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Critical Conversations: Say This, Not That!

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In a time when clinicians are having thousands of difficult discussions with patients and families, it may be appropriate to recall a lesson learned from the medical futility movement: the words we choose matter. We now know to say, "This treatment won't be beneficial" rather than, "Continuing care is futile," to avoid sending the message to families that their loved one is not worth caring for. As clinical ethicists, we have participated in countless critical conversations. We have heard many questions and comments intended to convey one message, only to see families and patients take away another (Table 1). Here, we identify some commonly invoked phrases that can be misleading or disempowering and suggest alternatives for better communicating with those we serve. 

"What Do You Understand About Your Father's Condition?"

This question is intended to gauge someone's perception of their loved one's condition, hoping to get a sense of whether their expectations are realistic and to correct any misinformation. It may, however, cause a family member to feel that their understanding is being questioned or that they need to prove they know the right answers. Instead, saying something like, "What has the team been saying about your father's condition and treatment options?" can emphasize the shared responsibility of accurate communication. 

 "Your Mom Is Very Sick"

Families already know that their loved one is very sick; they just do not know how sick. This phrase is often used to indicate that a patient is unlikely to recover, but families may be misled by language that glosses over the important medical nuances that differentiate patients with a reasonable path to recovery from those without. It is hard to say to a fearful family, "Your mom is not responding to treatment in the way we had hoped. We don't think she is going to survive." Even so, being clear and direct in giving bad news empowers families to make more informed, if difficult, decisions.

"It's Your Decision…It's Up To You"

When clinicians say things along these lines, the intention is to reassure the patient or family member that we respect their autonomy or decision-making authority, but this phrasing can seem to place the burden of decision-making on patients or surrogates alone. They may feel forced to make a choice they do not feel prepared to make or left to take sole responsibility for its consequences. One way to avoid putting this weight on patients and families is to choose words like, "Help me understand what is important to you and we will figure out what to do next together." Another approach is to ask directly about the support they would like in making decisions. 

"Do You Want Us to 'Do Everything'?"

The framing of this question nudges patients or surrogates toward pursuing all available measures. Families may be reluctant to answer "no," feeling like the only alternative would be to "do nothing" or worrying they would be giving up too soon. Further, "everything" might mean different things to different people. Instead, we can be more specific in the questions we ask, identifying discrete options and describing the various paths forward. Saying something like, "We could keep him in the ICU on the ventilator and give him additional medications if he needs them or we could focus more on making sure he is comfortable than keeping him alive longer." Fully explaining what each of those options would look like can help families get a clearer picture of what would happen if they ade each choice. 

"There Is Nothing More We Can Do"

There is never "nothing more" that we can do. This language suggests that we are abandoning patients, walking away from them at a critical time. In contrast, when curative options are exhausted, there is plenty we can do to manage pain and control symptoms. We can also try to provide solace and connect them with supportive services such as palliative care, social work, or chaplaincy. What we mean to say is, "We don't have any further treatments that will slow down your wife's disease, but we can manage her pain and make sure that she is as comfortable as possible." This approach makes it clear that they will not be alone in facing whatever is to come. 

"I Don't Have a Crystal Ball…"

We use this phrase to make it clear to patients or families that we cannot predict prognosis with complete certainty. Patients and families, however, can interpret it to mean almost anything can happen. When they ask questions about prognosis, they are not usually asking for guarantees. Instead, they are asking for information that can help them make decisions and prepare for what lies ahead. This information can be given by offering specific descriptions of the possibilities and their probabilities, using phrasing such as, "Based on my clinical experience, the best we can hope for is [X]. I think it is most likely that [Y]." This approach helps set expectations while conveying that the prediction is not a promise.

"Do You Have Any Questions?"

This inquiry is intended to ensure that patients or families have the opportunity to ask for information and to raise any concerns they may have. The closed-ended framing, however, can be heard as a signal that the conversation is over and that they have been given all of the information they need to know. Further, patients and families may be overwhelmed and confused by medical jargon and may feel guilty or embarrassed if they do not know which questions to ask. Open-ended framing such as "What questions can I answer for you about the care plan?" or "What else can I tell you?" sets the expectation that there is more they might like to know, sincerely inviting them to ask.Critical conversations are never easy—for clinicians, for patients, or for families—but changes in the words we use can make a big difference. We hope these insights from our experience can help make these discussions a bit easier for all.

References
    • Kon A.A. Futile and potentially inappropriate interventions: semantics matter.Perspect Biol Med. 2017; 60: 383-389
    • DeForest A. Better words for better deaths.N Engl J Med. 2019; 380: 211-213
    • Vig E.K.,Starks H.,Taylor J.S.,Hopley E.K.,Freyer-Edwards K.  Surviving surrogate decision-making: what helps and hampers the experience of making medical decisions for others.J Gen Intern Med. 2007; 22: 1274-1279
    • Kruser J.M.,Taylor L.J.,Campbell T.C.,et al. "Best case/worst case": training surgeons to use a novel communication tool for high-risk acute surgical problems.J Pain Symptom Manage. 2017; 53: 711-719

Source :Chest Journal

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Friday, 22 January 2021

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