Negotiated practices: understanding hospital palliative care as an affective economy

This dissertation is an exploration of contemporary hospital-based palliative care informed by ethnographic research in two large hospitals in Western Canada. My objective was to explore how the concept of an “affective economy” contributes to understanding the ways in which the dying process is currently negotiated in these spaces. Through extending existing scholarship on discourse, emotional labour, affect, affective economies, and literature on institutionalized end-of-life care as a form of social governance, I define an affective economy of hospitalized palliative care as a discursive formation, which is understood and explained through its emotional labour practices, and which attempts to organize the dying process in order to facilitate a good death. Primary attention is given to three aspects of clinicians’ emotional labour practices: therapeutic relationship building, addressing total pain, and offering of the dying role. Through interviews, fieldnotes, and case studies, I trace how these are relational practices of knowledge and power that circulate and privilege clinicians’ understandings of the emergent physical states of the patient, along with clinicians’ cultural authority to define the appropriate emotional orientations to these understandings. I also explore how these orientations are negotiated, validated, and/or contested through claims to narrative authority by all involved parties. I propose that, within an affective economy framing, hospitalized palliative care is best understood as constituted by two, not always complementary, discourses. These discourses both construct and reflect tensions within care provision, including: the evolution and mainstreaming of care, the requirement for rapid patient transitions, the rise of business modeling, and increased patient and family member involvement in clinical care decisions. This research contributes to the study of dying in three key ways. First, no one has yet conceptualized hospitalized palliative care as an affective economy. In doing so, the specific moments and networks of relations that constitute this form of care are understandable as a cultural system that attempts to make human capacities productive, even at the very end of life. Secondly, I forward an understanding that clinicians’ privileged position is one that often occurs within active and sustained negotiations, where emotional orientations to dying process are generated, validated, and/or contested within the perceived rights and obligations of all involved parties. Third, this framing encourages an understanding of hospitalized palliative care in contemporary Canadian hospitals as necessarily fluid and ambivalent, defined as much by negotiation and disjuncture as by mutuality and cooperation.