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Communicating Difficult Messages to Patients

Effective communication is an integral part of excellent patient care.  It 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. It is often assumed that being good at communicating with patients is an inherent skill. On the contrary, these skills can be learned and improved with practice.

The following videos demonstrate two essential communication skills for discussions with patients who have chronic kidney disease: Ask-Tell-Ask and Recognizing and Responding to Emotion.

Video One: Ask-Tell-Ask

Clinicians are very good at providing information to patients. However, they often fail to query whether the patient really understands his or her medical issues and the advice given for treating it. Chronic kidney disease is often an abstract concept for patients, particularly since they may not have symptoms until kidney function is very impaired. Further, some patients possess limited health literacy. As​k-Tell-Ask is a patient-centered technique that is used to clarify a patient's understanding and perspective. This is a skill and framework that 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. It also means asking permission before giving information.​​​​​​​​​​​​​​​




Using Ask-Tell-Ask
Using Ask-Tell-Ask (1:11)

This video demonstrates Ask-Tell-Ask, an essential communication skill for discussions with patients who have chronic kidney disease.

Learn more about how Ask-Tell-Ask is used in this video

In this video, the clinician asks the patient, “What have you been told about your kidney problem?”  Another question might be, “What have others told you about your kidney problem?” The patient provides information that allows the clinician to consider what further information to give.  The clinician also “asks” permission, “Is it all right if I share some more information about your kidney problem?” 

The “Tell” is not shown in this video for the sake of brevity but is implied by the patient’s answer to the second “Ask.”  The “Tell,” or giving information, should be done concisely and without jargon and technological terms in order to enhance patient understanding. 

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?” —is an approach that allows the clinician to make certain that what has been conveyed has been understood.  Another way to pose this question is by asking, “What will you tell your family about our conversation when you get home?”  If the patient does not fully comprehend what has been explained, the clinician can further clarify.

Video Two: Recognizing and Responding to Emotion

Many conversations in nephrology trigger emotions in patients. These include discussing bad news (for example, giving the initial diagnosis of chronic kidney disease or discussing the approach of end-stage kidney disease), discussing prognosis (for instance, talking about an unfavorable kidney biopsy result), addressing uncertainty, discussing complex decisions (for example, whether or not to do dialysis in a frail, older patient), and addressing transitions in care (for example, discussing possible dialysis withdrawal). Emotions are common reactions. Clinicians often overlook emotions in patients and ​instead continue to provide important cognitive information. However, it is essential to recognize and respond to emotions in patients since not doing so can interfere with a patient's ability to absorb and incorporate important cognitive information. In addition, responding to emotion helps patients to understand and adjust to the serious news that is being discussed. It also transforms the clinician-patient relationship through support, validation, and building trust. Emotions, both verbal statements and non-verbal responses, should be considered clinical data to track.



Recognizing and Responding to Emotion
Recognizing and Responding to Emotion (1:12)

This video demonstrates Recognizing and Responding to Emotion, an essential communication skill for discussions with patients who have chronic kidney disease.

Learn more about how Recognizing and Responding to Emotion is demonstrated in this video

A skill for responding to emotion is the use of the NURSE acronym, which stands for name the emotion, understand the emotion, respect the patient, support the patient and explore the emotion further.  Statements made by a clinician that name the emotion, show understanding of the emotion, respect for the patient, support the patient, or explore the emotion further help to validate the patient and promote adjustment to serious news that is being discussed. The use of this acronym for responding to emotion is demonstrated in this 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 clearly has an emotional reaction, both verbally and non-verbally, to this news.  Rather than continuing to talk about the next steps (cognitive information), the clinician has responded to the emotion.  He has named the emotion that the patient has displayed: “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 (cognitive information). 

This video also demonstrates some essential components of giving bad news to a patient. Once again this involves using the skill of Ask-Tell-Ask. What is primarily demonstrated is the Tell. This should be done very directly and concisely. In this video the clinician tells the patient in a simple, straightforward manner (and 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 makes a plan 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.

To summarize, by using the framework and skill of Ask-Tell-Ask, the clinician is able to ask for understanding of the situation and ask 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. 

These videos and supporting materials were developed in collaboration with Robert Cohen, MD, MSc, Beth Israel Deaconess Medical Center.

September 24, 2014

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