Physicians tend to talk too much, especially when delivering bad news to patients, said Kencee Graves, MD, FACP. “Sometimes our patients need fewer words, more space,” she said at a session at the Society of Hospital Medicine's CONVERGE conference, held in late March in Austin, Texas.
During the talk, Dr. Graves and Elizabeth Gundersen, MD, recommended avoiding wordiness, as well as some other tactics and phrases physicians commonly use in serious care conversations, and offered viable alternatives.
Avoid: Talking too much.
Try instead: Asking the patient what they understand, giving the headline, and answering questions.
Rather than providing a full explanation of the medical problem up front, ask patients what they understand about their situation, said Dr. Graves, who is an associate professor of hospital medicine and palliative medicine at University of Utah Hospital in Salt Lake City. “That will let you know where they're coming from and where you need to start in giving information.”
She recommended sharing knowledge in the form of a headline—a dozen words or fewer (e.g., “I'm worried that your cancer is back”)—not a full story. It is difficult for anyone to process new information when overwhelmed by emotion. After delivering the headline, pause and respond to a patient's emotion, which she described as both a wave (big and powerful but will eventually end) and a train going through a tunnel (it needs to pass, and nothing can change that). “It will end, but we do have to work with it,” Dr. Graves said.
Avoid: “I understand what you're going through.”
Try instead: “This helps me understand …” or any NURSE statement.
No physician has complete understanding of any patient's suffering, Dr. Graves said. A helpful mnemonic for responding to emotion with empathy is NURSE: Name (“You sound frustrated”), Understand (“It is understandable that you feel this way”), Respect (“I can see you really care about your mother”), Support (“We will do everything we can to support you through this process”), and Explore (“Can you tell me more about …”), she said.
Avoid: Focusing only on facts.
Try instead: Listening to patients and families and addressing emotional responses.
Some questions patients and families ask are emotional in nature. “A good one is, ‘Are you telling me my mom is never going to get better?’ That is an emotional question; that's not a factual question,” Dr. Graves said. “So responding to emotion using a NURSE statement will help you address that family's concern more than giving data.”
Avoid: Ignoring a pattern of decline.
Try instead: “Could we talk about what things might look like …?”
Patients generally want to understand if they have limited life expectancy so that they can plan ahead, so try to introduce goals-of-care conversations, Dr. Graves said. “Many of us avoid prognosis because it's scary, we're not comfortable doing it, and it's hard to talk about,” she said. “I would advocate that we owe our patients accurate information communicated in a skillful, compassionate way.”
Prognosis is not just about a time estimate, but also an idea of what that time will look like, Dr. Graves noted. “When I hear that somebody is spending all of their time in bed or a chair and they're losing weight, that means, to me, we're getting toward the end of life,” she said.
Avoid: Predicting a specific life expectancy.
Try instead: Giving a range: moments to hours, hours to days, days to weeks, weeks to months, etc.
Dr. Graves reviewed four trajectories of dying: sudden death (high functioning over time before a sudden drop), terminal illness (high functioning over time before a steep decline), organ failure (a pattern of repeatedly getting better, then worse as function declines over time), and frailty (functional status drops slowly over time, with a stepwise decline in the final years). “Always describe a range,” she advised. “Just giving people an exact time frame causes a lot of distress.” While not true for every case specifically, these trajectories can be helpful to get a general idea of what the future could look like.
Avoid: False hope, vague terms, and euphemisms, such as “not doing well” or “very sick.”
Try instead: “Sick enough to die.”
After asking patients' and families' permission to discuss prognosis, it's important to be transparent in those discussions, said Dr. Gundersen, an associate professor of medicine at the University of Colorado School of Medicine in Aurora. “If we say, ‘Your loved one is not doing well,’ to us, it might be very clear, but to them, they're not understanding that the patient's sick enough to die,” she said.
Instead, try telling them exactly that. “Say, ‘I am worried that your loved one is sick enough to die,’” Dr. Gundersen said. “It still has that uncertainty there. You're not sure that they're going to die; you're worried that they are sick enough to die. And so that way, you're being very clear about what you are worried about while still allowing that uncertainty at the edges.”
Avoid: Making hope the enemy.
Try instead: “I hope … and I worry …” or “I wish …”
“Oftentimes, in our desire to be honest, we feel the need to stamp out hope every time a family member has it,” Dr. Gundersen said. If an unresponsive patient squeezes a loved one's hand, a physician might reply, “Oh, that's just a reflex,” she offered as an example.
“If you do that over and over and over again, the family will start to think that you are aligned against them. You can still be honest … but you don't necessarily need to undercut them,” Dr. Gundersen said. “You can say, ‘Well, if they were going to respond to anybody, I'm sure it would be you,’ or something like that. That shows that you are also hoping with them, even while expressing you're worried that they're sick enough to die and educating them about the patient's condition.”
Avoid: Listening with the intent to reply.
Try instead: Focusing on understanding.
Doctors learn in training that if they are about to do a procedure, they shouldn't go in hungry, Dr. Gundersen said. “When I go into a patient's room, about to have a serious conversation, we consider that a procedure,” she said. “So I try to be physically comfortable so that I can give my attention to the patient and family.”
Most people don't listen with the intent to understand; they listen with the intent to reply, noted Dr. Gundersen. “Sometimes I'm listening to patients, and they're sharing all of this heart-wrenching stuff, and I'm thinking, ‘Holy cow, what am I possibly going to say?’” To help maintain focus on what the patient is saying and not on your reply in these situations, she offered helpful phrases to have handy: “Can you tell me more about that? What would that look like? What else?”
Sometimes saying nothing is the right answer. “I've learned to be comfortable with the fact that if I don't know what to say, maybe the best thing is for me not to say anything, and to pause and listen and sit in silence with the patient. And typically, if you sit in silence with somebody, they will start talking first,” Dr. Gundersen said. “When I'm teaching this concept to residents and they are skeptical that silence works, then I do it to them. We'll be standing outside the patient's room, and I'll say nothing, and they will invariably start talking. It's an ‘aha!’ moment.”
Avoid: “There's nothing more we can do.”
Try instead: Describing the pattern of decline and how it might look if it continues.
Saying that there's nothing more the care team can do gives the impression that you're giving up on the patient, she said. Instead, try asking for permission to share your concerns about what the patient's decline might look like if it continues.
Avoid: “A feeding tube (or other patient-suggested intervention) isn't going to help.”
Try instead: “What are you hoping that that will help with?”
Most physicians have encountered “daughter from California” syndrome (or “daughter from New York” syndrome for those in California), Dr. Gundersen said. “The daughter has just arrived from out of town, insists on ‘not giving up,’” she said. “If you look at Wikipedia, there's actually an entry for the daughter from California” to describe a situation where a previously disengaged relative, who is often angry, articulate, and informed, challenges the care or insists on pursuing aggressive measures to prolong life.
In these situations, don't immediately shoot down suggested interventions, Dr. Gundersen recommended. “Try to figure out what the daughter is hoping to accomplish with that, and use that as a starting point … [for] brainstorming the options,” she said. “Say, ‘OK, here's some options, can we talk about the pros and cons of these options?’ So instead of you unilaterally saying, ‘That's not going to work; this is going to work,’ having these options we can discuss and getting to a point of looking for options that could meet their goals.”
Avoid: “She is just going to keep coming back to the hospital.”
Try instead: “Can you tell me what a good day looks like?”
In situations like organ failure, where the patient may have rebounded before, families may see their loved one as a fighter, Dr. Gundersen said. “Sometimes we'll say, ‘Tell me more about that. How do you see your mom as a fighter?’ And then you can segue into ‘OK, in this situation, what do you think she would fight for? Would she fight to be in the hospital, would she fight to be in another setting?’”
Try discussing “good, bad, and ugly hypothetical” outcomes, as imagined situations can be less intimidating to the family, Dr. Gundersen advised. “‘What are you hoping for?’ That's the good. And then the bad is, ‘OK, what if she doesn't get better? … How do you think she would like us to proceed in that situation?’” she said. “And then the ugly is, ‘OK, in a worst-case scenario,’ and then we start a code-status discussion.”
Avoid: Unresolved conflict affecting your interactions.
Try instead: “I wish, I worry, and I wonder …”
Don't be afraid to approach angry patients or families, and remember that anger is sadness' bodyguard, Dr. Gundersen said. “When we have these conflicts, our impulse is to avoid them. And unfortunately, that tends to make it worse,” she said. “So just try to use words and phrases that open up the conversation, as opposed to being more adversarial, saying things like, ‘I wish that we had better options, I wish we had different treatments, I wonder if we can try this' and using NURSE statements to support emotions.”
Know that some conflicts can't be resolved, Dr. Gundersen said, adding that one helpful palliative care acronym (that can be difficult to achieve) is NATO: not attached to outcomes, whether they're clinical or related to conflict. “As hard as that is, sometimes patients just need to walk their journey,” she said. In those cases, focus on maintaining a supportive relationship with the patient and family and lean on your support system.
Try instead: Ands.
Make sure to say things like “‘I hope your mother gets better too, and I'm worried,” not “but I'm worried,” Dr. Gundersen said. “Because it's like if I go to [Dr. Graves] and say, ‘That's a nice blazer, but …’ something bad's coming after it.”