The art of honest and empathetic communication is fundamental to being an excellent clinician. And, it can be improved with intentional practice.
This pithy statement opens Hippocrates’ “Aphorisms,” and though it is quoted less than the ubiquitous Oath, or the famous rejoinder to “do no harm,” it’s a phrase that’s stuck with me throughout my education.
We often care for patients and their families at their worst moments of physical, psychosocial, and spiritual suffering. I’m constantly humbled by their strength in the face of uncertainty and grief—and by the significance of our work—the art of guiding them forward. In moments of updating someone about their son or daughter in the ICU, or admitting someone’s mother or father to their most likely last hospitalization, Hippocrates’ words echo in my mind.
“Life is short.” All of us, and all of our patients, will eventually succumb to nature’s course. But, “art is long.” How can we respond to uncertainty with grace? How can we hone our craft and uphold our responsibility in the face of mortality?
In searching for an answer to those questions, I became a palliative care physician. I did so because our most profound duty is to walk with our patients no matter what happens and to combine honesty with empathy as we guide them through their illness. This includes communicating with them clearly, tactfully, and honestly.
Though I’m not an expert on a specific disease, or a specific organ system, and I can’t offer any special disease-directed procedures or treatments, I can offer my presence, support, and expertise on managing the symptoms that accompany serious illness, as well as my communication skills. Communication is an art that I’m grateful to have discovered, and that I must continue to practice.
How can we improve our art of communicating about serious illness with patients and families?
Here are four fundamental tips that I’ve found useful:
1. Practice intentionally.
Breaking bad news, discussing difficult topics such as spirituality or death, and tailoring medical recommendations to match patients’ goals and values—these are complex procedures, just like suturing a wound or inserting a central line. They only improve with intentional practice.
Take a moment after every patient encounter to reflect with both learners and supervisors on specific words you used, emotions you noticed, and key moments or inflection points in the conversation that went well or that could have gone better.
2. Ask for help.
Find a clinician (or a dozen!) whose communication skills you respect. Steal all of their catchphrases and favorite scripts. Ask how they would respond to specific questions or tough conversations.
Consult your institution’s palliative care practitioners and ask them if you can sit in on, or be observed during, a difficult conversation. We are always excited and appreciative for the opportunity to share our passion with you!
3. Be curious.
The pitfall of so many goals-of-care conversations is our inability to see past our own agenda. We have bad news we want to deliver; we want the code status to be changed; we think the discharge plan should be so-and-so.
To align our goals with our patients’, we need to know where they and their loved ones are coming from. Below are some phrases I’ve found helpful:
“I want to make sure I give you the right amount of information. Can you tell me what you’ve heard so far?”
“When you say you want ‘everything done,’ can I clarify what you mean by ‘everything?'”
“I know that you’re hoping for a miracle. Can you tell me more about what that would look like?”
These simple open-ended questions give patients and families a chance to express what’s truly on their minds. When people feel heard, supported, and understood, they tend to embrace complicated or upsetting information better.
4. Use the “3 Ws.”
Three words allow the clinician to express empathy and to acknowledge the medical reality:
“I wish things were different. I wish I had better news. I wish I had better words to comfort you.”
“I worry that this action may cause more harm than good. I worry that we’re not making meaningful progress. I worry that time is short—shorter than we all hoped for.”
“I wonder if it’s time to focus less on the cancer and more on you, your symptoms, and getting you out of the hospital to a more familiar place?”
“I wonder what [the patient] would say to us, if he could understand us and speak for himself?”