Communicating Difficult Messages to Patients
Effective communication builds trust, improves patient understanding and adherence to medical regimens, may reduce diagnostic testing costs and hospital readmissions, promotes patient and clinician satisfaction, and improves clinical outcomes. But communicating effectively with patients can be challenging. Low health literacy and heightened emotions can impede a patient’s ability to comprehend and retain information. These challenges may be exacerbated during difficult conversations, including:
- Bad news (e.g., initial diagnosis of CKD or unfavorable biopsy results)
- Prognosis (e.g., end-stage kidney disease, life expectancy)
- Complex decisions (e.g., whether to initiate dialysis in a frail, older patient)
- Uncertainties (e.g., when a donor organ may become available)
- Transitions in care (e.g., possible dialysis withdrawal)
While it is often assumed that being a good communicator is an inherent skill, communication skill can be learned and improved with practice. It is up to clinicians to make sure the patient understands the intended message. It may be easy to assume a patient’s silence indicates understanding, but he or she may not feel comfortable asking questions. Additionally, it may be easy to overlook emotions in patients and continue to provide important cognitive information rather than addressing the emotional response.
The following videos demonstrate two communication techniques that can be used to foster more effective conversations and increase patient understanding. Additional information is also provided on how to integrate the two techniques.
Technique One: Ask-Tell-Ask
Ask-Tell-Ask is a patient-centered technique that is used to clarify a patient's understanding and perspective. The framework promotes dialogue by assessing what the patient understands (Ask) before giving information (Tell) and ultimately checking (Ask) for understanding of what has been told. Every conversation should begin with an "ask" to clarify understanding and to gain permission before adding more information.
In this video, the clinician asks the patient, “What have you been told about your kidney problem?”. The patient provides information that the clinician uses to decide what further information to give. The clinician also “asks” permission, “Is it all right if I share some more information about your kidney problem?”, before adding additional information.
The “Tell,” or information sharing, should be in plain language, concise, no jargon, with limited technological terms. (The “Tell” is not shown in this video for the sake of brevity, but the content is implied by the patient’s answer to the second “Ask.”)
The second “Ask” by the clinician— “I’m not always clear about how I explain things. Could you tell me in your own words what we talked about?”—allows the clinician to make certain that the conveyed information was understood. Another way to pose this question is by asking, “What will you tell your family about our conversation when you get home?” If it is apparent the patient does not fully comprehend what has been explained, the clinician can further clarify.
Technique 2: Recognizing and Responding to Emotion using NURSE
NURSE is a technique for responding to emotion. When faced with emotional patients, clinician should
- Name the emotion
- Understand the emotion
- Respect the patient
- Support the patient
- Explore the emotion further
Acknowledging and validating emotional responses helps patients to gather themselves, and adjust to better process serious news. It also strengthens the clinician-patient relationship through demonstrating empathy and support.
In the video, the clinician is giving the patient the bad news that the chronic kidney function has worsened since a recent hospitalization to the point that a transplant or dialysis need to be considered. The patient has an emotional reaction, both verbally and non-verbally. Rather than continuing to add information about the next steps, the clinician has addresses the emotion. He names the emotion: “I can see this is really a surprise.” When the patient talks about all that he has done recently to take care of his kidneys, the clinician has responded by showing respect for his efforts: “You’ve been doing a great job.” He has also shown support for the patient: “We’ll work together to get you through this. We’ll work on a plan.” He has also used an “I wish” statement: “I wish I had better news.” “I wish” statements acknowledge disappointment and allow the clinician to join with the patient in recognizing loss. It is not until the patient’s emotions start to subside that the clinician begins to talk about the plan.
Integrating Ask-Tell-Ask and NURSE
Chronic kidney disease is often an abstract concept for patients. They may not have symptoms until kidney function is noticeably impaired. Providing too much information at once may result in overload. By using the framework of Ask-Tell-Ask, and incorporating NURSE as needed, a clinician is able to ask for the patient’s understanding of the situation and permission to give more information before delivering the bad news. The bad news is delivered succinctly and clearly. After emotion has been acknowledged, the clinician is able to give more information and ultimately ask the patient if he understands what has been discussed before the encounter ends.
In the NURSE video, the clinician tells the patient, straightforward manner, without jargon, that his kidney function has worsened significantly. He begins by firing what is known as a “warning shot” to prepare the patient for the news: “Your kidney function has become a lot worse.” He proceeds to tell him that it has worsened to the point that one needs to consider the “next steps: dialysis or a transplant.” Prior to giving the bad news (not shown), the clinician asked the patient how he thinks his kidneys are functioning presently. The patient responded that he wasn’t sure because he has been really focused on his heart issues since being hospitalized for a heart attack. The clinician asks permission to give the patient news about his kidney function before proceeding: “I wonder if it’s all right if we talk about how your kidney function has been doing since your hospitalization?” After the clinician responds to emotion, he provides some information (not shown) about the options for dialysis and transplantation and plans for him to get further education in the near future. He then makes certain that the patient has understood what was discussed by asking the patient what he will tell the family about the discussion today when he returns home. He also asks if the patient has any questions.
Importance of Recording Emotional Responses
Emotional responses, both verbal and non-verbal, should be recorded and considered clinical data. Patients may begin to exhibit signs of depression, and may require additional treatment by other specialists. These records may be vital in the successful holistic treatment of the patient.
These videos and supporting materials were developed in collaboration with Robert Cohen, MD, MSc, Beth Israel Deaconess Medical Center.