Abstract
Abstract
The communication skills of noticing emotional cues and responding empathically are necessary but insufficient for some conversations about redefining goals of care. For some patients, an empathic response by a clinician is insufficient to move the conversation forward. We describe an expert approach that links empathy to action. In this approach, we outline (1) how affect provides a spotlight that illuminates what is important, (2) how empathy affords a way to connect with patients and families that engages deep values, (3) how clinicians can infer deep values through an associative process with patients, and (4) how clinicians can then design actions with patients and families and nurture their commitment to the actions.
Introduction
I
The new consult was a 45-year-old man with metastatic colon cancer, hospitalized the previous day for a pain crisis. An abdominal computed tomography (CT) showed progression of liver metastases despite third-line chemotherapy. The palliative care fellow presented the case with a detailed plan for pain management. The attending said, “I agree with your plan—nicely done. So I'm wondering how this case might illustrate one of the communication issues we talked about in our conference last week.” The fellow said, “If we're talking about communication, I did get kind of stuck at one point. The patient was aware of the fact that the only chemo left is a clinical trial—he's not sure he wants to do it—he wants to spend all his time with his kids. I could see he was getting teary, so I said, “I can see how sad you are”—I was trying to respond to his emotion, like we talked about in conference. He got teary, didn't say anything. So I said, “This is really sad” again. Then he said, “Yes it's sad but what should I do?” I wasn't sure what to say next. I tried saying, “One thing we can do is hospice,” but he looked away and said, “How about later?”
For the attending who is trying to teach communication, existing literature offers the following points: responding empathically is seen by many patients as kindness; for some patients, multiple encounters will be needed2–4 ; and that providing a comfortable silence can enable patients to pull themselves together. 5 We would not quarrel with any of these teachings, but from our experience we feel that there is another level of skill development.
This new level of skill development is accessible to clinicians who have learned to (a) see the emotional cues, (b) respond with empathic statements that name the emotion, and (c) assess whether the patient is ready to move forward. This represents a high level of communication skill. What we have not seen in the literature is our observation that at this skill level, empathy has value beyond the internal experiences of patients and clinicians—it opens a door to a kind of inquiry beyond logical questioning that enables clinicians to grasp the deep values that should shape goals of care. This is an expert approach that links empathy to action. The steps in this approach address (1) how affect provides a spotlight that illuminates what is important, (2) how empathy affords a way to connect with patients and families that engages deep values, (3) how clinicians can infer deep values through an associative process with patients, and (4) how clinicians can then design actions with patients and families, and nurture their commitment to the actions.
Moving Toward “Wise Mind”
In making this process explicit, we have found it useful to see humans as having two minds—an emotional mind and a rational mind. The emotional mind is where feelings and intuitions originate, and it is involuntary (although we all exercise different levels of self-regulation on how we act on our feelings). The rational mind is analytical and logical, and it works only when we exert effort. 6 Linehan developed the idea of “wise mind” to describe what acting on our values looks like in the best sense: an integration of emotion mind and rational mind. 7 Wise mind is where we can grasp the bigger picture, and for patients facing difficult medical decisions, wise mind is the place where medical decisions that match values originate. What is especially useful is that wise mind is a capacity that can be learned, and clinicians who know wise mind themselves can introduce their patients to it. So in this framework, when the fellow noticed the emotional cue (“getting teary”) and made an empathic statement (“I can see how sad you are”), what he had done was open a window into the patient's emotional mind. What the fellow hadn't done was recruit the rational mind in a way that moves that patient toward wise mind. That's what our process is designed to accomplish.
1. Seeing the affect as a spotlight
In debriefing the case, the attending asked the fellow, “Do you have a idea of what the sadness was about?” The fellow replied, “I assume it was about dying—isn't that what everyone is sad about?” The attending said, “Well, maybe. Since he didn't tell you, how about if we say we're not sure. Let's try to understand more about the sadness. To do that, we need to learn to listen in a different way. Let's do the following. I'll talk to him, and instead of listening for the details and watching for an answer, try listening in a different way. Listen for the emotional tone—I mean a feeling or a story or a picture. Don't worry about whether you are correct. And notice where I go with the conversation.”
What the attending did was frame the patient's emotion as a spotlight that illuminates something important—yet at this moment unknown. Rather than try to turn off the patient's emotional mind or ignore it, the attending set up the possibility that it could be heard in a different way. What can be confusing for physicians who have been trained to prioritize their rational minds is that the connection between emotions and deep values is often nonlinear, rooted in personal history more than medical fact. But considering the emotion to be a spotlight rather than a distraction is a helpful step in moving patients toward wise mind.
2. Using the patient's affect as a focus to connect
When the attending met with the patient, he said, “Nice to meet you…[introduces self]…Tell me what you took away from your talk earlier today with the other doctor on our team.” The patient said, “That I'm hosed—no more options. It's terrible.” His eyes began to fill with tears. The attending said, both for the patient's and the fellow's benefit, “I notice that your eyes are welling up. This is a very tough reality to accept.” The patient nodded, and a moment of silence passed. The attending said, “In my business, this is one of the toughest moments.” The patient looked up and said, “I feel like I'm being a wimp, when I need to be strong.”
What the attending had done was connect to the affective tone of the moment. He commented on the patient's eyes welling up as a nonjudgmental way to describe sadness. Then he validated the difficulty of the moment (“in my business”). It is not so important to figure out exactly what emotion your patient is having. Our rule is: Connect first, before you try to figure out what is being spotlighted.
We concede that what the attending did was not so different from what the fellow had done: notice the emotional cue, and respond in a way that acknowledges the patient's experience. Where the difference lies is that the attending was not trying to dissipate the emotion or wait for it to pass—on the contrary, the attending was seeking to connect to and engage with the patient's emotional mind. When the attending said, “I see your eyes are welling up,” the underlying message the attending was giving to the patient was, “I see you're upset,” “I feel you're deeply hurting,” “I am willing to be here with you,” and finally, “I can stay here without being thrown too far off balance—and you can, too.” Obviously, this requires that the attending can recognize the patient's emotion, articulate a response, and also regulate his own emotions. These functions have been well described in the medical literature.3,8–12 What has not been described for palliative care is in the next step.
3. Reading between the lines of affect to infer what's important
The attending then said, “I wish I had a simple solution.” The patient replied, “Oh, that's not what I'm after. None of the real solutions in my life have been simple.” The attending said, “What has not been simple for you?” “Well,” the patient said, “for one thing, having kids as a gay man has not been simple.” The attending said, “How is that true now?” The patient got teary again. “Now I need to be strong for them. And I don't know how to do it.”
What the attending had done goes beyond responding empathically. The attending had noticed that the patient described his life as not “simple,” and asked the patient to elaborate on what is “not simple” now, in the moment. The attending was acting on an inference that “not simple” represents something important about the way this patient was interpreting his life. Some observers might call this intuitive—but we consider it to be a skill that this attending had cultivated. This “listening for inferences” skill is a way of listening to patients that is not looking for data points, but rather is sifting through associations that the patient makes13–16 —these are often associations patients describe as “lessons I've learned in life” or “things I know about myself.”
We have labeled this skill as “listening for inferences” because we want to emphasize the need to work from incomplete evidence. However, this process of inference is not based on logic. It is more like reading a novel for its symbolic meanings, 17 or listening to a symphony to feel the sense of the music, 18 than looking for specific words or chords. We experience this as using a different mode of receiving the external world—we let the wave wash over us rather than look for the fish, the seaweed, and the sand. Then we describe one of our associations back to the patient, and see if what we mention creates a spark of recognition—this step of checking in on our associations is an iterative step that keeps us from veering out of the patient's world and into our own. We're not too worried about picking the “right” association, because if the patient doesn't resonate with it he will often provide a new iteration of your comment—a remark that points closer to his deep concerns.
Once we see a spark of recognition—in this case the patient's role as a parent (“I need to be strong for them”)—we explore more directly. In this case, the attending said, “I am wondering—are you worried about who's going to take care of the kids?” The patient replied, “No, I know my partner will take care of them, it will just be harder for him.” To the attending, the patient's matter-of-fact tone suggested that this particular issue was reasonably settled. So the attending tried a different association: “So maybe the big issue is something else, maybe just that you won't be there yourself for them?” The patient gasped a little and said, “That's it—I'll miss seeing them grow into adults. That shouldn't be happening.” The attending's hypothesis generation, while being careful not to assume or project, was critical to the patient's discovery and articulation of the issue. For the patient, hearing the attending's hunches reflected back helped him reflect on what lay beneath the surface of the emotions.
4. The action plan as a process of joint design
Rather than directly offer solutions of his own, the attending turned the issue back to the patient by saying, “So let's think about something you could do that gets at missing them grow into adults. Do you have thoughts about this?” The patient gave a look of worry, and said, “I've never faced the reality of this, I guess. I don't know.” So the attending offered, “I have seen other patients write letters to leave for their children, as a way they can be present at future events. It's not the same as being there, I know. But it will enable you to be there for them at least a little. Is that something you would be interested in?” The patient nodded, and said “Hmm…if I can pull it off.”
What the attending did was move from an inference that created a spark of recognition to a proposal for an action step. The attending drew on her experience to suggest an action (writing letters); the patient's response (“Hmm…”) suggested interest, but not commitment. So the last piece of work for the attending would be to develop the patient's commitment to act (in this case, the action might be for the patient to meet a social worker who has experience with this kind of legacy building, or another team member).
We define success in these conversations as developing a commitment by the patient to act.19,20 The pitfall we see is that a well-meaning clinician may try to cover too many bases at the expense of building commitment. The hallmark of success is not the number of topics covered—success is moving patients toward constructive action.
Why This Process Is Worth the Effort
We concede this process is more complicated than earlier guides to “goals of care” discussions that we have written about previously. In those earlier guides, we've suggested questions such as, “When you think of the future, what worries you?” and “If time turns out to be limited, what's important to you?” 3 We are not suggesting that those questions have no value—we still use them. But the efficacy of those questions depends, we have come to realize, on the patient's ability to go from recognizing his own emotion (such as the sadness in this case) to taking an action on his own. To go back to our case, when talking to the fellow, the patient got stuck in his sadness (his emotional mind), and then when the fellow asked a question about goals (to his rational mind), he couldn't make the leap. This patient, like many others, needed more guidance from a wise clinician who could use the process we've described. The process provides a scaffold to enable patients who are in their emotional mind to recruit their rational mind, and move into wise mind—from which they can make medical decisions that honor their deep values.
How Do You Learn to Infer?
This step is likely to be the most unfamiliar for readers of the medical literature. We think that the infer step requires that the clinician learns to turn on an associative capacity that tunes in to the patient's emotional mind, and to allocate a substantial portion of his or her attention to it during a conversation. Interestingly, both of us feel that we became acquainted with this skill in other fields—by interpreting literature in seminars, or watching talented psychotherapists, or listening to music in a way that allows the deliberative mind to loosen its grip. The associative capacity involves interpretation and creative thinking, rather than judging, deducing, or concluding, and it becomes more activated with use. Thus we offer the following assignments. Try using your associative capacity when you are watching someone else conduct an interview. See what enables you to see parallels, patterns, metaphors, or stories. When you try it during a patient interview, use it in short increments. Don't be discouraged if nothing seems conclusive—you're looking for hunches, not “ah-ha” moments. Finally, watch for ways in which patients describe themselves, or their lives—and ask them for more about those descriptors (think back to the patient's use of “simple” in the case). Resist the temptation to fall back into your journalist mode—asking the who, what, when, why, and how of the story—remember that you are trying to tap into the patient's emotional, nonlinear mind.
Common Reasons Why the Process Doesn't Always Work
These skills do not replace history taking or clinical reasoning. These are advanced skills for a clinician accomplished in fundamental palliative care skills. Because the skill of “listening for inferences” depends on the clinician's associative capacity, a common problem is not allowing for time to build associations and try out hunches. If you offer something to the patient, and it doesn't resonate, better to come up with another association to try rather than offer the same hunch again—you'll be seen as pushing your agenda. Another problem occurs when clinicians expect patients to be happy and grateful after these difficult conversations. Although that might happen, we most often see a valuable conversation end with patients feeling ambivalent about tradeoffs that are bittersweet (as one patient sighed, “another growth experience”). A conversation that ends in “you're so wonderful, doctor” leaves us a little bit worried—it shouldn't be about us. One that ends in “I know I have to do this, it's just hard” is better evidence that we've done the work we set out to do.
Summary
This expert approach to approaching affect in conversations about serious illness is intended for clinicians who are already accomplished in foundational communication skills such as agenda setting, detection of emotion cues, and responding to emotion with empathic statements. The approach has four steps: (1) it provides a spotlight that illuminates what is important, (2) it affords a way to connect with patients and families, (3) it enables clinicians to use inferences with patients to construct values, and (4) it enables clinicians and patients to design further action together.
Footnotes
Acknowledgments
We would like to acknowledge helpful advice from Holly Yang, MD, Elise Carey, MD, Wendy Anderson, MD, MS, and the Fondation Brocher in Geneva, Switzerland.
Author Disclosure Statement
No competing financial interests exist.