Communication is an extremely complex task. By listening to every level of the patient's and family's communication, health professionals gain maximum information and understanding of their patient's illness experience and become best prepared to provide education and support.

Patients and families living with far-advanced, incurable illness face significant challenges as they make decisions regarding their health care. Most have little experience with being seriously ill. They are novices to the world of illness and medical treatments. Yet they are immersed in the medical environment and are being asked to make urgent life and death decisions. Assisting patients and families to make decisions that are centered on their values and life experience as well as their disease process is a basic task of all healthcare providers.

Set the Scene

In the hustle bustle of a busy medical care unit, it is often difficult to find a quiet corner. A patient's room, with the privacy curtain pulled around the bed, an empty office or conference room, or a table in the cafeteria can work well. Include the patient in the conversation if at all possible - and ask the patient's permission to include other family members or loved ones. If the patient is competent, encourage participation by at least one surrogate decision-maker who can represent the patient's wishes if his condition worsens.

Open-ended Questions

An open-ended question is the most effective way of beginning to gather information from the patient and family. Asking open-ended questions allows you to understand what issues and information are important to them as well as becoming familiar with their style of communication. Open-ended questions provide an opening or invitation for the patient or family to tell the story important to them.

"What has your doctor told you about your illness?"

"I can tell this has been really hard for both of you. What can we do now that would be of help to you?"

"What are the most important issues to address now to help your mom?"

Reflective Statements

Given the complexity of communication, reflective statements are a helpful tool in clarifying your understanding as well as the patient's understanding.

"What I heard you just say is, that you want more information regarding pain management before you take morphine. Is that what you intended?"

"I'm confused because I just heard you say two different things; that you don't want to hear any more bad news and also that you don't think anything is wrong."

Intuitive Knowledge

Health professionals develop instincts about the meaning of a patient's verbal and nonverbal responses. After being with a patient, they may sense anger or depression. The patient may not have explicitly expressed anger in their words or said they were depressed, but on a "gut" or intuitive level the caregiver senses this emotion. Skilled professionals pay attention to such intuitive or tacit knowledge and allow it to guide them in their exploration of the patient and family experience.

"I can appreciate that this discussion has been difficult."

"You must be exhausted."

"It sounds like you feel caught in the middle."

Being Present

It is difficult for professional caregivers to be in a situation where all their skills and technology will not ultimately change the final outcome of a terminal illness. We are action oriented, often geared toward helping our patients and families get better. When our bag of technologic marvels is empty, what is our role?

Recent research tells us that as patients and families approach the end of life, we often feel we don't have a role. We withdraw from the patient and family. One of the hardest tasks is to be emotionally present during moments when there is nothing that "can be done." Being a physical and emotional witness to the plight of another is often all that patients and families need.

Accepting the limits of what we are able to do by sitting with the patient and family who have just been informed of a poor prognosis or being in the home of a patient who is deteriorating and attesting to their experience and the unique meaning it has to them, may be all the family and patient expect.

Cultivating the ability to be present in the moment with patients and families and be a witness to their personal struggles is one of the most difficult but important skills a professional caregiver can possess.

Empathic statements and actions

Empathy is defined as the action of understanding, being aware of and sensitive to another without having the feelings, thoughts and experiences fully communicated in an objectively explicit manner. Exhibiting empathy comes naturally to some and is difficult for others. Yet it is a skill that can be learned and practiced. Being sure that communication occurs in a quiet situation, sitting and facing the patient, nodding your head, and sharing reflective comments on how difficult the situation is for the patient and for you, are all simple actions which communicate understanding of the patient's experience.

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