Sometimes patients and clinicians don’t agree and there is conflict. Many people prefer to avoid conflict, however working through it allows us to discuss our differences of opinion, explore the options, and come up with an agreement that we all can live with. Good communication skills can help shift the focus from “Who’s right?” to “What’s our shared interest?” This roadmap is different as it is about how you find your path amidst conflict. Start by noticing there is a disagreement. Prepare yourself by pausing, being curious, and assuming positive intent. Invite the other person’s perspective and listen to their story, emotion, and what it means to their sense of self. Identify what is at the root of the conflict and if possible, articulate it as a shared interest. Brainstorm to address the shared interest, and look for options that address everyone’s goals. Remember that conflicts occur because people care deeply, which means that resolving the conflict will take time and effort. Even in instances where it is not possible to agree, skillful communication can allow for graceful disagreement.

Conflict with our colleagues is stressful and evokes strong emotion, yet handled well can improve outcomes and relationships and enhance collaboration. There are issues of hierarchy, power, and respect. Similar to dealing with conflict with patients is the need to establish a safe space, practice deep listening, and earn trust. Being open to exploring the breadth of the problem, both parties perspectives, your role in the conflict, how you feel about events, and what it means to you will help you approach the situation with a more open mind. Keeping a focus on improving the situation and relationship rather than solely on being right will help maintain calm. The roadmap for conflict with colleagues includes noticing when conflict is bubbling up, preparing your approach instead of jumping in reactively, starting softly to avoid provoking defensiveness, inviting the other person’s perspective before you share yours, using neutral language to reframe emotionally charged issues, acknowledging the emotion of the situation (rather than handling your colleague’s emotions directly), and finding a path forward that addresses both parties’ concerns, creating new options where needed.

To hone your skills, one needs to observe what “good” looks like, practice, and receive feedback. We recommend setting a communication skills goal before the encounter, and then debriefing how it went, celebrating what you did well, and considering what to do differently next time, as well as what you learned in the process. Practicing skills in conversation roadmaps is incomplete without building of our internal capacities, like curiosity and emotional awareness, which help us foster more authentic connection. Learning new skills is not linear. Be kind to yourself when you’re having a bad day or feeling burnt out. Better communication skills can help they leads to more engaged clinical encounters which provide positive feedback making patient care more rewarding. Also, the roadmaps in this book are a kind of scaffold for learning, intended to provide support until you get your foundation settled. After a while, you may no longer need them. True expertise requires building both skills and capacities, practicing regularly, and caring for oneself in the process.

Multiple family members means multiple perspectives, agendas, emotions, and values. And, families are more than a collection of individuals. They have with their own way of functioning as a whole. When meeting with family about their loved one’s care, there are important steps similar to the maps we used with patients themselves. First, pre-meet to decide who’s going to be invited. The team should also agree upon a big picture headline. During the conference, introduce all participants and the purpose of meeting. Assess what the family knows and their different perspectives. Update the family using a headline, and address questions and concerns. Empathize and respond to the various emotions in the room. Prioritize the patient’s values. Align with the patient’s values and support the family. Finally, summarize and provide a concrete follow-up plan. An effective family conference can get everyone on the same page, ensure that the patient and family understand the medical situation, and help the family and care team come together to make treatment decisions that align with the patient’s values.

Some situations are particularly challenging. These include high-stakes, high-emotion conversations, like when patients talk about miracles or when they request hastened death. In the case of miracles, it is because they understand how bad things are that miracles are invoked. In the case of requests for hastened death, the request is brought on by suffering or fear of suffering. In both cases, the first thing is to do is take a breath and then explore, rather than react from a place of emotion. Another challenge is when responding to emotion isn’t enough. This can occur when a patient really does want information, when patients are coping through intellectualizing, when the emotion is too overwhelming, or when the level of emotion (and sometimes physical agitation) is elevated to the point of feeling or being unsafe. Each of these requires a tailored response like giving information, nonconfrontation, or containment before being able to move forward. Finally, in situations when our own emotions become elevated, it is important to allow ourselves to feel while being mindful we remain of service to the patient, and that we get support from trusted team members and colleagues.

Discussing treatment options is more complex than giving information and making a recommendation. Today, shared decision making includes patient access to the electronic medical record and internet searches, however patients still turn to their clinicians as the most important and trusted source. In addition to balancing information and emotion, clinicians need to take into account how involved patients wish to be in decision making. A roadmap for discussing treatment decisions is: 1. Prepare for the visit, 2. Frame the decision to be made, 3. Ask about decision-making preferences explicitly, 4. Adapt the discussion and recommendations based on patient decision-making preferences (shared decision making, clinician-led decision making, pros/cons), 5. Check for patient understanding, 6. Establish how the patient wants to proceed with the decision-making process. Take care with how statistics are presented and consider providing decision aides. Asking patients how they want to make decisions will help ground decisions in their values.

When prolonging life with acceptable quality of life becomes difficult, goals of care discussion are necessary. For clinicians and patients, the discontinuation of disease-modifying therapy can feel like a failure. This can lead clinicians to offer treatments we don’t believe are good options or offering treatment on the condition that our patients make an improbable recovery. The roadmap for late stage goals of care discussions is REMAP. Reframe why the status quo isn’t working, expect emotion and respond with empathy, map big picture values, align with the patient’s values, and finally plan medical treatments based on what’s important to your patient. Some things to note: Mapping thoroughly will help you make sure you don’t miss something important. A useful shift in thinking for many clinicians is first talking about what you will do before talking about what should be stopped or you won’t offer. And, clearly linking your recommendations to the patient’s values will help your proposed plan be more acceptable. By grounding ourselves in what is medically possible and using the patient’s values to guide our next steps, we can cocreate a plan that is both possible and meaningful.

Most clinicians prefer that patients plan for their future illness care before things become urgent or they lose the ability to make decisions. Completing an advance directive form by itself does not always impact future care decisions. Rather than focusing on hypothetical specific treatment decisions in the future or the completion of forms, conversations early in serious illness focusing on what matters most to patients may help guide care decisions over time and prepare patients and families for future conversations about specifics in real time when things do progress. The key is to plan on multiple small conversations over time. A roadmap for having these early goals of care discussion is PAUSE (Pause to make time for the conversation, Ask permission to discuss the topic and explain why, Uncover values first (don’t lead with code status), Suggest selecting a surrogate, Expect emotion/End). Some patients shy away from considering a future state when their disease has worsened, and are not interested in talking about what matters to them. Exploring why using a motivational approach and focusing on your relationship may help plant the seed and make future conversations easier.

Clinicians and patients have varying degrees of comfort in discussing prognosis. Patients can swing between worry or understanding that death is near and hope or optimism that lets them live life. This prognostication awareness pendulum may require a clinician negotiate the discussion over time. The cognitive roadmap for prognosis discussion is ADAPT (Ask what they know about their medical condition, Discover what they want to know about prognosis, Anticipate ambivalence, Provide information about what to expect, and Track emotion and respond with empathy). Some patients want prognostic information, some don’t, and some are ambivalent. While respecting their wishes, exploring why in each of these scenarios may be helpful to understand their concerns and how best to address them. Be aware that patients and their family members may have different prognostic information needs. Having separate conversations (with permission) may be in order. When they are concerned about destroying hope or prognosis is uncertain, using the frame of “hope and worry” can be helpful. Finally, when patients or family members don’t believe our prognosis, be curious as to why and focus on the relationship.

Four core communication skills are “Ask-tell-ask”, recognize and respond to emotion, ask permission to move forward, and “Tell me more…” “Ask-tell-ask” is asking what the patient or surrogate knows about the medical situation, telling them the headline (information and meaning), and asking what they are taking away from your conversation. Recognizing and responding to emotion, both verbal and nonverbal, can allow patients to discuss additional medical information, builds connection between clinician and patient, and can clarify what is important to the patient. Responding to emotion may be nonverbal or verbal (e.g., NURSE statements), and may include simple or complex reflections or “wish statements”. Asking permission to move the conversation forward signposts that there is a transition, allows patients control, and helps you judge if they are ready. Finally, “Tell me more…” helps clarify informational needs or allow a deeper view into a patient’s reasoning or emotional space, giving the clinician guidance on where to direct the conversation. In telemedicine, communication skills need to be adapted as some of the in-person nonverbal skills are less effective or impossible.

While most clinicians have experience discussing resuscitation, talking about dying requires the patient and family be willing to think about the medical treatment not working. Clinicians hesitate to bring up dying because they worry it will raise strong emotions, and they’re not sure what to do. Like REMAP, discussing code status requires a shared understanding of the “big picture”, responding to emotions, eliciting values, and making a recommendation about code status based on the medical reality and the individual patient’s values even if they differ from our own. The frame of “hope for the best, prepare for the worst” may help with the discussion. As people near the end of life, there are often questions that are hard for patients and families to ask, like what dying looks like, issues brought up by trauma or stigma, spiritual or existential concerns, or when the dying process is longer than anticipated. When clinicians create space for these sorts of concerns, we can address uncertainty and suffering that would have otherwise gone unspoken. Finally, being able to say goodbye to a patient requires insight and skill, but can be deeply meaningful for all involved.

The VitalTalk roadmap for talking about serious news is GUIDE (Get ready, Understand, Inform, Demonstrate empathy, and Equip patient for next steps). Getting ready includes planning the details of the meeting, including why and how the information is to be shared. The next step is understanding what the patient expects from the visit and what they have been told so far. Prior to giving information, the clinician should ask permission to share what they know. The news should be shared using a headline containing both data and what it means for the patient’s life. Afterwards, the clinician should demonstrate empathy by recognizing and responding to emotion. Equipping the patient includes discussing next steps, summarizing, and checking for shared understanding. There may also be challenges of patients receiving potentially too little or too much information when families say “don’t tell” or due to asynchronous electronic results delivery respectively. How much patients want to know and how and when they get information can be clarified through preparatory discussions. Finally, medical errors are another form of serious news that require an apology along with the headline.

The times in between significant medical events allow for different conversations with patients about living with uncertainty, the effects of their disease and its treatment, the fear of the next crisis, or figuring out who they are now and what they might hope for their future. Sometimes worry about becoming more ill or dying shows up in conversations in disguise, like being fixated on a particular test that a clinician might consider medically less important or even unnecessary. Sometimes completing cancer therapy brings a mix of emotion, relief that it is done and worry that it may not really be. Other times patients who have recovered from an exacerbation, like in heart failure, realize how much they have changed due to the disease and its treatment, and while glad they survived are simultaneously unhappy about how their life has changed. The roadmap for clinicians in these more calm but uncertain times is to ask your patient’s perspective, respond to their emotion (often exploring to create a deeper understanding), and offer your clinical experience of other patients which might apply to help clarify the issues at hand, provide different perspective, and offer support.

Discussing serious news can be difficult and a skilled clinician can improve their patient’s care and feeling of being cared for. Communication is central to the effective medical practice, and the data shows that clinicians can learn to improve their skills. This book will focus on the broad domains of communication skills and cognitive roadmaps. Through personal reflection as well as honing communication skills and using roadmaps, clinicians can cultivate internal psychological capacities that lead to more skillful and authentic conversations. Our basic principles at VitalTalk are to start with the patient’s agenda, track emotional and cognitive data, stay at the patient’s pace, express empathy explicitly, discuss what can be done before the things that can’t, cover big picture goals before specific interventions, pay true attention, and ask for the patient’s take away. In addition to reading about serious illness communication, these skills are best learned through observation, practice, and feedback.