometimes supports her with practical assistance. The transcript begins as the patient describes getting up in the morning to use the toilet. She mentions using a bedside commode downstairs where she sleeps (lines 3–4, 6), which implies that she doesn’t have a toilet downstairs. The therapist treats this mention of the commode as broaching an agenda item (e.g., Svennevig, 2012), saying that was one of my- (line 7), presumably on the way to saying “questions.” And so while the patient did not mention this detail as a point of concern, OT2 targets it as something of importance and proceeds to write on her notepad. As she does so, the patient confirms that, indeed, I haven’t got a toilet downstairs (line 11).

At this point (line 12), OT2 has sought and received confirmation about the layout of the patient’s home and may now proceed to her next question. She does not do so, however, and a gap emerges as she writes on her notepad (line 12). This provides an opportunity for the patient to continue speaking (Sacks et al., 1974). With and-prefacing (line 13; Heritage & Sorjonen, 1994) she builds on her response by answering more than the question required (cf. Stivers & Heritage, 2001). Specifically, she verbalizes something that was implicated by prior talk, but so far unmentioned: emptying the commode. That is, she anticipates that this task might be topicalized as a potential problem.

She begins to assert competence in this task with I do empty it out mys- (line 16; Heritage & Sefi, 1992), but then suspends her turn to insert a parenthetical remark (Mazeland, 2007). In an aside, she modifies her claim of self-sufficiency by acknowledging the help of her friend (the companion), who regularly comes round to have a look see if it wants emptying (lines 17–20). The companion acknowledges this with laughter, which the patient reciprocates in the form of smile voice quality (lines 19–21). Their shared appreciation of this provides a place for the patient to end the aside and to return to her description, which she does using but and recycling to where she had abandoned her talk (line 23).

She resumes her competence assertion with I do do it myself (line 23). The inclusion of the do-auxiliary in this turn indexes a presumption to the contrary (C. W. Raymond, 2017). That is, she orients to a possible presumption by the therapist that the patient cannot empty the commode unassisted. She undertakes to dispel this in the procedural detailing that follows: I put it on my-(tether it) t’my trolley, and put it on there and get to my stair chair, and go heh.h up and do it. (lines 26–27). This description offers evidence for her competence claim in its granularity (as compared to I do it myself; Schegloff, 2000). The assembled details depict a “no problem” picture in that she anticipates potential problems of dexterity (handling the commode) and mobility (getting upstairs). Compared to the previous cases, here there is no explicit alternative method advanced by the therapist for undertaking this task. The patient is thus not indicating a preference for her personal practice over another. What her description seems to accomplish instead is an anticipation of questioning from OT2. The OT had oriented to the presence/absence of a downstairs bathroom as on the agenda (line 7), and in response the patient describes a solution to a problem (emptying the commode) which had not been proposed as such. This creates an environment where, should the OT wish to treat the absence of a downstairs bathroom as problematic, the patient’s description preemptively addresses it and treats is as non-problematic. In response, OT2 acknowledges the patient’s description and then asks about the related bathroom matter of washing and dressing upstairs (lines 30–33). In moving on with her own agenda items, she no longer problematizes the matter of the commode.

As this case demonstrates, hearable within questions are subsequent questions and a larger agenda, which in this setting means potential healthcare recommendations. Orienting to this as a decision-making context, patients may detail their procedure for an everyday activity which had not yet been mentioned, but which was perhaps forthcoming. In doing so, they may prevent problematic interpretations and head off further questioning. This lets the patient show themselves – ahead of its potential topicalization – as aware of and capably dealing with problems presented by their condition.

Rejecting the problem and the relevance of a recommendation

In contrast to the cases shown thus far, in which patients acknowledged in one way or another that there was a problem, the patient in Extract 4 challenges the very assumption of a problem in need of management, and therefore the relevance of any possible solution. This is thus yet another context for SDM, but one in which the details of the patient’s procedure aims to revise a presupposition about the nature of the problem. Extract 4 comes from the same consultation as Extract 3 and starts with the patient describing how she sleeps without a fan (I don’t have anything on at night). This occasions the addition of a detail from her friend, who makes it known that the patient sleeps downstairs on the settee (line 3), rather than upstairs on a normal bed, which would be the default assumption in a British context. Clinically, this is potentially problematic since it implicates issues like insomnia, depression (Kay & Dzierzewski, 2015), and falling from the bed. As the interaction proceeds, the therapist dwells on some of these possibilities despite the patient’s avowals to the contrary.

Extract 4. Procedural detailing used to reject not only the recommendation but also the implication of a problem for which the recommendation was given.

Transcript of a palliative care consultation between a patient and an occupational therapist. The patient is accompanied by her friend/neighbor, who brought her to the consultation. The patient is talking about how she sleeps at night, to which her friend adds that she sleeps on a settee downstairs. This sleeping arrangement is targeted as problematic over multiple turns by the therapist, who eventually makes an offer of a special bed that the patient could get to sleep on downstairs. The patient rejects this first by saying she’d already tried one of those hospital beds and didn’t like it. She then uses procedural detailing to describe her sleeping routine, depicting it as unproblematic and normal.

The therapist addresses the patient’s sleeping habits first by asking whether she manage[s] to sleep (line 8) on the settee. Her word choice of “manage” introduces the possibility of a problematic sleeping arrangement in that it implies obstacles to the achievement of sleep. The patient resists this presumption of a problem by countering with an upgraded claim of I sleep really well (line 10). The therapist does not accept her claim (e.g., with a sequence-closing third; Schegloff, 2007), but persists by asking her to confirm the claim with Do you. (line 11), thus treating the patient’s claim as unsatisfactory. Again, the patient counters by reaffirming yeah I do sleep well (line 12; C. W. Raymond, 2017). So, though OT2 has not explicitly problematized the patient’s sleeping habits, she has treated it as such in the design and repetition of her questioning.

The patient and OT2 have thus arrived at something of an impasse: the patient insisting on the adequacy of her sleeping routine and OT2 remaining skeptical of the patient’s claims. A lapse in conversation (Hoey, 2020) then emerges as OT2 forgoes the opportunity to move onto another topic, letting silence develop while gazing at the patient, thereby preserving the possibility for the patient to expand and treating the matter as not yet resolved. Similarly, the patient remains silent, thus treating her response as needing no elaboration (line 13). In this environment, OT2 takes the initiative to offer the patient an alternative sleeping arrangement (beds that we could get for you downstairs).

OT2 prefaces her offer by raising the possibility that the patient has been offered such beds by other health professionals (lines 16–19), thus positioning her offer as a repeat offer. This suspision is confirmed by the patient, who enters in overlap where the offer was recognizably underway (line 21; Jefferson, 1984). The patient further fits her response to the repeat offer by reporting her past negative experience with just the sort of bed being offered (lines 21–28). She thus declines the offer by disclosing having tried it already. Furthermore she reconfirms her preference for the settee, claiming she was happier there (line 32) than the hospital bed.

Having declined the recommendation, the patient describes her sleeping procedure as normal, unremarkable, and under control rather than accountable, peculiar, and requiring intervention (Edwards, 1994). As such, her procedural detailing addresses the implicit problematization of her routine. After dismissing the notion that she sleeps with the television on (lines 33–34)—which itself betrays an awareness of healthy sleeping habits – she details her bedtime routine. She starts by professing I turn that off at ten o’clock (line 34), a time that is hearable as “a reasonable time to stop watching TV,” the implication being that her bedtime is unproblematic. She similarly presents her sleeping configuration as untroubled: an:d (then), (0.4).h just get my cushions right and I’ve got a pilla, (lines 36–37). These particular details orient to the clinical issue of sleeping position. Because lying flat would disturb her breathing, getting my cushions right and using a pilla demonstrate capable management of that issue. She brings her description to possible completion with and I go ↑slee:p (line 38)—a plain formulation that renders the activity as uncomplicated. She delivers this with terminal high prosody (see Extract 2), which communicates something like “I don’t know what else to add.” We see some evidence for this in how she gazes to her companion as if to confer with her on the matter (line 37). The companion reacts with laughter (line 39), which seems to confirm “nothing to add” and treats the patient’s activity itself as laughable. We take the laughability to be the patient’s position of belaboring the obvious: having to describe something about which, by its nature, there isn’t much to say. Consider the patient’s next turn: £And that’s ↑it.£ (line 40). With this, she hearably redoes her prior turn by packaging it in the same terminal high prosody, and also aligns with the companion’s laughter by producing it in smiley voice. She thus retroactively shows herself as engaged in “belaboring the obvious” by producing the results of a search for “something else to add,” which in this case is “nothing else.” And so, by treating her description as exhaustive (Jefferson, 1990), she recommits to its essential adequacy and resists any characterization of it as problematic.

In response to the patient’s description, OT2 acknowledges (Yeah) but pushes back on the implication that the patient’s routine behavior is adequate. She checks, rather than taking it as established, that the patient manages to sleep with the arrangements so described (and you do sleep; line 41). In this way – similar to Extract 2—she maintains her stance of problematizing the patient’s practice despite the patient’s claims of adequacy. In contrast to Extract 2, where PT2 pursues her recommendation by objecting to the patient’s claimed adequacy, here OT2 pursues by soliciting more details about the patient’s sleeping (so are you quite fla:t_; line 43), which could uncover evidence of a problem. So, compared to the previous extracts, there isn’t mutual acknowledgment of a problem in need of management, yet the therapist persists in treating it as problematic.

Discussion

We have focused on occupational and physiotherapy assessments in palliative care, with an interest in how patients participate in SDM regarding activities for daily living (showering, getting dressed, etc.). Using conversation analysis, we documented one method by which patients take up a stance toward the problems that their life-limiting conditions present and toward possible solutions. With procedural detailing, patients describe in step-by-step fashion their method for an everyday activity in the context of actual or anticipated healthcare recommendations from the therapist. In our data, patients used procedural detailing to express preference for personal practices and reject alternative recommendations (Extracts 1 and 2), anticipate and head off topicalization of potential problems (Extract 3), and counter therapists’ suppositions about the patient’s problems (Extract 4). What these uses share is a depiction of the patient’s practice as adequate, under control, and unproblematic – that is, as normal everyday routines in need of no intervention.

These findings are consistent with studies that document people’s use of descriptions for social action (e.g., Edwards & Potter, 1992; Edwards, 1994; Potter, 1996). With procedural detailing, patients described some habitual activity, not as neutral perceptual reports, but as selectively rendered scenes of normality. Absent from these descriptions were any indications of stress, difficulty, or pain, despite participants’ orientations to admitted (Extracts 1 and 2) or assumed hardship (Extracts 3 and 4).¹ Instead, we found claims of capability, adequacy, and routinicity. The routine character of patient’s activities was observed through the inclusion of temporal adverbials like usually, the usage of present habitual tense verbs, and narrative quality conveyed through the sequential listing of events. The structure of lists seems to afford particular modulations of action, as observed in the exceeding of the three-item list structure (Extract 2) and the use of “array-exhaustive” (Jefferson, 1990) components including terminal high prosody (Extracts 2, 4) and and that’s it (Extract 4).

The practice seems fitted to the patients’ practical problem of having to characterize aspects of daily living for clinical assessment. That is, in the absence of actual demonstrations of their daily activity, their verbal descriptions must suffice. These descriptions can evidence patients’ stated or implied claims of competence by as observers of scenes of daily living, and thereby furnishing them with what’s needed to draw conclusions for themselves, which are not necessarily spelled out.

Our study contributes to research on OT/PT assessments by illustrating the significance of patients’ descriptions of routine everyday activities in a palliative care context. While prior research has demonstrated that patients value engagement in everyday tasks (e.g., Boa et al., 2019; von Post & Wagman, 2019), we have shown where and why patients raise descriptions of these tasks and concurrently convey their preferences. That is, following an actual or anticipated recommendation, patients’ procedural detailings embody their preference for leaving their existing practices unaltered, and they are ostensibly understood as such by the OTs/PTs (as shown in Extracts 1 and 2). This advances our understanding of patient preferences by putting it into their social-interactional context and asking why patients raise them on particular occasions – something easily overlooked if one is limited to the content or themes in patients’ talk (e.g., in qualitative interviews). Additionally, while it’s easy to focus on explicit statements of preference, we show how preferences can be conveyed by implication, by “showing” (in descriptions of procedures) that existing solutions and ways of doing things work well enough from the patient’s perspective. We also argue that these displays of patient preferences can indirectly embody patient values, like maintaining a sense of independence, dignity, and control in the organization of one’s daily living.

The study also contributes to research on SDM (Land et al., 2017) by identifying a previously undescribed method by which patients actively resist a healthcare measure. With procedural detailing patients provide an experientially grounded account (see Stivers & Timmermans, 2020) that serves to resist an actual or anticipated healthcare recommendation. As a method for SDM, this lets patients provide information on which care decisions can be made in a patient-centered way. Our analyses show that patients sometimes work to maintain their current routines because, to them, they are good enough, and because interventions might alter them in troublesome or unnecessary ways. Because therapists cannot always anticipate how the introduction of healthcare measures (which may modify the structure of daily activities) may affect the overall ecology of a patient’s everyday routines, proposed interventions may be experienced by patients as undermining (rather than enhancing) their independence and dignity. We have shown one way in which patients concretely indicate that some healthcare measure might impact their everyday routines and how they resist it on that basis.

Professional guidance (e.g., Ryan et al., 2014) acknowledges the importance of respecting a patient’s right to refuse treatment, and of aligning treatment to patient priorities more broadly. Our findings suggest that implementation of this guidance entails situated complexities when translating it into practice on a case-by-case basis. For example, patients with palliative care needs might sometimes have limited awareness of how further deterioration of their condition will affect their capabilities in the future, and thus how their existing routines may soon become ineffective (information that, by contrast, HCPs have access to based on their experience of supporting patients with comparable problems). Palliative care practitioners work to prevent problems by putting measures in place before patients reach a crisis point. It can nevertheless be difficult, in some cases, to persuade patients of the need for some changes to daily routines before reaching that point. Whilst a fuller exploration of these complexities was beyond the scope of this article and deserves further investigation, our analyses have shown that healthcare professionals sometimes acknowledge the patient’s existing practices and set recommended changes aside (Extract 1) while in other cases they question the adequacy of the patient’s solutions (Extract 2) and pursue alternatives to it (Extract 4).

Ultimately, we do not take our findings to suggest that healthcare professionals should always endorse (or avoid questioning) the claimed adequacy of patients’ existing routines (see, e.g., Timmermans, 2020). This is clearly a case-by-case decision, arguably based upon several factors, including the nature of the symptoms and difficulties being discussed, the clinical adequacy of the patient’s existing procedures, the patient’s displayed level of awareness of their condition, and the nature of the professional-patient relationship. However, regardless of the adequacy of patients’ reported solutions, we argue that their procedural detailings provide important glimpses into their preferences and values, which should be taken into consideration when recommending healthcare measures. By carefully selecting when to problematize and when to accept patients’ existing routines (even when less than ideal) practitioners may achieve a balance of care through supporting patients’ engagement in actions that preserve their level of independence (Karlsson & Berggren 2011, via Johnston et al., 2015) and dignity (Ostlund et al., 2019).

Acknowledgments

This work was supported by a Fulbright Scholarship from the Fulbright Commission for Elliott Hoey (#PS00303642). Versions of this paper were presented in 2021 at the Institute for Advanced Studies at Loughborough University and in 2022 for the Amsterdam Center for Language and Communication at the University of Amsterdam. We are indebted to Ruth Parry for her invaluable comments on a prior version of this article and to Ruth England, Laura Jenkins, and Ruth Parry for their critical feedback during early analyses. Important ethnographic developments for this project were made possible via the professional input of Tracey Elder, Lucy Fettes, and Andy Richardson.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The work was supported by the US-UK Fulbright Commission.

Notes

1. This is not to imply that pain went unreported or that it wasn’t discussed by patients. We have simply not focused on those portions of the consultations in this paper.