Communication Strategies

• A resource for communication techniques for serious illness is VitalTalk: https://www.vitaltalk.org/resources/
• Respond to Emotions (NURSE Statements)
  • Expect strong emotions when discussing serious illness with patients and families. Silence is often the most effective initial response.
  • Important to acknowledge patient’s feelings and validate their perspectives, even if providers may not agree with their views.
  • Empathic statements that address emotion can help to build therapeutic relationships.

• Ask-Tell-Ask: used to assess understanding and deliver information.
  • Ask what the family already understands, and how much they want to know.
  • Relay the information in a straightforward manner. Expect heightened emotions after sharing news (employ NURSE statements).
  • Ask patients/families if they understand what you just said and ask permission to discuss next steps.
    • “That was a lot of information. Can you tell me what you took away from this conversation?”
• Pairing Hope and Worry: allows providers to be honest about what they believe will happen clinically, and partner with the patient in hoping for a different outcome.
  • “I hope that the treatments will continue to work AND I worry that we may not have much time because of how much your cancer has spread.”
• “I Wish…” Statement: aligns clinician with patient while acknowledging the reality of the situation.
  • “I wish there was more we could do for you.”  

Challenging situations

• Lack of consensus:
  • Restate major question: “What would the patient say if she could speak for herself right now? Have you ever discussed with the patient what she would want if she were very sick and nearing the end of her life?”
    • If you have a strong opinion about the best plan of care, recommend it explicitly and explain why.
    • If possible, suggest that everybody think about the discussion and schedule a follow up meeting for the next day.
    • Try to understand values behind opinions: “Tell me more about why you feel strongly about this decision.” 
  • Ask for help: Palliative Care Consult service, Ethics Committee, other physicians (especially ones that may know patient/family well), cultural/religious leaders important to patient/family.
• Family conflict:
  • Serious illness may exacerbate pre-existing family conflict.
  • Debrief this with your team/ethics committee and strategize ways to contain conflict for the sake of making decisions about patient care.
• Decision-maker stress:
  • Studies have documented the intense stress that surrogate decision-makers face particularly when deciding to withdraw life-sustaining measures.
  • Use NURSE statements to help acknowledge this stress and align with caregivers.
  • Offer chaplain and social worker visits to supplement your efforts to help decision maker think through the pros/cons of each possible choice.

References & Resources

VitalTalk: website with videos and talking guides, mobile phone App, blogs, and communication training courses. http://vitaltalk.org/

Back AL, Arnold RM, Baile WF, Tulsky JA, Fryer-Edwards K. “Approaching Difficulty Communication Tasks in Oncology.” CA: Cancer J Clinicians. 2005. 55:164-177. PMID: 15890639

Jackson VA, Jacobsen J, Greer JA, Pril WF, Temel JS, Back AL. “The cultivation of prognostic awareness through the provision of early palliative care in the ambulatory setting: a communication gude.”  J. Pall Med. 16(8):894-900. PMID: 23787425

Casarett DJ, Quill TE. “I’m not ready for hospice”: Strategies for timely hospice discussions. Ann Int Med. 2007; 146:443-449. PMID: 17371889

Quill TE, Arnold R, Back AL. Discussing treatment preferences with patients who want "everything". Ann Intern Med. 2009 Sep 1;151(5):345-9. PMID: 19721022

Widera EW, Rosenfeld KE, Fromme EK, Sulmasy DP, Arnold RM. Approaching patients and family members who hope for a miracle. J Pain Symptom Manage. 2011 Jul;42(1):119-25. PMID: 21641763.