The idea that the “words” we use could themselves be errors is a powerful illustration of the problems we sometimes have communicating with our patients. Yet, the idea that these “words” are synonymous with a drug implies that the errors in use occur only at the therapeutic point of care. Further, given the need to communicate effectively throughout the course of an entire encounter, this idea should be expanded to consider effective use of “words” as vital elements of both the diagnostic and the therapeutic phases of a patient’s care. In fact, communication patterns are associated with subsequent health outcomes, and those physicians who capably give explanations and show sensitivity to patients’ concerns have patients who are more satisfied, better understand their health issues, and are more likely to be committed to their treatment plans.1 Most emergency physicians (EPs) can remember at least one strained encounter with a patient due to a word, phrase, or attempt at humor that the patient interpreted in a way that was not intended. While awkward, these situations can usually be salvaged, but there are times when the damage will remain despite our efforts to recover.

Effective communication has obvious benefits for the physician–patient relationship, but it may not have received appropriate priority in training. Gaining entry to medical school is based on objective criteria that do not assess the ability to transfer complex information to others. Even if this skill is initially present, it may atrophy over the years, as success is measured in grades rather than communication skills. It is even possible that the training process encourages young physicians to detach themselves from the strong emotions that patient care evokes.2 This detachment may later make it difficult for physicians to reengage with patients in a manner that would facilitate an empathetic understanding of the patient’s varied needs. Yet as important as such characteristics may be to patients,3 it is only in recent years that patient satisfaction has become important and a performance goal. The Accreditation Council for Graduate Medical Education (ACGME) has included interpersonal and communication skills as a competency.4 The long-term challenge will be to move beyond assessment for skills in communication and help students and residents gain (or rediscover) these skills if they are lacking, develop remediation programs when needed, and emphasize communication skills in those we select for training. In the short term, we need to encourage the use of tools that will allow reasonably effective communication during the most crucial encounters.

The article by Dr. Lamba describes a common scene in emergency medicine. A patient in distress and near the end of their life is brought into the emergency department (ED), with anguished family members overwhelmed by the suffering of a terminally ill loved one. The family or patient implores the EP for help, but to communicate exactly what interventions are helpful in this case requires that the EP rapidly bridge the gulf that exists between people who have never met and have no preexiting bond of trust. The author has outlined the many barriers that limit good communication in the chaotic ED setting. Poor communication can lead to unwanted or inappropriate use of resources, undue suffering, and as seen in this case, a miscommunication between a provider and a family member. As the author points out, when a loved one is suffering, any family member who believes that his or her choice is to do everything or to do nothing would choose the former.

The ED is a place where the range of human experience can play out in a single day. The occasional miracle mixes with random tragedies and all too often news must be given that will forever change the life of a patient or their family. As a physician you will move on to the next patient, but a patient or family will forever remember those single moments. It is appropriate to approach the method by which this communication will occur with all the care and concern that one would take when preparing to undertake a dangerous procedure. Just like any procedure, this is a learned skill. Increasingly, checklists are used to prepare for procedures, and similar aids are available to help providers approach difficult communication situations in a consistent manner. When telling family members about the death of a loved one, use of the mnemonic “GRIEV_ING” (gather, resources, introduce, education, verify, invite, nuts & bolts, give) has been found to improve death notification skills in residents.5 When breaking bad news, “SPIKES” (setting, patient perceptions, invite, knowledge translation, explore emotions, summarize) has been adapted from the outpatient oncology setting.6 Each of these mnemonics can help the provider walk through the important steps of an interaction, such as clearly telling the family that their loved one has “died” or remembering to summarize the current understanding of a treatment plan. Unfortunately, checklists cannot force us to truly comprehend the pain or fear experienced by those we care for; they are simply memory aids to ensure a consistent approach. In the cases of communication we must be careful that the tools to improve consistency do not cause us to mindlessly move through the list. Empathy should be stressed, not as one of the points of a checklist, but as the element that diffuses through the entire encounter.

The ED may seem a difficult place to meet the emotional needs of patients and their families, and the case presented by Dr. Lamba makes it clear that conversations and decisions must sometimes be made quickly. Thinking through the steps of “SPIKES” is useful as an approach to delivering bad news, but to effectively communicate, the patient’s goals of care must be established. It is this goal setting that is the key to this case. First, the physician should start by determining what the patient already understands about his or her disease and the progression. If there is a lack of knowledge regarding what may have recently occurred, the EP may have to educate the patient. Second, the clinician needs to then explore the expectations and hopes. The patient may have unrealistic or conflicting goals, and again the EP can help the patient focus on what is most realistic and even how the patient might want to envision his or her death. Although physicians sometime shy away from making recommendations, it is acceptable for them to do so, but focus might be on providing comfort measures. Finally, as the goals of care begin to take shape, the physician should ensure that the patient understands and agrees, and the next steps should be outlined. A complete discussion of goal-setting can be obtained from the Education in Palliative and End-of-life Care for Emergency Medicine (EPEC-EM) curriculum.7 At this point, it is useful to review the steps in “SPIKES,” many of which will have been completed during the discussion regarding goals of care, but this is a good opportunity to ensure all the key steps have been covered.

The EP is not unique in needing to effectively use “words” to help our patients, but we do need to use them in a more intense setting than some of our colleagues. Further, “words” go both ways—we must effectively draw them out from our patients and then carefully give them back. We must be at our best when our patients may be at their worst. Approaching patients with empathy and a few clear steps may help make the most of the limited time most EPs feel they have and better ensure that patients and their families do not suffer the added injury of a poor interaction to the burdens many of them already carry.


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