The Most Dangerous Procedure in the Hospital?
central to the human experience of illness, and therefore central to medical
decision-making. Being an expert clinician now means being a skilled
communicator. Fortunately, communication skills can be learnt, mastered and
Communication is increasingly
recognised as medicine’s most important non-technical skill. Perhaps this is
self-evident: after all communication is how humans exchange meaning, reduce
complexity, address uncertainty, manage emotions, inform, encourage, comfort
and challenge. Communication is also central to the human experience of
illness, and therefore central to medical decision-making. However, it is also
complicated, nuanced and, consequently, error-prone. Therefore it should not be
left to chance, or always left to junior team-members. Fortunately,
communication can be learnt, mastered and measured (eds Cyna et al. 2011; St
Pierre et al. 2008; Brindley and Reynolds 2011; Brindley et al. 2014).
If communication is defined as “sharing,
uniting, or making understanding common” (eds Cyna et al. 2011; St Pierre et
al. 2008; Brindley and Reynolds 2011; Brindley et al. 2014), then better
communication is key to creating systems that are more trustworthy and
patient-focused (eds Cyna et al. 2011; St Pierre et al. 2008; Brindley and
Reynolds 2011; Brindley et al. 2014). Whereas intensive care medicine
previously focused on scientific discovery and technological advance, medicine
can also be understood as a complex social system (Brindley 2010). Therefore
intensive care medicine should now also make a “science of reducing complexity”
and a “science of managing uncertainty” (St Pierre et al. 2008; Brindley 2010).
Much of this will be achieved (or squandered) by how well we talk and listen.
Furthermore, patients often come to
intensive care units (ICUs) following bad outcomes and bad decisions: not just
bad pathology. Therefore, we are as much a Relationship Repair Unit (i.e. an
RRU) as an ICU (personal communication, J Ronco). Overall, communication
becomes one of our most potent ‘therapies’, and how we coordinate (or fragment)
ongoing care, bolster (or impair) cooperation, and grow (or erode) trust (eds
Cyna et al. 2011; St Pierre et al. 2008; Brindley and Reynolds 2011; Brindley
et al. 2014; Brindley 2010; Aron and Headrick 2002; Azoulay and Spring 2004;
Azoulay et al. 2000).
This review cannot exhaustively
cover (or comprehensively reference) a topic as capacious as communication.
Therefore healthcare professionals should read widely. The goal should be to
deliberately develop communication skills throughout our careers: such that ‘verbal
dexterity’ matches manual dexterity and factual know-how (eds Cyna et al. 2011;
St Pierre et al. 2008; Brindley and Reynolds 2011; Brindley et al. 2014;
Brindley 2010). This is because being an expert clinician now means being a
skilled communicator (eds Cyna et al. 2011; St Pierre et al. 2008; Brindley and
Reynolds 2011; Brindley et al. 2014; Brindley 2010; Aron and Headrick 2002;
Azoulay and Spring 2004; Azoulay et al. 2000). These skills will enhance
difficult decisionmaking: whether during acute medical crises; during handover
with colleagues, or, as is this article’s primary purpose, during discussions
with patients and surrogates.
Medical Communication: The Basics
Communication skills are rarely
innate, and do not necessarily improve through years of unstructured experience
(eds. Cyna et al. 2011; St Pierre et al. 2008; Brindley and Reynolds 2011;
Brindley et al. 2014). Similarly, communication is not onesize-fits-all, nor a
panacea. However, communication training is associated with increased
confidence, improved patient satisfaction, less anxiety, decreased depression
and lower posttraumatic stress (eds Cyna et al. 2011; Dunn et al. 2007; Leonard
et al. 2004). Communication can be a ‘placebo’ (i.e. good communication can
reduce pain and anxiety) or ‘nocebo’ (i.e. bad communication can increase pain
and anxiety) (eds Cyna et al. 2011). Better communication might also decrease
litigation and maintain hospital reputation (eds Cyna et al. 2011). Accordingly,
communication is everybody’s business: it should be taught to trainees,
expected from practitioners and supported by administration (eds Cyna et al.
2011; St Pierre et al. 2008; Brindley and Reynolds 2011; Brindley et al. 2014).
Communication is about listening as
much as talking. When we do talk it is also about more than just what words are
used (aka verbal communication) (St Pierre et al. 2008). We should also master
good paraverbal communication: how words are said (pitch, volume, pacing and
emphasis). Moreover, while this review focuses on verbal communication,
non-verbal communication is just as important. This includes appropriate body
language, suitable eye contact, response to emotions, the use of reflective
silence and active listening (see below). We really cannot not communicate:
failing to make the effort sends its own message (eds Cyna et al. 2011; St
Pierre et al. 2008; Brindley and Reynolds 2011; Brindley et al. 2014).
Why Communication (and Decision-Making) Is Often Difficult
Shannon and Weaver, working for Bell
Laboratories, developed a model for verbal communication still relevant to
medicine decades on (St Pierre et al. 2008). Simply put transmitters (i.e.
speakers) encode messages, and receivers (i.e. listeners) decode them. However,
both must be on the same channel (which in medicine could mean possessing
similar situational awareness and emotional states), and there should be
minimal interference (which in medicine could mean minimising chaos, stress, or
cognitive bias). They also identified the danger of ‘channel-overload’ (which
in medicine warns against communication that is unnecessarily complex).
Overload, which often results in indecision, also
occurs unless the receiver can filter data into usable
information: You receive data (“his blood
pressure is low”), but need to create usable
information (“his body is failing”) (St Pierre et al.
Shannon’s model has limitations.
Complex communication also requires meaning, which is harder to encode,
transmit and decode. This is one reason why we cannot assume that patients and
surrogates have reached the same conclusion as medical practitioners (St Pierre
et al. 2008). This in turn explains why doctors are commonly criticised for
failing to say what they mean, or mean what they say (“did you ever actually
say ‘he is dying’?”). This model also describes communication as unidirectional
(transmitter to receiver), whilst medical decision-making is commonly multi-directional,
across disciplines and across hierarchies (St Pierre et al. 2008; Brindley and Reynolds
2011; Brindley et al. 2014). Location should not affect data transmission, but
it affects communication quality, impact and efficiency. For example, when
transmitter and receiver are no longer face to face communication loses
important non-verbal cues (St Pierre et al. 2008). This is why the medical
telephone call is important to practise, and why confirming understanding by
routinely summarising and repeating back is an important fail-safe (eds Cyna et
al. 2011; St Pierre et al. 2008; Brindley and Reynolds 2011; Brindley et al.
Newer communication models focus on relationships,
not just tasks. The ‘four mouths and four ears model’ (St Pierre et al. 2008)
has sender and listener separated by a message with four equal sides: i) content;
ii) relationship; iii) self-revelation iv) appeal (St Pierre et al. 2008). Content
refers to facts and words. The relationship aspect means that senders reveal
(consciously and unconsciously) how they regard receivers through specific
words, intonations and nonverbal signals. Senders also indicate how they feel
about themselves, namely a ‘self-revelation’. Fourthly, there is an appeal (or
request) where messages encourage the receiver to do (or not do) something.
These four aspects apply to both talker and listener, namely we ‘speak with
four mouths’ and ‘listen with four ears’. This is often unconscious, and
depends upon mental state, expectation, and previous interactions (St Pierre et
al. 2008). Notably the sender cannot fully force the listener’s mind (and
vice-versa). A practical example follows:
When a doctor says to a patient or
surrogate: “What do you want me to do?” the doctor may presume he asked a
unambiguous question which respects autonomy. Perhaps he did, but intonation
can suggest otherwise. He may also have revealed his inability to make
difficult decisions or even frustration about the patient’s premorbid state (“it’s
too late...what do you expect me to be able to do!”). Also, the doctor’s
self-revelation could be one of either appropriate patient concern or
resignation (“I don’t have the time/training/authority for these complex cases…just
tell me what do you want”). His request or appeal (albeit unstated) might be to
try to subtly persuade the family (“I’m not sure ICU would be best”). In
contrast, senior doctors may wish to minimise the patient/ surrogate’s sense of
responsibility/guilt. In this case, communication should unequivocally state what
they believe is not appropriate but also what can be done (“life support doesn’t
treat this so won’t be offered. Instead, we will treat reversible conditions
and maintain comfort”).
The surrogate decision-maker also
listens with four ears, and any one can be more or less open. For example, a
content-based response would respond with objectivity (“I want everything”). If
the family member hears the self-revelation he might reply: “she’s been through
a lot, but she’s a fighter”. If the family member is attuned to relationship aspects,
or has previous disappointments from the medical professions, then they may be more
defensive (“You doctors give up too easily: I want everything”). Only rarely
will the listener have the state of mind to decipher the appeal: “so what I
think you’re telling me is..”. Regardless, this model shows how communication
can create a virtuous cycle that builds cooperation, or a vicious cycle that
destroys it (St Pierre et al. 2008; Brindley and Reynolds 2011).
Communication is affected (both in
meaning and interpretation) by the paraverbal (volume, tone, pitch, pacing) and
non-verbal (angry eyes; furrowed brow) (eds Cyna et al. 2011; St Pierre et al.
2008; Brindley and Reynolds 2011). These in turn are affected by subconscious
emotions and attitudes. If verbal and non-verbal are incongruent (words say one
thing; expressions another), then receivers typically deemphasise words, and
amplify the importance of tone and body language. With incongruence receivers
typically default to what they (or we) expected (“he said X, but I know what
doctors mean”). Incongruence promotes misinterpretation, and can be interpreted
as disingenuous (eds Cyna et al. 2011; St Pierre et al. 2008; Brindley and
Reynolds 2011). Congruence is even more important when those involved are
unfamiliar, or when the medical situation is novel, which is almost always for
families! Investing the time to establish ‘rapport’ (usually defined as ‘common
perspective’; ‘being in sync’ or ‘shared mental model’) can facilitate all
future interactions (eds Cyna et al. 2011; St Pierre et al. 2008; Brindley et
al. 2014). The effort demonstrated can also reinforce the patient’s
psychological reserves and resilience (eds Cyna et al. 2011; St Pierre et al.
2008; Brindley and Reynolds 2011).
Helping Patients and Surrogates Feel Safe to Communicate
As popularised by Pincince (2013)
and others, decisions are best made when people are not in hot emotional states
(anger, stress). To ‘cool’ emotions, patients and surrogates need familiarity,
which can be undermined by changing staff too frequently; predictability, which
can be threatened by keeping families waiting; intact support systems, which can
be destabilised if families feel excluded and a sense of control, which can be
weakened by illness and unfamiliarity. Hot emotional states lead to anger or intransigence
(aka ‘neural hijacking of the rational brain’). The psychologist Stephen Porges
explains this idea using the polyvagal theory: when calm our vagus nerve can
facilitate engagement; when angry it stimulates conflict ( Porges 2011). These
ideas apply to those that cannot talk (endotracheal tube; stroke), and those
that do not talk (fear, confusion, deference) (eds Cyna et al. 2011; Brindley
et al. 2014). For patients already burdened with illness, not being able to verbalise,
and not being understood, can accelerate a downward spiral into frustration and
disengagement. Also when healthcare workers do speak we may speak differently
than patients (eds. Cyna et al. 2011). Physicians often use technical language
and focus upon gathering information and delivering news. Patient language and
surrogate language often focuses on beliefs, fears and hopes, which explains
why they may cling onto any positive news (“so it’s not the worst you’ve ever
seen!”). Patient and surrogate coping strategies may include denial or
aggression, whereas caregivers intellectualise to protect emotions. Communication
that is sensitive, but objective, can bridge the caregiver’s ‘scientific world’
and the care-receiver’s ‘natural world’(eds. Cyna et al. 2011; Brindley et al.
Communication Tools That Can Aid Decision-Making
Especially when communicating bad news, doctors and
nurses should understand that, while routine for us, for families these are
sentinel moments, unlikely to be forgotten (eds. Cyna et al. 2011; Brindley et al.
2014). Combined with ‘active listening’ (where listeners pay close attention
and use feedback or rephrasing to demonstrate engagement and understanding), the
effort put into communication is a way to demonstrate non-abandonment (eds. Cyna
et al. 2011; Brindley et al. 2014). Communication tools and bundles (see below)
can also provide structure and reliability to complex communication. However,
they should never make interactionsrobotic and devoid of personal connection.
We also have tools to audit communication with patients
and surrogates (Black et al. 2013; Davidson et al. 2007). Black et al. (2013)
promoted a communication bundle with six requirements within 24 hours:
identification of i) the surrogate-decision maker; ii) code status; iii)
advance directive; iv) pain v) dyspnoea, and also vi) distribution of a brochure.
Four additional goals should be met within 72 hours: i) family meeting, ii)
discuss prognosis, iii) assess patient-specific goals, and iv) offer spiritual
care. This approach emphasises that decision-making requires more than just
data transmission. Patients are validated as people with values (not just
diseases) and part of a larger ‘lifesupport system’ that includes family,
friends and community (eds. Cyna et al. 2011; Brindley et al. 2014 Black et al.
2013; Davidson et al. 2007). All of the above should also explain why patients
and surrogates value clinicians’ communication skills at least as much as their
technical skills (Heyland et al. 2002). For difficult decision-making (and even
for simple decision-making!) communication is likely our greatest clinical
asset, or keenest liability.
This article is adapted from a more comprehensive review of high-stakes medical communication in the Handbook of Intensive Care Organization and Management (Editors A. Webb and G. Ramsay (Imperial College Press, 2016).
- Communication is central to the human experience
of illness, and therefore central to medical decision-making.
- Being an expert clinician now means being a
- Fortunately, communication skills can be learnt,
mastered and measured.