Initiating difficult conversations, supporting patient agency, and discussing death: Do you want to talk about what this means?

This article draws on the field of conversation analysis to examine audio recordings of terminal lung cancer patients, their family members, and their oncologist as they initiate discussions of prognosis. I find that the oncologist in this study uses different types of inquiries to set the topical agenda (discussion of prognosis), forecast the valence of the news, and work towards an acceptance of the nominated next action. I call these types of announcements “what this means inquiries (WTMIs).” This interactional tool also serves as a confirming strategy when a patient or caregiver initiates prognostic-talk or expresses “readiness” to discuss prognosis. I argue that despite a preferred positive response, WTMIs help diminish physicians’ asymmetrical influence on patient-doctor interactions and promote patient and caregiver agency. Participants collaboratively build interactional spaces to gather information and express conversational preferences. By responding to WTM inquiries, patients and caregivers can shape prognostic-talk. • This study examines how patients and oncologists discuss death and dying. • Uses Conversation Analysis to examine patient-doctor interactions. • Reveals the dynamic ways inquiries can be used to start prognostic discussions. • Discussing difficult prognostic news can contribute to patient agency. • Discussing death can be done in ways that strengthen the doctor-patient relationship.