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Difficult conversations: Exploring perspectives
Last month, in her Palliative Care column, Stephanie Harman, MD, wrote about communications at the end of life. Communication at the end of life requires handling patient’s emotions. In my column this month, I want to share a recent patient encounter to highlight some skills in dealing with difficult conversations.
A self-described “bull” and “hard-headed” person, Mr. DK is a 60-year-old man with extensive-stage small cell cancer diagnosed in April 2009. He always wanted to focus on the “positives.” He would say, “a positive attitude will help me beat this cancer.”
Initially, I tried to ask him what he meant, to be sure that we had the same understanding of the cancer. He would tell me, “I know that we are trying to control the cancer, but I know I am going to beat it.” Who can argue with that? Besides, at some level, he had heard what I said about the goal of controlling, not curing his cancer. I did not try to change his attitude.
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In late December, I saw him in the office with his son to discuss recurrent disease. My goal for the day was to break the bad news to him about recurrence and if he allowed, talk about the next steps including, treatment options. As expected, he had a difficult time accepting the news. He just could not believe it. He kept going back to how “it really can’t be true” and how “[he] felt great, better than ever,” and how “[he] was just recovering from the chemotherapy.”
Recalling what one of my mentors, Walter Baile, MD, a HemOnc Today Editorial Board member, had taught me, I knew that this was really an emotional reaction and that nothing I said about the next treatment would register with the patient. I would have to “address emotions before facts.” I used statements such as “it sounds like this is really hard to believe,” “I wish I had better results,” “this really sucks!” and others to try to address his emotions. He continued to be in disbelief. We never really talked about anything else and decided to meet again later in the week to discuss the situation further.
At the follow-up, he asked, “So, what does this mean?”
‘What does this mean?’
It is a common question that all oncologists get asked. It may be by a patient with a new diagnosis, a patient with recurrence, or by a family member. But, what does the question mean?
Is the question about the implications of the diagnosis, treatment, recurrence or prognosis, or is it just a statement of disbelief? For some, it raises existential questions about life and the meaning of life. For some, it is more about the practical aspects of life, such as, “Can I work? Will I be able to be as functional as I have been?” And for others, it is disbelief, “How could this be?”
I am never sure what exactly the question is when a patient asks me something that sounds like a prognostic question. So, I ask them, “What do you mean?” My patient then asked, “How long have I got?”
I had a decision to make at this moment. This was a question that could be answered by “a few months” or I could delve even deeper into what made him ask the question. The answer “you have a few months to live” would potentially lead to an emotional reaction — of disbelief — followed by some anxiety and eventually the discussion of treatment. I decided to explore a bit further and asked him a more direct question, “How would you use this information?”
To my surprise, a man that had always focused on the “positive attitude” and “hope” asked me about his prognosis, about his life expectancy so that “[he] could plan for his family.” He was asking about “what if…” the hopeful scenario did not come true?
I explored further. I said, “Tell me more.” He wanted to plan for his children; there were things he wanted to discuss with them. We spoke further about the implications of his prognosis and what it meant for his family with his social worker, and then discussed the treatment options.
During each encounter, patients provide many opportunities to discuss their emotions and having a framework such as SPIKES protocol is helpful in facilitating these discussions to help patients.
SPIKES is an acronym that provides a framework for communicating difficult news to patients. It includes strategies to address the setting of a conversation, to acknowledge a patient’s perceptions, to obtain an invitation to deliver news, to provide knowledge to a patients while also addressing their emotions, and finally, to summarize the situation and lay out a strategy to close out the conversation.
Biren Saraiya, MD, is an Assistant Professor at the Cancer Institute of New Jersey at UMDNJ-Robert Wood Johnson Medical School and is a member of the HemOnc Today Editorial Board.
For more information:
- Baile WF. The Oncologist. 2000;5: 302-311.