Ask permission.

Don’t assume you know what your patients wants to hear, and when. Ask permission before sharing information or advancing the conversation. My fellow and I met someone recently who had made enough tough decisions for one day. He didn’t want to talk about prognosis, or what a transition to comfort focus might look like.

It wasn’t “denial” or avoiding the issue, it was just fatigue. Ask permission before diving into another sensitive topic and check in. If your patient says “not right now,” then that’s perfectly fine. There are very few topics in medicine that must be discussed right then and there. Come back later, give your patient some space.

Show your patients how much you value their individual processing pace, and that you prioritize it over your own agenda. It’ll make the next conversation that much more effective.

Don’t mirror anger.

We discussed the technique of mirroring in Moments Matter #18 and how it can pull you further into your patient’s narrative, which is usually a very good thing. The one situation in which I intentionally don’t mirror is with an angry patient. If your patient is angry and posturing, or pacing the room, then you certainly don’t want to posture and pace beside them.

So what do you do in a situation like this? How do you respond to a volatile emotion like anger? I’ve found several techniques helpful. First, check your own emotional temperature and remind yourself to wonder more (stay curious, rather than closed off). Second (or perhaps first), make sure you’re safe. I’ve had to literally break up a fist fight in a family meeting, and it’s not something I dream of ever doing again. Along with staying safe is making sure there is an “out” in the room for your patient. You don’t want to set up a tight ring of chairs and create a sense of feeling trapped, which may escalate tension further. Leave a nice opening in case your patient needs to escape for a moment.

Third, figure out the direction of the anger. Is the anger directed at you because of something you said or did? Or is your patient angry at God, or the hospital, or cancer, or having had nothing to eat for 12 hours? Identifying the direction of anger can help identify your patient’s need in the moment, and help inform your response.

Finally, adopt a strategy of active listening and emotional alignment through empathetic response. Say as little as possible, and just listen. Often someone fuming with anger just needs time and space to vent, and a nonjudgmental ear. Sit down to physically lower the tension in the room, listen, and respond with empathy. Don’t feel like you need to apologize or justify the actions of others. Just listen.

In my experience, this strategy works 9 times out of 10 and often your patient de-escalates automatically. Many times my patients have thanked me for listening, and apologized for the angry outburst.

We’ll discuss what to do that 1 time out of 10 when it doesn’t work later…

Pick out the chocolate chips.

My daughter LOVES doing this. Every time I make her chocolate chip pancakes, or we go to Eat’n Park, she’ll take a few bites, say she’s full, then proceed to surgically remove and eat every single chocolate chip.

I asked her once what she’s feeling when she does this. Her reply? “Happy.”

So go ahead, pick out the chocolate chips. And if you ever need a prescription to pick out the chocolate chips, come find me.

I’ll write you one.

Slow down.

Literally. I’ve been in family meetings that felt like NASCAR races, with doctors speaking so quickly it left my head spinning. It’s not a race to get the information out, and trust me – your patients are likely already confused and overwhelmed and nauseated.

If you’re nervous because the Palliative Care attending is in the room listening, don’t be! We’re nice people. Take a deep breath, and slow down. How will you know that you need to slow down? Look for non-verbal cues like fidgeting, furrowed eyebrows, and looking around the room nervously. If you find yourself needing to take a deep breath while you’re speaking, that’s another sign.

One trick I use to slow the tempo of a conversation is to speak with my hands. I do this naturally but if I find the pace speeding up, then I intentionally slow things down with my hands much like a conductor. I’ll match the oscillation of my hands to a slower tempo. This works wonders, and not only helps me slow down but helps others in the conversation slow down, too (it also works really well for diffusing escalating tension).

So remember: slow down! It’ll help you get where you’re going that much faster.

When I met with our new HPM Fellows, we also read and discussed Rachel Naomi Remen’s piece “Helping, Fixing, or Serving.” If you haven’t read it before, I highly recommend it: it’s a nice, short reflection on service and human connection.

We also talked about how there’s a role for each, and that perhaps they should be fluid roles that shift and change depending on what our patients need. Sometimes out patients really just need their broken bone fixed, other times they need a genuine connection to help explore something tough or terrifying.

But how do we know what our patients need? There’s no sign outside the room. “Fixing needed now” or “desperately seeking human connection.” We figured out that maybe the best way forward is to never presume you know what your patients need. Instead, sit down and talk – human to human. Get to know your patients better, figure out what they need in the moment and tailor your role to meet that need. Then maybe we can move from helping, fixing, or serving to helping, fixing, and serving depending on what our patients need most in the moment.

Today I met with our new HPM Fellows. We had a wonderful time reflecting on the start of their fellowship, and some of their anxieties and hopes for the year. One of the questions they asked me was “how much do you use your palliative communication skills outside of work?”

I laughed, because this comes up all the time. “Palliative Communication” is really just “Good Communication.” Sure, it’s tailored to and framed for specific situations, but the fundamental skills of emotional recognition and response are the same.

At this point in my career and life, I’m pretty sure these skills just come out unannounced in unstructured conversation. I remember my wife at one point (jokingly?) saying “don’t use that palliative voodoo on me!” My kids will tell you I use “I wish” statements all the time on (with?) them. “I wish we could eat more candy right now, really I do” and “I wish our bodies could handle ice cream several times a day!” are favorites.

Take a moment and think about it. What “lines” or communication skills used at work have found their way into your daily routine?

Go back if you say you will.

Trust is a house of cards, it takes patience and perseverance to build and the slightest bump to topple. Following through on what you discuss with your patients is a huge step in building trust and rapport. If you say you’ll tell them the X-ray results, then make sure you review the X-ray and share the results.

If you tell them you’ll check on them later, then make sure you come back and check on them later. Your patients will remember if you don’t.

Feed yourself.

This one may seem obvious, but it bears repeating over and over again. Eat something. You can’t care for others if you don’t care for yourself, and part of caring for yourself means eating.

There were certainly moments in residency when I survived on saltines and call cocktails (diet ginger ale + cranberry juice), and times as an attending when I pushed through lunch because there were so many patients to see. What have I learned after all these years in medicine?

Feed yourself. And whenever possible, make it something incredibly delicious and memorable.

Wonder more.

Yesterday we explored the statement “they don’t deserve this,” which is usually followed by “it’s just not right.” How would you respond? How do you attend to the underlying emotion, how do you explore the weight of this statement? Because it’s a very heavy statement. It presumes a right versus wrong course of action.

I tend to use “I wonder” statements a lot in these situations. “I hear what you’re saying, and sense how frustrating this has been. I wonder what she would say if she could see what’s going on” or “I wonder why her family members, who seem to love her very much, are making decisions we feel aren’t right. I wonder if they’re scared. Or feeling guilty?”

I wonder statements are great because they reinforce curiosity, rather than fortification behind fixed beliefs. I wonder if there’s another perspective I should consider. I wonder if there’s something I’m not seeing.

If we wonder more, then we’ll remember that there’s no universal right or wrong, there’s only what matters most to our patients based on their unique identities and values.

They don’t deserve this.

How many times have you heard this before? They’re suffering, they don’t deserve this. They should just just be made comfortable.

What do you feel when you hear this? What do you think? What comes to mind?

Whenever I hear this, and I hear it quite often, I hear a cry for help. I hear moral distress. I hear something I need to explore further, and spend time providing support. Almost always, it’s said by a colleague in the hospital. Sometimes by a family member. But almost always by a colleague.

Whenever I hear this, I remind myself to pause and take a deep breath, and acknowledge the emotional toll of bearing witness or participating in a course that one feels should go differently. I remind myself not to dive into lecture mode or argue the implications of such a statement, but to float a bit with the humanity that’s just surfaced. I remind myself that maybe here, too, there is a need.