Effective communication has the potential to promote understanding, safety, and connection. It is the foundation of high-quality health care. Our use of language to heal is important in all facets of medicine, but words may be even more powerful when patients face a terminal diagnosis. When medications and life-saving interventions are less of a priority, language can instill hope and honor the human behind the illness. As such, I believe all physicians can learn effective communication principles from palliative care physicians, who rely on language to help patients traverse one of the most intimidating yet inevitable events in life: death.
Coming to terms with death is a challenge for patients, their loved ones, and their communities. In these circumstances, communication is fundamental to healing. As a first-year student with little to no training in communicating challenging diagnoses in a clinical setting, I sought out the expertise of oncologists and palliative care physicians to explore the overarching question: how can we improve our communication with patients at the end of life?
Inquiry before advocacy
So much of medical education is built on pattern recognition. Imagine walking into a patient room only to hear a patient’s first few sentences because you’ve immediately jumped to a diagnosis. Pattern recognition is helpful until it leads to impersonal care.
“Inquiry. Inquiry before advocacy,” says Dr. Toluwalase Ajai, a pediatric palliative care physician at Rady Children’s Hospital. “This lets me know not only how much the child knows about what’s going on in their body, but it also lets me take a deep breath and know how to deliver the information by asking that question.” We can improve our clinical acumen with curiosity and willingness to listen. You cannot treat what you do not know.
Through my ambulatory care apprenticeship (ACA) and our longitudinal clinical clerkship in our first two years of medical school, I have witnessed the healing capacity of palliative care and empathetic inquiry. One day, in the first few months of ACA, our team was assessing a 38-year-old woman who was declining quickly due to aggressive ovarian cancer.
“She was such a beautiful woman,” her husband said somberly as he massaged her hands. “It’s sad that she is leaving this world at such a young age.”
As she faced the final stages of life, the woman had limited consciousness due in part to the analgesics that reduced her cancer pain while also sedating her. The medical team sat quietly. As we saw the husband continue to gently massage his wife’s hands, we saw her smile occasionally. Even though she couldn’t express herself verbally, she was still attuned to touch and sound, which are commonly considered the last two senses that we lose before dying.
“She can hear you,” the physician gently whispered.
The husband lightened up immediately as though he were pleasantly surprised.
“Oh, my,” he said as he relaxed and smiled for a moment, wiping away his tears.
The social worker then mentioned that the hospital had a chaplain available for patients and their families to seek spiritual guidance and healing if they desired.
When asked about his thoughts on meeting with a chaplain, the husband responded, “You know what, why not? It can only help us during this challenging time.”
Even though there was nothing we could do to change the inevitability of her death, we could still offer some solace in a time of immense grief.
Understanding what matters
“I think there is sometimes a misunderstanding that the palliative care doctor is going to go in and get the do not resuscitate (DNR) order. That’s my job, but it’s not actually my job,” says Dr. Krishelle Leong Marc-Aurele, a perinatal palliative care physician at Rady Children’s Hospital.
“What I say to a family when I meet them is that my job is to understand what makes a good day for you, your child, what we can do to have more good days, and what’s really important as we think about the future,” Dr. Marc Aurele reflects.
“In response, most families will say, ‘Oh, that sounds great.’ And you could argue that that’s what every physician’s job is,” she concludes.
Part of the challenge with appreciating palliative care principles may be the stigma tied to the field’s commonly used terms. But there is so much more to palliative care than DNRs, advanced directives, and goals of care.
“Over the years, I have realized that ‘goals of care’ is just medical jargon. It doesn’t mean anything to people,” says Dr. Jared Rubenstein, pediatric palliative care physician at Texas Children’s Hospital.
“You should never ask someone what their goals of care are, verbatim. To me, goals of care are hopes, values, wishes, fears, and priorities,” Rubenstein mentions. “You can learn all those things without ever having a grave conversation.”
Communication styles that are unique to the palliative context exist for a reason, but that does not mean they cannot be applied across other disciplines in medicine. Training on effective communication in medical school is limited. In fact, one study that collected survey responses from residents highlighted that 88 percent had little to no training in end-of-life care. Perhaps it is time that we changed that.
Bringing palliative care communication to the forefront
Equipped with a willingness to learn from our patients, both current and future physicians can improve our ability to deliver care. This begins in medical school. We can implement targeted modules that engage palliative care educators early in our education. In the same way that we learn the different aspects of a physical exam, we can sharpen our patient interaction skills with systematic empathy and communication training. We can introduce more opportunities to work with the palliative care services during third-year rotations. By listening to patients, adopting a genuine curiosity for their condition, and identifying their priorities, we can improve health care quality for all – not just those dying.
Sahit Menon and Alec Terrana are medical students. Kathryn Winters is a palliative care physician. Desiree Shapiro is a psychiatrist.
