Abstract
Dear Editor:
There is a rhythm to discussions with patients who have serious illnesses. There are conversations that change the course of treatment, where big decisions are made, where serious news is given. Then there are so many moments in-between those big discussions. What do we do with them?
Much of communication training focuses on how to deliver bad news and the logistics of running a family meeting.1–4 What do we do the day after? What do we talk about? Do we rehash all the things we discussed yesterday (and maybe exhaust an emotionally vulnerable patient) or do we make small talk (and ignore the fact that we had a very difficult discussion)?
The conversations in-between the big discussions are a prime opportunity to focus on two components common to many communication training programs: relationship building (empathizing and emotional support)1,2,4 and engaging in narrative alignment (empowering and checking for understanding of medical information).1,4
Preparing for an In-Between Conversation
What do we want the patient to hear from us today?
Relationship building (Look for the emotion; if we do not see it, we ask)
○ We had a difficult conversation yesterday, how are you doing with all this?
○ How are you coping?
○ Waiting can be difficult. How are you filling your time?
Narrative alignment (Does the patient and family understand the medical narrative the way the medical team understands the medical narrative? Does the medical team understand the patient narrative the way the patient and family understands the patient narrative?)
○ What have you and your family been talking about since our big meeting the other day?
○ Were you surprised by anything we discussed yesterday?
○ Can I answer any questions or clarify medical information?
Conclusion
The in-between conversations, before and after a big conversation, provide a rich opportunity for relationship building and narrative alignment. These are the moments where we can gain new insights into the patient and family dynamics, and their understanding of medical information. These moments deepen the relationship between the medical team, patient, and family. The medical team may gain deeper insight into patient priorities and family dynamics, allowing the medical team to make recommendations that align with the patient's goals and values. The in-between moments can be useful clinically, but the true value may be that these are the quiet moments where we get to connect with our patients and families as people working together to find the best way forward in difficult times.