During palliative communications, we try to support patient hope as we discuss devastating prognoses, clarify understanding of treatment choices, and elicit values and goals to plan care. We may struggle to interact naturally while applying and practicing learned communications skills. Over time, the experience becomes more familiar, but such talks remain challenging for clinicians and patients alike. The communication concerns described by both seasoned clinicians and learners are represented in the following narrative poem.
Communication Fatigue
To be effective with patients so seriously ill, to converse and support with newly gained skill,
I've taken the courses, role played, and reviewed. Now I must plan, practice, and follow through.
I go through the chart, the lab values, and tests; armed with data to do my best.
I've staged the setting, a quiet scene, and minimized disruptions to stay serene.
Who should join us to hear what's discussed? Stepwise I work to build the trust.
A touch of the shoulder, some tissues nearby, to blot the tears in case you cry.
A glass of water to swallow emotions on hold, creating some pauses as distress unfolds.
So tell me, for you, what makes a good day? Share more about that, I remember to say.
Clarify goals of care and help articulate. Explore, facilitate, and formulate.
I can barely envision how much you've endured. I'm sorry we cannot restore, prolong, or cure.
What a trooper you've been, doing everything right. Recalling to praise for the arduous fight.
Have you thought about being sicker and what this could mean? I so wish you could be healed and off the machine.
I ask permission to talk with desired detail, and frame the prognosis so as not to derail.
I acknowledge emotions and nonverbal cues, apologize for my blunders, and start the redos.
I can't even imagine how anxious you feel; it's unsettling to hear these serious spiels.
I seek understanding about your current state, as such information will affect decisions you make.
We're in a different place now. Does that make sense? Respond with empathy and frequent silence.
Reflectively listen and motivationally interview. Recall the acronyms, the communications brew.
Avoid missteps, assumptions, and indelible regret, by providing a gentle expectations reset.
What would this look like if things go well? Continue to ask, tell, ask, and tell.
Guide the serious conversation; advance the care plan. Reframe expectation for lengthy lifespan.
Acknowledge the surfacing anticipatory grief. Guide the dialogue and later debrief.
Limit the tech jargon reflexively spewed. Emphasize respect during delivery of news.
Share knowledge to inform about what's in store. Sit down, lean in, and gaze up from the floor.
What else are you hoping for and what worries you now? No I'm not suggesting we throw in the towel.
Naming healthcare surrogates may seem frightening now, but it's important to choose your proxy somehow.
Your condition shows that you're on a brink, but home hospice is not the fearsome death knell you think.
How do you want to spend the rest of your time? At home or in hospital with devices and lines?
Would you prefer to be allowed a natural death, or artificially be given your final breath?
We probe other values and gauge the needs. Plan the follow-up with devotion and speed.
We find new goals to avert despair, searching for means to support your prayers.
Desperately invoking every communications device, to gain your confidence, and help ease your strife,
I think about care deficits we can reliably foretell, still trying to emphasize what we can do well.
But while focusing on choices, priorities and needs, I can't help but dwell on your unspoken pleas.
To maintain the crusade to carry on and live, to be ever-present for your spouse and kids.
So we discuss worth and joy in your remaining days, a quest to create meaning in other ways,
while seeking outlets for you to grieve, and define the legacy you want to leave.
I wonder as you contemplate premature demise, and quality not quantity, the consolation prize,
if exhaustive compassion is not the resilience assault, but instead it is conducting these difficult talks.
Now depleted and stuck, I may be out of my league, both of us affected by communication fatigue.
