After covering the foundation of communication skills with SPIKES and NURSE, we will build on this foundation and add some skills to improve our conversations. In this post, we will discuss three phrases that can help with emotionally challenging situations in a conversation.
I wish
Many times, patients hope for things that are not possible.
Tell me you can cure this cancer
My goal is to make it to XYZ
How can you respond when you don’t think the outcome patients and families hope for is impossible/unlikely/improbable? How do we communicate that?
First and foremost, we go back to our foundation and reflect on what the patient said and how they said it. Is the patient asking us to “tell them that we can cure the cancer?” or that “they can make it to the event XYZ?” or are they just hoping that we would say that? The tone of their voice and the actions around the statement, such as eye contact and posture, can give you a clue. They may just be verbalizing their exacerbations or what they hope for, with full knowledge that they don’t think it is likely.
If that is the case, then not doing anything (being silent, being present) is likely the best thing to do. If you feel the urge to say something, what are your choices?
You can say, “I am sorry. I don’t think those goals are possible” - that is a true statement and a possible response. If that patient already knew that, it did not add value.
“I wish the same” is another way to respond that suggests that as a human being, you wish for the same outcomes.
There are different versions of “I wish …” such as, “There is nothing more I would want than …”
What if…
In the same conversation, at the same point when a patient or family suggests an outcome that is very hopeful or very dire, we can use another phrase to understand what is behind their statements.
When a patient or family suggest an outcome that is unrealistically hopeful, one can probe them with a statement and a question: “I hear what you are hoping for… I wonder what worries you the most” Or “what is your what if…?” I have learned that patients and families often express their hopes in front of the other person to avoid disappointing them. Everyone in the room may know what the “elephant is” (that the patient is dying) but no one wants to acknowledge it. By gently asking the question about “what if…” you can allow patient and family to open up and express their fears. I have found that providing that space is a powerful gesture of compassion and care.
What if… is not just only about their fears, it also works about their hopes. Sometimes pattients and families have very negative thoughts on the outcome, worse than what our experience would tell us. How do we explore that? By asking “I hear what you are worried about, I wonder if you can share what your hopes are” or “what is your what if, what if things turned out better?” Many patients will open up and tell you about how they prepare for challenges, some may want to “prepare for the worse” an that is absolutely ok. We just have to also at least have a conversation about “hoping for the best.”
At no point am I advocating for false hope. This is about reality.
…but…
So far, we have talked about what to do. This one topic is about what not to do. Or at least know that you are doing it and you mean to use this word.
Its a three letter word. b. u. t.
Here is what I hear many times. “I am also hoping that this treatment will be a miracl for you, but I don’t …”
Whether it is in an patient room or in real life, anything we say before “but” is not heard and may actually be aggrevating for the listener as patronizing. (Check with your spouse or loved ones on this if you wish).
If you mean to tell the patient that they have unreasonable expectations of your intervnetions, then I wish is a better way to acknowledge their wishes and then probing for their worse case scenarios will allow for better conversation.
Be clear of what you mean to communicate. Avoid “but” if possible because it negates what is said before. Sometimes people replace “but” with “and,” if that is your prference just realize that it is not the word that is bad, it is how we use it. If we use it to “pacify” the other person and patronize them, then whether it is “but” or “and” it will have the same results.
I would love to hear from you about some of your experiences and phrases that you use in these challenging conversations.
As always, if you like these topics, comment, like and share with your friends, family and colleagues as we want to have “one meaningful converastion at a time!”
Biren Saraiya MD