In the Institute of Medicine’s 2014 report Dying in America,1 the report’s authors found that while frequent clinician-patient conversations about end-of-life care, goals, and preferences are necessary to avoid unwanted treatment, most patients do not have those conversations with their physicians. As a result, “Clinicians need to initiate conversations about end-of-life care choices and work to ensure that patient and family decision-making is based on adequate information and understanding,” concluded the study authors.
Incorporating precise language and good communication skills into his oncology practice to ensure that his patients understand their prognosis and treatment options and teaching other oncologists how to become good communicators in their practices is the lifework of Anthony L. Back, MD, Professor of Medicine at the University of Washington and the Fred Hutchinson Cancer Research Center and Co-Director of the Cambia Palliative Care Center of Excellence at the University of Washington, Seattle.
In addition to his clinical practice, Dr. Back conducts research on patient/clinician communication and interventions to help make oncologists and nurse practitioners more effective oncology care providers. He is the recipient of the American Cancer Society’s Pathfinder in Palliative Care Award and the American Academy for Hospice and Palliative Medicine’s National Leadership Award and the coauthor of Mastering Communication With Seriously Ill Patients: Balancing Honesty With Empathy and Hope (Cambridge University Press, 2009). Two years ago, Dr. Back and his colleagues launched VitalTalk.org, a nonprofit website dedicated to disseminating effective research-based communication strategies to physicians.
The ASCO Post talked with Dr. Back about what constitutes good communication skills, the barriers impeding communication and decision-making about goals of care with seriously ill patients, and how oncologists can become more effective communicators.
Emotionally Loaded Conversations
Please discuss the importance of having good communication and listening skills when talking with patients, especially when addressing difficult issues like advance care planning and end-of-life care.
A study in JAMA Internal Medicine looked at barriers to goals of care conversations with seriously ill hospitalized patients and their families.2 The study surveyed hospital-based clinicians on the importance of 21 barriers to goals of care discussions rated on a 7-point scale. The study found that the clinicians perceive family member–related and patient-related factors as the most important barriers to goals of care discussions.
That’s fine, but I am concerned that the study finding encapsulates a worldview many clinicians have that patients—and not physicians—are the problem when it comes to effective end-of-life discussions. These conversations with patients are emotionally loaded, and just being good at giving information isn’t enough.
Physicians feel that patients don’t want to know about the seriousness of their illness and resist talking about it, and a lot of oncologists find the problem frustrating. But the approach that I try to embody when a patient is reluctant to discuss end-of-life care is to ask myself, what could I do differently to engage this patient in this difficult conversation? Effectively engaging patients in these difficult discussions takes a repertoire of different kinds of communication skills.
Instead of blaming the patient, it is our responsibility as oncologists to find a way to individualize the way we talk to patients about things like advance directives, based on the patient’s ability to cope with the information at a particular time. If the patient says, “I don’t want to talk about advance directives,” you have to find another way to engage the patient. That is our responsibility.
If the patient is distressed and nervous, starting with an acknowledgement that this is a difficult conversation to have can help give patients time to gather their emotional bearings and hear what you are saying. Or asking patients about how other family members coped with a similar situation or what patients said to their spouses about the situation might give clinicians a clue to how to start the conversation.
So some of the skills in being a great communicator—not just a good one—are the ability to listen for emotional cues, to pick up on stories patients are telling you about their experience with cancer, what their family members’ or friends’ experiences with cancer or other life-threatening diseases were, and knowing when to slow down or stop the conversation temporarily if the patient is getting so upset he can’t hear you anymore. Clinicians also have to have the ability to summarize patients’ clinical situation in language they can understand.
Benefits to Patients
What are some of the benefits to patients when they are clear about what their desires are for end-of-life care?
Good communication between clinicians and patients helps patients understand the reality of their situation and helps them make better decisions about their treatment, meaning that their treatments will match their values and goals for quality of life over aggressive care. It also helps ensure that they will have fewer regrets about their decisions.
When clinicians and patients have strong communication, patients will weigh their doctors’ recommendations more carefully. They will also have a sense of being cared for, and that alone can have a therapeutic effect on patients.
Benefits to Physicians
How does having great communication skills benefit oncologists?
The reality is that providing oncology care is pretty stressful. Studies show that having communication skills training is associated with less physician burnout. I think having a repertoire of great communication skills helps physicians feel they can be more effective providers by helping their patients make the best-informed medical decisions, whether that means matching up a patient’s clinical needs with the most effective therapies or being okay with a patient’s decision to try something else.
Improving Communication Skills
Please give some suggestions on how oncologists can become more effective communicators.
One important suggestion for physicians is simply to be attuned to the patient’s emotional state and to use that knowledge as data on how to navigate the course of the conversation. It can also be helpful to ask a member of the medical team—for example, a nurse or social worker—to critique your conversation with the patient and to tell you one thing that you did well and one area you could improve.
Pausing every few minutes during the conversation with patients to gauge how much they are absorbing of what you are saying is another good communication skill to adopt. For example, stopping at different points during the conversation and asking, “What are you taking away from what I am saying so far?” Asking that question periodically gives physicians instant feedback.
We have designed an online guide on VitalTalk.org to help physicians navigate tough situations and sharpen their communication skills. The website has one-page guides that offer quick, actionable insights on various topics, including talking about dying, transitions/goals of care, conflicts, and discussing prognosis, which can be downloaded for free. The website also includes video demonstrations of conversations between oncologists and patients on such topics as establishing rapport, tracking and responding to emotion, disclosing serious news, and resetting goals of care.
Advice for Patients
You recommend that patients write down any questions they may have about their care before the office visit. How does that help forge better physician-patient communication?
Patients who bring a list of questions to the office visit develop better comprehension of the information given about their cancer, such as prognosis. What I find in my own practice is that asking patients to bring in a list of questions has two benefits.
First, patients come to the visit more focused—the fact that they thought about and wrote down their concerns enables the big issues to surface more quickly. And, second, I can read through the list and prioritize the most important questions that I need to answer and then triage other questions to a nurse, nutritionist, or other member of the medical team.
I also advise patients to bring someone with them to the office visit so they have another ear in case they miss something. I reassure patients not to worry if they missed some piece of the information discussed because there will be more opportunities to go over the details of the discussion again in other meetings. ■
Disclosure: Dr. Back reported no potential conflicts of interest.
References
1. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Institute of Medicine of the National Academies, September 17, 2014. Available at www.iom.edu/endoflife. Accessed March 20, 2015.
2. You JJ, Downar J, Fowler RA, et al: Barriers to goals of care discussions with seriously ill hospitalized patients and their families. JAMA Intern Med. February 2, 2015 (early release online).
Addressing the evolving needs of cancer survivors at various stages of their illness and care, Palliative Care in Oncology is guest edited by Jamie H. Von Roenn, MD. Dr. Von Roenn is ASCO’s Senior Director of Education, Science and Professional Development Department.
