PHYSICIANS AND FAMILY MEMBERS LEARN TO DO NO HARM WHEN COMMUNICATING

These 'never words' can cause harm if said by clinicians to patients and families dealing with serious illness.

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Seriously ill patients and family members face intense emotional suffering, and researchers, including a Texas A&M University professor, say clinicians must engage in "compassionate communication" as part of the treatment process. They have identified so-called "never words" that should not be said under any circumstances, offer methods for clinicians to determine their own never words, and provide more helpful language to use instead.

In a recent paper published in Mayo Clinic Proceedings, Texas A&M University Distinguished Professor of Marketing at Mays Business School Dr. Leonard Berry and co-authors from Henry Ford Health in Detroit assert that despite rapid progress in the treatment of serious illnesses such as cancer, advanced heart failure, and end-stage pulmonary disease, certain "timeless" aspects of the patient experience remain, like fear.

"Communicating the nature, purpose, and intended duration of often complex treatments, and setting realistic expectations about what they offer still comes up against timeless patient experiences: fear, intense emotions, lack of medical expertise, and the sometimes unrealistic hope for a cure," they write. The "intense, daunting nature of these conversations" may cause clinicians to resort to learned communication habits or declarative statements.

Even a single word may scare patients and families, make them feel disempowered, and negate the effectiveness of shared decision-making.

"Because seriously ill patients and their families are understandably frightened, they 'hang' on every word their doctor will say," notes Berry, a senior fellow at the Institute for Healthcare Improvement. "Serious illness is not only a matter of physical suffering but also emotional suffering. The doctor's behavior, including their verbal and nonverbal communication, can exacerbate or reduce emotional suffering."

Berry said doctors use insensitive language all too often when communicating critical information. Patients and families must feel "psychologically safe" communicating with healthcare professionals, including expressing concern about the proposed treatment plan or their fears. The researchers say if doctors respond using "never words," they may undermine patients' and families' confidence in speaking and do so without realizing the needless alarm or offense they have inflicted.

Never Words

Berry said patients and families must feel "psychologically safe" when communicating with health care professionals, expressing concern about the proposed treatment plan, or conveying their fears. The researchers say if doctors respond using "never words," they may undermine patients' and families' confidence in speaking freely.

"Never-words are conversation stoppers," the researchers write. "They seize power from the very patients whose own voices are essential to making optimal decisions about their medical care."

Utilizing clinician surveys, the researchers identified never words, including:

• "There is nothing else we can do."
• "She will not get better."
• "Withdrawing care."
• "Circling the drain."
• "Do you want us to do everything?"
• "Fight" or "battle."
• "I don't know why you waited so long to come in."
• "What were your other doctors doing/thinking?"

In another study specific to cancer care, clinicians were asked for words or phrases they would never use with a patient, with the top results including:

• "Let's not worry about that now."
• "You are lucky it's only stage 2."
• "You failed chemo."

'"Let's not worry about that now' is not only a non-answer to a patient's legitimate concern, it's dismissive," the researchers said. Pointing out that cancer is in an early stage is "presumptive, assuming the patient should feel gratitude, without allowing room for the patient's anxiety and fear in having cancer." And, Berry said, patients do not fail chemo; chemo fails patients.

What Doctors Should Say Instead

Healthcare professionals can start a dialogue by inviting honest, thoughtful inquiries and responses from patients and families. "They should learn to recognize words and phrases that unintentionally frighten, offend, or diminish agency and work to reimagine their own communication," the researchers stated.

Berry says such an opportunity can arise when doctors encourage patients to speak up. "Something as simple as, 'What questions do you have for me?' rather than, 'Do you have any questions?' invites candid conversation," he said.

The researchers recommend alternative language and rationale for each of the never words. For example, instead of "She will not get better," the doctor could say, "I'm worried she won't get better." The rationale is that the provider will replace a firm pessimistic prediction with an expression of concern.

Using words like "fight" and "battle" may imply that sheer will can overcome illness, and patients may feel as if they're letting loved ones down by not fighting hard enough. Instead, doctors could say, "We will face this difficult disease together," to clarify that patients have a team behind them.

Spreading Awareness

The researchers said that medical groups and educators can raise awareness of never words in multiple ways, including integrating the discussion into courses and professional development.

"The emphasis in medical school is understandably on the science of medicine, but it is important to incorporate communications training into the curriculum," Berry said. "A key opportunity is medical school students and graduates having superb patient-centered, skilled communicators as role models in their clinical training during medical school and residency."

Mentorships are also invaluable as more experienced doctors can share communication techniques they've found successful and which to avoid. The study notes, "Mentors can not only disclose harmful phrases that they personally have abandoned and replaced by more generative phrases but may also model walking back language that lands poorly…Such mentorship facilitates progress in how future generations of clinicians interact with patients and stimulates open dialogue about the added suffering and disempowerment that poor, unmindful communication can cause."

Collaborators on the study are Dr. Rana Lee Adawi Awdish, critical care physician and medical director of care experience, Henry Ford Health, and Dr. Gillian Grafton, advanced heart failure and transplant cardiologist, Cardiac Intensive Care Unit, Henry Ford Health.

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