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Five Ways to Have a Serious Conversation
Palliative care physician Paige Patterson is an expert at having tough conversations. We asked how she engages patients about their wishes, worries, and plans for the future. For Paige, having a process makes serious conversations easier.
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uring her training at the University of Louisville, Paige Patterson thought she would be a hospitalist. She enjoyed handling acute care issues and spending time with patients but realized she couldn’t do as much for her patients as she wanted. Even in clinic, her encounters were short—only enough time to deal with one or two problems.

In Patterson’s last year of residency at the University of Utah, she completed a rotation in palliative care, which helped her realize what she really missed about being a doctor.

1. Communicate with the whole person

In palliative care, I get to heal the whole person and family. When I visit patients, I first describe palliative care. It comes from the word to palliate , meaning to make better or to make more comfortable. Palliative care is for people who have a chronic, life-threatening, or life-limiting disease.

Palliative care not only addresses a patient’s physical needs but also concentrates on their emotional needs. I talk frankly—about their medical issues and about what they want from their care. It’s my job to look at them as a whole person. By thinking and acting in terms of the whole person, the patient’s emotional needs are weighed the same as their medical needs. Having hard conversations is just as important as clinical care.

2. Use a guide to ask about the hard stuff

Initiating difficult conversations isn't easy. Surgeon, author, and public health thought leader Atul Gawande developed a five-step Serious Illness Conversation Guide in conjunction with Ariadne Labs. I ask my patients a series of open-ended questions adapted from their list:

Flow Description Paige's Palliative Examples
SET UP Set up the conversation
  • "How are you doing?"
ASSESS Assess understanding and information preferences
  • "Can you tell me what your doctors have told you about your disease?"
  • "Do you understand what your diagnosis is?"
  • "Do you want to know your prognosis?"
SHARE
Share the prognosis (hard topic)
  • "This may be as strong as you feel."*
EXPLORE Explore what's important to the patient
  • "What do you do that's so important you can't imagine living without it?"
  • "What are your biggest worries?" (People rarely lead with their biggest worries.)
  • "When you think about your health in the future, what are you most afraid of?" (Some people are afraid of pain. Most people are afraid of being a burden to their loved ones.)
CLOSE Close the conversation by summarizing what you've heard, make recommendations, and affirm your commitment to the patient
  • "It sounds like ________ is very important to you."*
  • "Given your goals and priorities, I recommend..."*
  • "We're in this together."*

* Questions taken directly from the Serious Illness Conversation Guide.

3. When you’re stuck in a conversation, “drop the rope”

As providers, we have to learn to not talk at a patient. We use a phrase in palliative care—“drop the rope.” Instead of arguing with a patient or trying to persuade them to see your side, use an empathetic statement. Statements like “That really sucks. I understand that it’s hard to take medication every day. What would help you feel better? What can I do to help you reach your goals?” Palliative care is about two-way communication, not just the way I think it should be.

For patients, hospice is particularly scary—the big H. I’ll say, “Listen, I know you’re not ready for this right now, but I want you to know what it may look like in the future in case it comes up.” Even people who think they know what hospice is sometimes say, “Wow, that was really good information. Yes, it was a hard conversation—but I’m glad we had it.” That’s so rewarding.

4. Stay resilient in the face of tough emotion

As providers, we’re trained to hold emotions at bay—to leave them at the door when you go on to see another patient. I try really, really hard, even if I have to take a minute in between patients to sit and breathe deeply. It’s emotionally draining work. It’s hard to stay resilient. I haven’t found a healthy balance yet. If I have a particularly hard day with a patient, I have to let myself feel it. Maybe even cry a little bit after the visit. I’m a crier—that’s what I do.

Good days can be really sad days. I find fulfillment in having some closure with my patients. I feel good when I’ve opened up these discussions about their health and what they want for the future, and the patient understands our plan going forward.

5. Compassion goes both ways

Having a serious illness is tough on patients, tough on families, and tough on caregivers. By helping them, I feel like I’m finally making a difference as a doctor. I’m changing people’s lives for the better. That gives me more meaning in my life.

When my father died, the palliative care I provide helped me understand my own grieving process. I knew about the anticipatory grief part that comes. I knew about the strain it puts on caregivers. A lot of times patients feel like they’re a burden, but I tell my patients that this is the last act of love those caregivers can provide. So please let them. It’s truly a gift to be able to take care of a loved one that’s dying.

Contributor

Paige Patterson

Palliative Care Physician, Assistant Professor, University of Utah Health