How the more life discourse constrains end-of-life conversations in the primary care of medically frail older adults: A critical ethnography

There is growing emphasis for primary care clinicians to initiate and engage in end-of-life (EOL) conversations with medically frail older adults. However, EOL conversations happen most often when death is imminent or are avoided altogether. The objective of this study was to understand the socio-political forces shaping EOL conversations between clinicians, medically frail older adults and/or their care partners within an urban primary care setting, a Family Health Team in Ontario, Canada. We conducted an eight-month critical ethnography in 2019 involving observations and interviews of clinicians, patients, and care partners (n ​= ​35). Analyzing this data for discourses and power-knowledge systems we found that two discourses, frailty and more life shape EOL conversations in this setting. More life discourse disrupts EOL conversations by making it more difficult to talk about decline and dying as well as personal goals. Biomedicine and clinical practice guidelines comprised the two major power-knowledge systems that increase the influence of more life in this setting as well as the norm of seeking longevity. Improving EOL conversations is complex and requires addressing the power-knowledge systems that perpetuate more life as well as a discursive shift towards prioritizing relationships and people's life worlds. Primary care as a specialty can critically reflect on the ways it is entrenched in a culture of care that valorizes more life and (re)create clinical practice guidelines and evaluations to align with person-centredness more meaningfully. Future research should involve patients, care-partners, and interprofessional clinicians to co-create approaches to care that can better accommodate frailty talk.