Navigating Communication With Seriously Ill Patients: Balancing Honesty With Empathy and Hope

Book Title: Navigating Communication With Seriously Ill Patients: Balancing Honesty With Empathy and Hope, 2nd Edition

Authors: Robert M. Arnold, Anthony L. Back, Elise D. Carey, James A. Tulsky, Gordon J.

Wood, Holly B. Yang

Publication Details: Cambridge University Press, 2024, 256 pp., $39.99 paperback

Many books on doctor-patient communication are available, but this one, Navigating Communication With Seriously Ill Patients, stands apart in its detailed analysis of the most challenging clinical interactions. The authors are experienced palliative care physicians from highly regarded medical schools and health care systems. Revised after 15 years, this second edition includes refinements in their VitalTalks curriculum and gives more attention to the role that power, culture, gender, and race play in communication. This¹ is a guidebook that first dissects the phrases, timing, and progression of conversations, and then coaches clinicians to practice individual skills and build their capacity for engaging in challenging conversations. The authors offer a concrete skill-building model that needs to be rehearsed, reviewed, and reflected on with intention and focus. As with teaching someone to play an instrument, this method identifes the building blocks of scales and fingering patterns that make for the artistic flow of conversation.

The book begins with a broad overview of foundational skills that most physicians will recognize: for example, asking patients what they know about their diagnosis or allowing silence after delivering important news. It then suggests cognitive maps such as REMAP (Reframe, Empathy, Map out goals, Align with patient, and Plan treatments), and reminds physicians to consider their own capacites (eg, self-awareness, empathy, curiosity). Subsequent chapters are devoted to common scenarios such as discussing prognosis, goals of care, family conferences, and conflicts between clinicians and patients. Each scenario includes a sample dialogue that portrays and labels a specific skill or cognitive map, using an acronym to help the reader remember it. For example, the cognitive road map for discussions on planning for the future uses PAUSE: Pause, Ask permission, Uncover values, Suggest support, Expect emotion. Each step in the dialogue from the scenarios is explained, describing “What happened” and “What we can learn.” Alternate endings to the scenarios to are often provided, as are common contingencies (eg, “What if the patient doesn’t want to talk about their goals?”). Chapters end with a bottom-line summary and “homework” to help cement the learning and with a list of resources, including video examples, articles, and recommendations from professional organizations.

The two chapters covering team conflict and patient conflict focus on underappreciated dynamics that the authors address well. Simple suggestions, such as replacing “but” with “and” while moving toward shared interests, are valuable strategies. The authors also acknowledge that some situations are unresolvable despite good communication. The final chapters in the book focus on the ability of clinicians to know themselves, to acknowledge the emotional toll of difficult conversations, and to seek support and time for processing their impact. The book concludes with a call for clinicians to cultivate their own skills to enhance the art of medicine.

For a family physician, this book can supply the words to label the challenges encountered in difficult emotional conversations. Clinicians will recognize the pitfalls and derailments of the clinical conversations portrayed and will be reassured by learning skills that can be relied on when faced with challenging encounters. The book can be read as a whole or used as a go-to reminder of a cognitive map and strategies to manage these conversations. On our first reading, we found ourselves agreeing wholeheartedly with the book’s recommendations, but we struggled to put them into day-to-day clinical practice or to remember its acronyms weeks later. Finding the time and focus to practice these skills is a heavy lift for a busy family physcian. However, this book also makes an excellent point-of-care resource to prepare for challenging patient or family encounters. We recommend that physicians in training and seasoned clinicians read this book and keep it close at hand as they gradually strengthen the practice of person-centered communication in the most difficult situations.