ACADEMIC EMERGENCY MEDICINE 2011; 18:93–95 © 2011 by the Society for Academic Emergency Medicine
Effective communication is the key component of every patient–physician encounter and is essential for shared decision-making. “Words” are perhaps the most frequently dispensed “drug,” while communication is the most frequently performed “procedure” in emergency medicine. Yet, communication skills are often learned by trial and error, as opposed to the methodical approach followed for teaching all other technical procedures. The case presented below highlights the importance of incorporating effective communication skills as tools for our daily practice.
The single biggest problem in communication is the illusion that it has taken place.
--George Bernard Shaw
Mrs. M, a 56-year-old cachectic female, pale, short of breath, restless, confused, and moaning, arrived in the emergency department (ED) at change of shift. Her respiratory rate was 48 breaths/min, her blood pressure was 70 mm Hg by palpation, and her oxygen saturation was 91% on 100% oxygen via a nonrebreather mask. Her anxious husband provided a brief history at the bedside: breast cancer diagnosed 6 months ago, with extensive metastatic disease to bone, lungs, and liver. Palliative chemotherapy and radiation failed to slow the progression of the disease, and hospice care was recently recommended by the oncologist.
Initial conversation with an ED care provider:
Emergency department provider: “Sir, your wife is having severe shortness of breath. We need to make a decision right now for her treatment. Do you want us to put a tube in her lungs and put her on a breathing machine or not do anything because she has metastatic cancer?”
Husband: “Will that machine help her breathe and get better?”
ED: “It will oxygenate her better.”
Husband: “Will she die if we don’t put the tube in? What would you recommend?”
ED: “She will die soon without the machine. This is not my decision; you have to let us know what you want.”
Husband: “Do whatever you need to do in order to stop her from suffering. I cannot see her like this.”
Interpretation provided to incoming staff: “The patient is not a do not resuscitate/do not intubate (DNR/DNI). Knowing she has such widespread metastatic cancer, her husband wants everything done, so we have no choice but to intubate, place her on a ventilator, and admit her to the intensive care unit (ICU).”
Reflection: Given the above conversation and choices provided, would anyone choose the “death and doing nothing” option for their loved one? Providing information for feasible treatment options and eliciting goals of care is part of the daily practice of emergency medicine (EM). Failure to communicate effectively hinders this practice of patient-centered medicine, and this perceived lack of communication remains the impetus for most malpractice suits initiated in medicine.1
In the busy ED environment, it is easy to make communication errors, not just in end-of-life situations, but during other interactions, as well, especially if a systematic approach is not followed. For example, after his abdominal computed tomography (CT) scan, a patient is advised by the physician to follow-up with his oncologist for worsening disease; however, only then does the physician discover that the patient was unaware that he had cancer.
Emergency physicians face unique communication challenges: 1) the ED environment is loud with many distractions, from beeping monitors to agitated patients; 2) no prior patient–physician relationships exist; 3) limited background information is available to help families make decisions; 4) acute situations often necessitate fast decision-making; 5) gathering information from families is a lower priority compared to saving a life; 6) many patients present with preexisting cognitive deficits due to psychiatric illness, substance abuse, dementia, etc.; 7) reimbursement favors an aggressive procedure-driven approach; 8) time constraints due to overcrowding; 9) lack of privacy and adequate space to sit down and converse; 10) emotionally charged and sometimes hostile situations due to an unexpected or traumatic death; and 11) patients with varied cultural backgrounds and sometimes significant language barriers. However, effective communication is the backbone of daily EM practice since, along with patients, we routinely interact with multiple consultants from varied fields, primary care and prehospital care providers, hospital administrators, and varied ED staff, from volunteers and security personnel to nursing and medical students. Understandably, eliciting patient preferences and determining goals of care takes time, and a busy ED is not conducive to lengthy communications. Therefore, it is vital to learn techniques to be efficient communicators and to develop a consistent approach to every medical encounter.
Communication remains one of the six core competencies for EM residency training.2 Established guidelines exist for performance and certification in many EM procedures. For example, a central line placement triggers an automatic mental checklist so all steps from initial site identification and obtaining supplies to discarding all used sharps and ordering a follow-up radiograph are meticulously followed. However, no specific guidelines to teach skills for effective communication are offered, and it is still a skill often learned by residents using a “trial-and-error” method.3 Perhaps communication should also be taught like a procedure, so it triggers a similar consistent mental checklist.
Current communication literature is often compartmentalized and addressed as a subspecialty-specific approach.3–5 Emphasizing an approach such as the “delivery of bad news” encourages its use only in specific situations.3 Communication is taught as an art, not a science, with phrases like “empathize” and “acknowledge,” which are not familiar to procedure-based specialties. A review of the literature reveals some common themes that emerge across disciplines, and incorporation of these elements may provide an effective tool to teach a consistent approach to communication in the ED. The act of “preparation” is highlighted: 1) familiarize oneself with background information, 2) set a clear goal for the discussion, and 3) prepare the environment (seating for all participants preferred), because this signals the importance being placed on the discussion.4–6 Eliciting a summary by the patient or family has also been well established as a way of creating rapport, as well as establishing a baseline to build on.4–7 Identifying the patient’s/family’s main concerns with a direct question is important to create a shared agenda.4–6 The closing of an encounter by highlighting some defined “next steps” for patients and families helps lend a sense of control and emphasizes nonabandonment.4
Consistent and regular application over time is necessary to develop and retain a skill, and mnemonics are familiar to most learners as memorizing techniques.8 Some mnemonics like “SPIKES” (setting, perception, invitation, knowledge, empathy, summary), which is used for communicating “bad news,” may have an action-based, wider applicability. For clinicians interested in pursuing further skill-enhancing courses, the Education in Palliative and End-of-life Care (EPEC-EM) is an excellent resource.9 In conclusion, a consistent procedural approach to effective communication is necessary to practice a shared decision-making and patient-centered model of care.
A second conversation with Mrs. M’s husband followed:
Emergency department provider: “Sir, let us step into the next room which is quieter, so we can concentrate on discussing the best care options for your wife and her condition.”—Preparation
ED provider: “Tell me about what has been going on with Mrs. M and what you know of her condition.”—Eliciting a summary
Husband (crying): “She is dying, and she is suffering from the cancer spread all over her body. Her breathing is getting worse and she kept refusing to come to the hospital for the last week. Today I just could not see her suffering and decided to bring her in.”
ED provider: “I understand this must be very difficult for you. Looking at her oncologist’s notes, it also seems like the disease is widespread with no hope for cure and hospice was offered. Is that right?”—Preparation, validation of emotions, empathy
Husband: “Yes, we all know she is dying but thought we had more time.”
ED: “Since you know your wife best, can you help me understand her views regarding her disease and what would be her main concern now, if she could talk to me?”—Establishing decision-making as proxy for patient, eliciting main concerns
Husband: “She is an independent, stubborn woman, and dislikes hospitals. She fought the cancer hard, but she would have told you that she hates being helpless like this.”
ED: “Since we know there is no cure for her cancer, we should focus on her now and not the disease. Based on what you have told me about her, I do not recommend a breathing machine because it will not help to treat the cause of her suffering and may actually prolong it. We will make sure we do everything to make her comfortable and decrease her discomfort. Are there any concerns or questions you have that I can help you with?”—Eliciting concerns, offering recommendations, summary of plan
Husband: “I want a pastor to perform last rites. She is a woman of faith.”
ED: “We will call the pastor and give her some medications through her IV to decrease her discomfort. I will be here to answer any other questions that you might have.”—Emphasize nonabandonment, outline next steps
The patient died in the ED 45 minutes later with her husband, son, and pastor at the bedside. The family was grateful to the ED staff for providing their loved one a peaceful death and giving them a chance to say goodbye to her.
Supervising Editor: Carey Chisholm, MD.