Episode 3: Patient and Family Communication
When communicating with patients and families about serious illness and end of life, family disagreements are common, often because of different understandings about what the best course of treatment may be. In this episode of The Talk, physicians share techniques for navigating complicated family dynamics, including the mechanics of family meetings, and discuss cultural humility and helpful phrases and questions.
At the outset of a serious diagnosis, family physicians can help set a tone of inclusion and clear communication, while always keeping the patient at the center. A family meeting can be a helpful way to understand the concerns and questions of family members and chart a course of care that best meets the patient’s wishes.
Palliative care director and family physician Lowell Kleinman always listens to the patient’s story first and then gets permission from the patient to ask family members, “Can you tell me in your view, through your eyes, what’s been going on and what are some of the questions that you might have?” Although there may be significant disagreements about how much and what kind of treatment to give a patient, physicians can always try to find the common thread of agreement among family members—which is often that no one wants the patient to suffer.
Finding common ground can be more complicated with family members who live far away – especially those who are the designated health care proxy. Medical ethicist Steve Heilig describes a “distance rule” – “the farther the surrogate is away from your actual bedside…the more likely they seem to be, in general, to request and demand continued care, more care, intensive care.”
As primary care doctors often have a relationship with their patients before, during and after a diagnosis, they can play a helpful role in coaching patients and families through these difficult transition points and serve as a central landing place during the course of an illness. Throughout, it is important for physicians to remember how difficult serious illness is for both patients and families.
Recently retired family physician Bo Greaves encourages simple, empathetic phrases like “I really feel how hard this is…we may not be able to talk about it today, and that’s fine.” In addition to empathetic and inclusive words, other factors such as eye contact, body language and a quiet setting can help put patients and family members at ease.
Of course navigating language differences can play a big part in communicating with patients and families. Family physician Michelle Quiogue, who is bilingual, notices her Spanish-speaking patients trust her more easily when they realize she is fluent in their native language. She says, “Once I start communicating with them and they see that I really do speak Spanish fluently, you can see them relax, and then many times they’ll say ‘I’m so glad I can explain myself.’”
Direct communication is ideal if a provider is bilingual, but a medical interpreter may also be beneficial, especially considering that speaking the same language is not always the same as understanding how certain words are used in a particular cultural context.
Whether considering the linguistic, cultural or spiritual consideration of a family’s approach to illness and end of life, family physician Chris Flores recommends what he calls “cultural humility.” He encourages the importance of being flexible and open-minded, questioning our own assumptions and looking “through the eyes of the patient that’s in the room with us.” Regardless of the physician’s own spiritual or cultural identification, physicians should be prepared to ask what spiritual and cultural considerations might help patients and families near the end of life or as they cope with a serious illness.
To serve as open-minded and compassionate guides to patients and families as they face the end of life, family physicians ultimately may need to contemplate their own mortality. Family physician and medical professor Catherine Forest asks all physicians to consider, “When you face the end of your life, are you clear what that might entail? Have you really faced that with family members?”
For more information on how to communicate with patients and their families, CAFP recommends the following resources: