What Are the Key Elements to Having a Conversation About Communicating Serious News and Setting Goals?

Introduction and Scope of the Problem

The two most common communication tasks faced by palliative care clinicians are communicating serious news and discussing transitions in goals of care. Although these skills are often taught as part of general medical, nursing, and social work curricula, the skills needed by palliative care clinicians are generally more complex. Table 32.1 presents some common topics in palliative care conversations that differ from more routine conversations about goals of care. A palliative care consultation often involves both communicating serious news and discussing care preferences; however, the literature separates these into two distinct communication tasks. This chapter provides a discussion of the communication science surrounding these tasks, a summary of the key elements for each of these tasks, including the evidence for the recommendations when available, and suggested language for these conversations.

Relevant Communication Science

The science surrounding the tasks of communicating serious news and discussing transitions in goals of care represents the perspectives of the patient and the clinician(s).

From the patient’s perspective, hearing serious news may provoke various emotions, including shock, fright, acceptance, and sadness. A patient’s understanding of and emotional adjustment to the illness are affected by two factors that are within clinician control: (1) the manner in which the patient is told the serious news and (2) the manner in which the clinician responds to the emotion provoked by the serious news.

Patients’ preferences vary in their desire for how serious news is discussed. Studies have found that some patients prefer to have a close relative or friend present, that others are open to having allied health professionals such as chaplains or social workers present for or even delivering the serious news, and that the amount of information a patient or family believes is appropriate to share varies with age, gender, ethnicity, and even type of disease. This heterogeneity of patient preferences regarding how to best communicate serious news suggests that each individual patient should be asked about preferences as part of the preparatory work for a serious-news conversation.

The manner in which the clinician responds to the patient’s emotion, the second factor affecting a patient’s understanding of presented information and emotional adjustment, depends on the clinician’s ability to recognize emotions expressed during the conversation. From the clinician’s perspective, the emotionally charged nature of communicating serious news and discussing transitions in goals of care makes these communication tasks especially challenging. The experience of delivering serious news induces both psychological and physiological stress for clinicians, who may experience various worries, including being blamed for the serious news, unleashing emotion in patients that they then don’t know how to address, and expressing their own emotion. Indeed, existing studies indicate that physicians commonly overlook emotional cues and make few empathic responses when talking to patients. Because emotion can be expressed at any point in the conversation, the skillful clinician will be ready to respond to this emotion in an empathic manner at any point. Empathic responses to emotion align the clinician with the patient and seem to help patients and family members process what is happening so that they can understand more of what the clinician says.

Existing communication guidelines present a stepwise approach to the tasks of communicating serious news and discussing transitions in goals of care while also taking into account factors affecting a patient’s understanding of information and emotional adjustment.

Summary of Evidence Regarding Communication Recommendations

This chapter consolidates the existing data to present a stepwise guide of elements to consider before, during, and after an encounter. Although medical encounters in which either serious news is delivered or in which a transition in goals of care is discussed are rarely linear, stepwise guidelines offer several advantages for the learner, the medical educator, and the clinician. First, these stepwise approaches serve as useful cognitive frameworks for learners who may be asked to observe one of these encounters. In reflecting on such an observed encounter, the learner who has been primed with a short didactic describing a stepwise approach will be able to scaffold observations into clear steps. For the medical educator, stepwise guidelines translate to skills that can be taught, observed, and evaluated. Finally, for the advanced palliative care practitioner, stepwise guidelines serve as the foundation on which to build a wider breadth of skills. These may be particularly important for the experienced practitioner to draw on when met with complex or challenging communication interactions.

For this discussion, these skills will be illustrated using the setting of a palliative care family meeting. Elements of this framework may also be helpful in an initial palliative care consultation or when clinicians find themselves in a position of needing to respond to patient and family medical concerns in follow-up visits. In addition, it should be noted that this chapter covers both communicating serious news and discussing transitions in goals of care. These represent two distinct communication tasks that may or may not be covered in a single conversation, depending on the situation and the patient’s cognitive and emotional capacity to continue with the conversation after hearing the serious news. For the purposes of this chapter, the two tasks will be presented in sequence.