Triadic Communication—Naming the Third Person

What Is Triadic Communication?

Triadic communication is a fundamental part of health care communication and a key feature of adolescent and young adults with cancer (AYAC) care.^1–4 Triadic communication refers to the presence of a third person, who is not a health care professional, in a clinical encounter. ⁵

The evidence related to triadic communication is limited but growing, including a mixed-methods study of triadic communication in adolescents, ⁶ a large systematic review of physician-patient-companion communication in adults ⁷ and a literature review of pediatric consultations in primary care. ⁸ We recently published a systematic review of triadic communication in AYAC aged 13–24. ⁴ The terminology for the third person is highly variable, with a range of possibilities including “parent,” “companion,” “carer,” “caregiver,” “informal caregiver,” “advocate,” “proxy decision-maker,” “relative,” and “next of kin.” This heterogeneity may be compounded by the diverse disciplines investigating the topic (e.g., medicine, linguistics, sociology, and psychology). ⁷ Are these terms appropriate for the third person accompanying AYACs?

The third person has the potential to encourage or hinder the voice of the young person, and this is a dynamic process across the cancer pathway.^9,10 The presence of a third person is concurrently helpful and challenging for AYACs. They can undertake helpful roles and responsibilities such as asking questions on behalf of the young person, retaining information from health care professionals, and promoting autonomy. However, young people can also experience limited communication in the presence of a third person. Examples include communication being directed to the third person; the third person may dominate the communication, and may filter information to protect the young person. ⁴ However, their objective (most of the time) is to support the young person in the way the third person perceives is best. There can be instances where the third person’s perspective or priority differs from that of the young person, and acknowledging these differing perspectives is crucial to navigating triadic communication. If a third person encourages (or coerces) a decision or requests care that is not clinically in the young person’s best interest, the role of the health care professional in managing the encounter is critical. It is paramount that the young person is held central in the triadic communication encounter, unproxied by the third person. ¹¹ Establishing the young person’s perspective can be challenging due to bidirectional nondisclosure as a result of mutual protectionism, especially at points of high threat in the cancer experience. ⁹ For these reasons it is essential that health care professionals offer one-on-one time alone with a trusted professional to elicit the young person’s perspective and deliver quality AYAC health care.^1,4,5,9,12

Who Is the Third Person?

The most common third person is a parent, often a mother.^2–4 The age range of AYAC care extends up to the 25th birthday in the United Kingdom (UK), but upper limits of 29 and 39 years are recognized internationally. Therefore, the frequent focus on parents may seem surprising, potentially impacting the generalizability of evidence. Societal changes over recent decades are leading to young adults becoming increasingly dependent on, and interconnected with, parents.^13–15 This could be for several reasons, including expansion of tertiary education, longer periods of inadequate employment, declining marriage rates, and technological advances. ¹⁶ In addition, AYAC face a life-limiting illness with grueling treatment and experience a tendency towards behavioral regression. ¹⁷ Cancer anchors the young person in a state of dependency that conflicts with the natural transition of adolescence and early adulthood. ¹⁸

Clinicians perceive that the third person will be a parent, which may reflect the historical position of AYAC cancer care being in pediatric. ¹⁹ There is a paucity of data for non-parental third parties, which may represent a reality of clinical practice. However, bias towards AYAC-parental dyads in research may also contribute bias.^18,20,21 We want to draw attention to this significant gap in the literature to stimulate debate among clinicians, educators, and researchers. We argue it is not appropriate to assume the third person is a parent, especially when considering services that serve patients up to the age of 39. Although parents remain important stakeholders, a non-parental third person may be present in many clinical communication encounters with a young person.

In the literature, non-parental third parties described feeling relegated to a non-participatory role by a parent, and mothers described the struggle to relinquish their role as primary supporter.^18,21 Health care professionals may contribute to this subconsciously by failing to take such relationships as seriously as parental ones. In order to promote young people’s autonomy and independence, we argue for increased recognition that the third person may not be a parent and for health professionals to empower others according to the needs and preferences of the young person.

What Should They Be Called?

Terms such as “carer” or “informal caregiver” are used in older adult care, but these evoke images that may not feel consistent with AYAC care. There has been increasing recognition that health care for AYACs needs to differ from that received by children and adults,^11,22 and these terms may not be aligned with the unique needs of this population. Carers in the UK are widely defined in health care policy as “lay people in a close and supportive role who share in the illness experience of the patient and who undertake vital care work and emotion management.” ²³ This definition may not feel relevant to young people and their third person. Knowles et al ²⁴ found that family and supportive friends (aged 29–69) of patients with long-term conditions did not identify as carers to avoid undermining the independence of their “care recipient.” This is a key principle underpinning AYAC-centered health care, addressing the developmental needs of young people aged 14–24. ²⁵ How, then, should we refer to this person?

The term we give to this person needs to be appropriate for all parties in the triad and reflect the roles undertaken in the communication encounter. To our knowledge, to date there has been no research investigating the preferred term for the third person. We undertook a professional engagement activity at the Global AYA Cancer Congress in 2023. Our workshop, entitled “Words Matter: Communicating Effectively with Adolescents and Young Adults with Cancer Along the Cancer Care Continuum,” included over 70 health care professionals. During the workshop we asked what word they would commonly use to describe the third person. There was a wide range of suggestions and no overall consensus. The suggestions offered by professionals included words such as “carer,” “caregiver,” “advocate,” “parent,” “champion,” “companion,” “significant other,” “patient navigator,” and “helping hand.” However, the most frequently used words included the word support or supporter: “support person,” “first supporter,” “support system member,” and “supportive loved one.”

This suggests that a term incorporating “support” may be of value. Iannarino ²¹ (Associate Professor of Health Communication, University of Michigan) has adopted the terms “first supporter” and “second supporter” in his work on non-parental third parties. The word “support’ means “to bear all or part of the weight,” and evidence suggests this is what a third person does in triadic communication. ⁴ Sometimes the third person may do most of the communication (requested or not by the young person). It is a health care professional’s role to elicit the young person’s preferences and navigate the triad, permitting the third person to communicate as much, or as little, as the young person wants and needs at that given time. This will ensure they remain in their desired role within the communication encounter, whether that is active driver or collaborative participant. “Supporter” also means “to encourage and advocate for.” We suggest that the term “supporter” better aligns with the goals of AYAC care, as it is less likely than terms such as “carer” to undermine autonomy and independence. We hope that this will remind clinicians that the third person may not always be a parent and aid inclusion of non-parental supporters if this meets the needs and wishes of young people.

Conclusion

We suggest the term “supporter” is used for the third person in triadic communication. This aligns with the overarching principles of AYAC care: autonomy, developmentally appropriate care, and shared decision-making. Health care professionals need to support the voice of young people in triadic communication encounters, and recognizing the important role of non-parental supporters may help in this goal. There may be other appropriate terms, and we encourage further thought, debate, and research to investigate the perspectives of young people, supporters, and health care professionals. Whatever terminology is chosen, it must be able to be consistently applied to all supporters and must enhance communication and patient-centered care.