3 Conversation analysis of authentic care decision conversations 55 The physician now begins an elaborate multi-unit turn [27] (lines 416-434) and produces three accounts for the nomination of the topic: the camera project (lines 416-417), the realization that this information was missing in the system (lines 422-424), and the possibility the patient might have her own ideas (lines 430-434). The multi-unit turn is marked by the aid of various ‘rush throughs’: ‘a practice in which a speaker, approaching a possible completion of a turnconstructional unit, speeds up the talk, withholds a dropping pitch or the intake of breath, and phrases the talk to bridge what would otherwise be the juncture at the end of a unit’ [27] (e.g. lines 418-419 and 426-427). The patient uses various ‘continuers’ (see ‘no’s’ in lines 420, 425 and 430), thereby claiming understanding and encouraging the physician to continue [27]. Besides the hesitation marker and multiple accounts the physician provides for introducing the topic of care decisions, there are also repairs noticeable in lines 417-418 (‘that you- that we’) and line 422 (‘and I was↑ (.) when we were- when I was’). Repairs are generally preceded by a ‘trouble source’, i.e. something apprehended as a problem [28], and are observed in talk about ‘sensitive’ issues [16,29]. Furthermore, in line 427, the physician uses hypothetical talk (what if). In our data, hypothetical future scenarios are sketched to explore the patient’s thoughts and wishes in particular scenarios, such as ‘imagine you come to the hospital and are very ill’ or ‘what if there is an emergency, let’s say, something happens to your heart’. Across several settings, hypothetical questions have shown to be effective in encouraging patients to engage with difficult issues but at the same time show the ‘serious and sensitive’ nature of these topics [16]. In the multi-unit turn, the physician does not ask the patient a direct question. He uses declarative utterances designed as ‘my side’ tellings [30] in lines 423424 and 429. In a ‘my side’ telling, the speaker has less access to information than the recipient does. That is the case here because the patient’s thoughts and wishes are in the patient’s epistemic domain [31,32]. The physician requests information by these my-side telling declaratives [30], after which the patient responds. Her decision (no limitations) is documented in the EHR, and the consultation is closed. Example 1 is typical of the exchanges in our data. Care decisions are introduced in the ‘treatment and course of disease’ phase as a final point on the agenda. While the ‘last topic’ is made explicit in some of the examples in our data (e.g. one last thing, one more point, I had one last (little/ silly) question), example 1 demonstrates a more implicit instance of ‘last topic to be discussed’.
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