Communicating with patients and families

Communication can be the most effective medical therapy.

General talk tips:

  • talk less, listen more
  • be aware of non-verbal communication
  • get a professional interpreter if first language not English
  • use plain language
  • check for patient/family understanding when giving medical information

Patient Dignity Question

This one question can provide very useful information that will aid in the care of the whole person:

“What do I need to know about you as a person to give you the best care possible?”

Breaking Bad News


S=Setting up interview

  • preparation, privacy, involve significant other

P=assess patient’s Perception

  • “Tell me what you understand about what is happening?”

I=Invitation to information

  • “Some people like all the information, others just want the big picture. How much information is right for you?”

K=sharing Knowledge and information

  • words of warning: “I have some bad news for you…”
  • share information in plain and clear language
  • check for patient understanding: “Is this making sense to you?”

E=addressing Emotions with Empathetic responses

  • empathize and validate “This must be difficult for you…”
  • when not sure what to say – silence is OK

S=Strategy and Summary

  • identify coping strategies, sources of support
  • ask if patient/family have any questions
  • plan for the future “I will come back to see how you are tomorrow”

Advance care planning conversations

Patient/family need clinician to initiate

Ongoing conversation

Introduce early in illness and revisit after change in disease status, hospitalization or if patient asks.

Future plans

“Have you discussed your thoughts about the future with your family or ever put them down in writing?”


“How do you make decisions. Do you make them on your own or make them as a family?”

“If you were unable to speak for yourself who will make decisions for you?”

“Do you have any fears or worries about the future?”

“Is there anything that would be worse than death for you?”

Aware of all options

“There may come a time when we suggest treatments you don’t feel comfortable with or a time when you wish to stop treatment. We will understand and support you in this decision and will continue to work with you to have you live as well as possible.”


“Some people like to know all the details, others just want the big picture and some prefer not to discuss it at all. What is best for you?”

If information desired, start with
“Tell me what you understand about your illness.”

If prognosis uncertain
“We are not very good at predicting how long people live with your disease, but I would estimate years/months/days.”

Other useful phrases
“We cannot cure your disease, but our goal is to help you live as well as you can for as long as you can.”

“Although we don’t have any further treatments to reverse the disease, there’s always something we can do to help you feel better.”

CPR in advanced illness

  • success rate very low in advanced illness
  • not obliged to offer futile treatment but should always explain why it is not being offered
  • focus on what will be done and not what is no longer offered

“We will do everything we can to help you live as well as you can for as long as you can but when you die we will help you to have a peaceful and natural death.”

if there is unwillingness to accept this explore concerns and myths:

  • DNR does NOT mean no more treatment
  • CPR will not improve the outcome of the illness

CPR video decision-aid for patients:

End-of-life discussion

Discussion about withdrawal/withholding of treatment; transitioning to end-of-life care

Follow modified SPIKES – see Breaking Bad News

S=Include significant others

P=“Tell me what you understand about your illness at this time?”

I=“Are you the kind of person who wants to know all the details, just the outline or not talk about this at all?” “Do you make decisions on your own or as a family?”

K=“When you began the treatment the hope was that the disease would remain controlled (or cured) Unfortunately the disease is continuing to progress and we need to consider what is next.”

Give information about disease state, reason for withdrawal/withholding and focus on what can still be done.

“Although we do not have any further treatments to reverse or stop this disease, there is always something we can do to help you feel better.”

Share information, and check for understanding or questions.

If there is a decision to be made: “Would it be helpful to you if the team made a recommendation?”

Decision-making can be a process and may need further meetings

E=validate feelings with empathy

S=summarize discussion and decisions if made. Document and share with team so everyone “on the same page”. Or plan to meet to further discuss or decide

Goals of care

  • assist in developing care plan that best fits patient’s beliefs and values
  • part of ongoing process and may change over time as patient condition changes.
  • can be part of end-of-life or advance care planning conversations or on its own

“How is this illness affecting you and your family?”

“What is most important to you now?”

“Does the treatment you are receiving feel right to you?”

“Do you have any worries or concerns about the future?”

  • Confirm what you heard from the patient:

“So what I am hearing is that you feel …”

Cross-cultural questions

may be useful if patient/family have ongoing distress over direction of care, non-compliance with treatment, requesting futile treatment, have distrust of healthcare team

Kleiman’s questions:

  • “What do you think has caused your problem?”
  • “Why do you think it started when it did?”
  • “What do you think your sickness does to you?”
  • “How severe is your sickness? Will it have a short or long course?”
  • “What kind of treatment do you think you should receive?”
  • “What are the most important results you hope to receive from this treatment?”
  • “What are the chief problems your sickness has caused for you?”
  • “What do you fear most about your sickness?”

Specific situations

Talk tips for difficult situations

“Don’t tell them they are dying”

explore and try to understand basis of request

ethical obligation is to ask the patient what information they want about their illness – and to respect this

if English is not language of the patient – get professional interpreter and ask about preference for information and decision-making

“Everything must be done”

aggressive disease therapy not indicated yet patient/family repeatedly request full medical therapy

explore what patient/family understand about the illness – consider cultural questions, ensure family fully informed

explore what “everything must be done” means to patient and family

find “common ground” between patient/family and healthcare team and work from this point

Build trust with patient/family and ensure consistent messaging

ethics consultation very helpful


patient/family anger with life and health situation can be projected on to healthcare team

do not take personally, but do not ignore

Identify the emotion

“You seem angry today.”

If you understand cause of anger you can validate it. “It must be hard for you to hear this bad news”

If you do not understand the source of the anger ask: “Can you help me understand why you are feeling this way?”

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