Learning to Talk

The doctor walked into the exam room where the patient sat on the edge of the exam table. In her late 50's, she was slender and held herself erect, tense as if preparing to slide off that paper-covered surface. The young doctor, maybe in her mid 20's self-consciously shuffled the papers she had in her hand. She stood a couple of feet from the patient and made eye contact.

"I have the results of your tests, Mrs. T.," she said in a somber voice.

"I've been anxious to hear them," was the reply.

"You have a malignancy." The words were followed by a shriek of joy from the patient. "Oh, good, I was so afraid you were going to say that it was cancer." She held her hands to her mouth and seemed to hold back sobs of relief.

The doctor began to stutter and her eyes widened, "No, yes, I mean...What I meant to say is that it is cancer, Mrs. T. I'm sorry I wasn't clear."

The patient's relief gave way to a horrified look, followed by tears and mumbled words, "It can't be; it just can't be."

Fortunately, the above scenario was part of a practice session in a class for medical students. The "doctor" was a young first year, learning that it matters what words we use when we talk with patients.

I can remember as a hospice nurse, doing admissions and being careful about word choice. After explanations of our services, detailed checklists and signatures, the process usually culminated with a question and answer session just to make sure the patient and their family knew what to expect from us, their new hospice nurses. We tried to wait until the patient or the family asked about topics related to prognosis and then double checked to see what their medical provider had already communicated.

Sometimes they did ask the tough questions: "So how long do I have?" or "What is going to happen as I die?" or "What do I do if I get to where I can't communicate?"

It's important to consider how we answer questions that our patients pose to us and that we impart what truth we can with gentleness and compassion. In discussing this topic, my friend said, "Yes nurses need to talk....and so do doctors. Many times the doctor has told the patient a lot about their condition thinking they have covered everything. But the patient is confused by the 'Doctor Talk' and is embarrassed to ask for clarification. Then it is left up to the nurse to be the interpreter." How do we know what to say?

Ask Questions Back First

Clarify what they know, how much information they have and how they have interpreted what they know so far.

It's Perfectly Fine to Say, "I Don't Know"

Sometimes it is exactly the right thing to say. We are not at liberty, as nurses, to impart information about prognosis or testing unless the doctor has already had a chance to talk with them. Then we can clarify or help them understand what was said and what it means. It can be helpful to go one step further and say, "I will try to find out," but only when we really feel some measure of confidence that we will be able to find out. If we say we will and then get busy and don't get time to follow up, we will want to be sure and let the patient know what we were not able to follow up. Otherwise they may feel lied to or betrayed.

Answer Only What They Ask

We learn this with kids, often by answering a different question than they intended to ask. If the patient asks, "Will I have pain?" then it is helpful to answer that question and talk about strategies we will help them use to cope with the pain, without going into other symptom management problems that might arise later. Staying focused on the question at hand is hard to do, but an important learned skill.

Know Yourself

Work on your own issues when it comes to talking with patients. If people frequently mention that you talk a lot, then it might be time to pause and hold back from saying everything you think needs to be said. If you are quiet and maybe answer questions with one word responses, it may be time to expand your horizons in terms of patient conversations. Learning new ways to communicate with patients is not necessarily a skill that comes naturally; as with all of our professional nursing skills, we must hone our trade, observe others who are experts in the field, and learn as we go.

Sometimes You Have to Initiate the Questions

Part of being good at caring for our patients involves listening to what they don't ask as well as what they do. When a patient is silent, appears distressed or depressed, it may be time for the nurse to ask probing questions. I can remember a hospice patient who never, ever had any questions. He was dying from lung cancer and breathing made a lot of conversation difficult, but he was closed off from his family and from us as his hospice nurses. We tried to engage him but our usual approaches just didn't seem to break through. Finally, one of the PCTs sat down next to him and said, "I'm worried about you. You are awfully quiet. Will you share with me what's on your mind? I promise I will listen and try to help as best I can." The patient went on to share his anger about his condition and the fact that he did not want to be in hospice-he wasn't angry with us, he said, just the fact that he was sick. Their conversation ended with her squeezing his hand and acknowledging that she had really heard him, "I'm sorry that this happened to you. It really stinks." That encounter seemed to help break the ice in our caring for this man. He never did talk a lot or ask many questions, but her question to him seemed to clear the air.

Whoever thought nurses need to learn to talk? As with all areas of nursing, learning to talk with patients and communicate well is a skill. It may come more naturally to some than to others, but there is no doubt that we can all improve, take hints from one another and offer pats on the back to our peers who do a good job talking.