CLEAR Conversations in the Henry Ford Physician’s News, January 2016

Screenshot 2015-07-24 08.15.57

“Doctor, why did this happen to me?”

 When faced with a patient or surrogate decision-maker who asks a difficult question, one to which we may not have answers, we are often left feeling inadequate. So much of our training has focused us on the importance of having answers for our patients. We can forget that these very tough, sometimes un-answerable, questions can be interpreted as expressions of emotion rather than primarily cognitive.

  How can we do better?

 The best medical care requires that we “attend,” or accompany, our patients through their illness. We have to acknowledge that recognizing and responding to emotion is very challenging. Then we can reflect on the effectiveness of our own communication skills. The next time you find yourself considering how you might answer those “impossible” questions, or respond to expressions of emotion, pause and consider a patient-centered approach: respond to the underlying emotion with a NURSE statement and then pause and allow the patient to respond.

 1.       Name the emotion

2.       Understanding response

3.       Respect

4.       Support

5.       Explore

 Using this roadmap will improve your chances of successfully navigating tough questions and connecting with your patient, while minimizing feelings of defeat. Read examples of each tool used in the sample conversations below and consider them as responses to questions such as, “Doctor, why did this happen to me?”

Step

What you say

1.    Name the emotion

“You seem very sad [overwhelmed, etc.]”

“I can see this is not what you were hoping for.”

2.    Understanding response

“I can only imagine what you are going through.”

“This is an overwhelming situation.”

“This is very difficult news.”

3.    Respect

“You are doing a great job managing a difficult illness.”

4.    Support

“I/The team will continue to work with you to figure out the next steps.”

“I wish I had better news.”

5.    Explore

“Tell me more about what worries you.”

 We have a responsibility to guide our patients and their surrogates through illness. We can acknowledge the challenge in navigating strong emotions and that, at times, our patients/surrogates will express their emotion by asking difficult or existential questions. This understandable discomfort need not be the end of our value as physicians; it can be the beginning of a new conversation.

 For more reading on published evidence about discussing prognosis: Back, Anthony L.; Arnold, Robert M., “‘Isn’t There Anything More You Can Do?’: When Empathic Statements Work and When They Don’t”; Journal of Palliative Medicine, 2013, v16(11): 1429-1432 and Back, Anthony L, et al, “Approaching Difficult Communication Tasks in Oncology.”; CA: Cancer J Clin 2005;55;164-177.

 This is one of many skills that can be practiced with the CLEAR Conversations Program. Established by a group of Henry Ford physicians in 2012, the goal of the program is to improve conversations between providers and patients.

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