Engaging Emotions in Communicating Serious News

Scenario:

Ms. A is a 77-year-old woman with relapsed, refractory mantle cell lymphoma. Her comorbidities precluded her from clinical trial enrollment and other disease-directed therapies. She presented for a follow-up visit with her hematologist, Dr. B, to review her most recent imaging.

In opening the discussion, Dr. B checked in with Ms. A about how she was doing. Ms. A replied shakily, “I’m doing well and want to know what the scans showed.” He replied, “Unfortunately, your scans show the cancer is back.” Ms. A was shocked, “Well, what do we do next?” Dr. B replied, “This is difficult because we don’t have anything else to offer.” Ms. A became upset and began crying. Dr. B tried to calm her, “But you got all the right therapies,” and rattled off all the therapies she tried before adding, "It’s now time to discuss hospice care.” Ms. A left the office overwhelmed and unsure how she would communicate with her family.

Question:

How would you have approached this conversation with Ms. A if she were your patient?

Explanation:

Dr. B attempted to communicate serious news without responding to Ms. A’s emotional cues. Both Ms. A and Dr. B are left with the memory of an unpleasant exchange. Communicating any information, particularly progression of disease, requires acknowledging emotional cues.1 When clinicians respond to these cues and express empathy, patients are able to better understand and recall medical information.2 A practical approach involves using NURSE statements.

Let’s explore how the prior exchange could have gone better.

[N]aming the emotion: Dr. B checked in with Ms. A about how she was doing. Ms. A replied shakily, “I’m doing well but nervous about what the scans showed.” Dr. B replied, “I can see you’re anxious to go through your scan results, so let’s go through them.”

Naming and acknowledging the emotion (in this case, anxiety) would allow Dr. B to signal to Ms. A that her feelings have been noted and are valid. Emotions can make it difficult for physicians and patients alike to process information.4 Taking a moment to identify them explicitly has been shown to help clinicians better understand patients and therefore more effectively address their concerns.5

[U]nderstanding the patient’s perspective: He replied, “Unfortunately, your scans show the cancer is back.” Ms. A was shocked, “Well, what do we do next?” Dr. B replied, “With this update, I can understand your concern and would like to discuss what to do next.”

Expressing an understanding of the patient’s perspective has also been linked to better information recall6 and would allow Dr. B to transition to a discussion of hospice care. However, statements such as, “I understand how you feel,” may be misinterpreted as, “I know already – so don’t bother.” An alternative statement could be, “I can’t even imagine how upsetting it must be to hear this information.”

[R]especting the patient: Dr. B stated, “Up until now, we have been treating your disease to improve how you feel, and you’ve done everything in your ability to make sure these treatments work, from coming to appointments on time to letting us know when you weren’t feeling well.”

In this alternative scenario, Dr. B offered respect by praising her past efforts. Praise can be a pleasant surprise to patients when it is authentic and in the context of a trusting relationship with their clinicians. These statements reminded Ms. A of her efforts as she grapples with this unsettling information.7

[S]upporting the patient: Dr. B continued, “Unfortunately, we have no more treatments for the disease.” Ms. A began to cry. Dr. B paused to allow her a moment to process. Ms. A replied, “So this is it, huh? You’re just going to let me die?” Dr. B replied, “This news is upsetting to both of us. While I have no more cancer therapy to offer you, I will be with you as we map out the next steps.” Dr. B paused again.

Here, Dr. B communicated support and non-abandonment. Although empathy is an appropriate initial response, Ms. A’s reply made it clear she was wondering what would follow disease-directed therapy.8 Of note, Dr. B’s pause following this NURSE statement allowed space for Ms. A to acknowledge the empathic response.9

[E]xploring concerns: Ms. A collected herself and was less tearful, “I’m sorry, I’m just really overwhelmed right now. You and your team have been great.” Dr. B replies, “No need to apologize, this is difficult news for all of us. Can you share with me what’s on your mind?” Sniffling, Ms. A said, “I do not want to suffer and be in pain. I want to spend time with my family.”

In the fifth alternative, Dr. B explored her concerns to better understand her worries. Once she made them explicit, Dr. B could then explain how her concerns can be addressed and could then present his recommendations.3

Conclusion:

Dr. B said, “These are all important things for me to hear, and I thank you for sharing these with me. If it’s alright with you, I’d like to make a recommendation.” Ms. A nods. Dr. B introduced hospice care, and Ms. A received the information. After hearing everything, she expressed that she would prefer to speak with her family before deciding. She went home with a better understanding of her advanced illness, and after speaking with her family, elected for hospice care.
Communicating medical information requires responding to emotions. Rather than trying to “fix” emotions, clinicians can use NURSE statements to express empathy while delivering serious news.

1. Baile WF, Buckman R, Lenzi R, et al. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5:302-311.
2. Jansen J, van Weert JCM, de Groot J, et al. Emotional and informational patient cues: the impact of nurses’ responses on recall. Patient Educ Couns. 2010;79:218-224.
3. van Vliet LM, Epstein AS. Current state of the art and science of patient-clinician communication in progressive disease: patients’ need to know and need to feel known. J Clin Oncol. 2014;32:3474-3478.
4. Epstein AS. Not just words: caring for the patient by caring about language. JAMA Intern Med. 2013;173:727-728.
5. Adams K, Cimino JEW, Arnold RM, et al. Why should I talk about emotion? Communication patterns associated with physician discussion of patient expressions of negative emotion in hospital admission encounters. Patient Educ Couns. 2012;89:44-50.
6. Hall JA. Clinicians’ accuracy in perceiving patients: its relevance for clinical practice and a narrative review of methods and correlates. Patient Educ Couns. 2011;84:319-324.
7. Back AL, Arnold RM, Baile WF, et al. When praise is wroth considering in a difficult conversation. Lancet. 2010;376:866-867.
8. Back AL, Arnold RM. “Isn’t there anything more you can do?”: When empathic statements work, and when they don’t. J Palliat Med. 2013;16:1429-1432.
9. Hsu I, Saha S, Korthuis PT, et al. Providing support to patients in emotional encounters: a new perspective on missed empathic opportunities. Patient Educ Couns. 2012;88:436-442.