Navigating Difficult Conversations

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shephard, a medical oncologist here at Cleveland Clinic Directing the Taussig Early Cancer Therapeutics Program and Co-Directing the Cleveland Clinic Sarcoma Program. Today I'm very happy to be joined by Dr. Laura Shoemaker, Chair of Palliative and Supportive Care here at Cleveland Clinic. She's here today to talk to us about navigating difficult conversations, so welcome, Laura.

Laura Shoemaker, DO: Thank you. It's a pleasure to be here.

Dale Shepard, MD, PhD: So, I told everyone your title. Give us a little bit more of an idea, though, about what do you do here at Cleveland Clinic.

Laura Shoemaker, DO: Sure. Well, you mentioned I'm the leader of our Palliative and Supportive Care group here at Cleveland Clinic. That's my leadership role, but clinically, I'm a palliative medicine physician, so I treat and support patients and families who are experiencing serious illness, everything from cancer to advanced cardiac, lung, neurological diseases.

Dale Shepard, MD, PhD: We have a lot of different people that might be listening in, different backgrounds, palliative care is a word that scares some people. We're going to talk about difficult conversations, but maybe it starts with just if someone were to come see you, what is palliative care?

Laura Shoemaker, DO: Yeah, well, thanks for asking. Palliative care, simply put, is really just specialized care for people who are living with serious illness. It's provided by a team of palliative specialists, so that includes physicians like me, also includes nurses, social workers, sometimes complimentary therapists. The goal is to improve quality of life and reduce suffering for both patients and families as they navigate all the complexities of serious illness. Those things range from physical symptoms like pain, bowel issues, sleep issues, the emotional impact of serious illness, mood-related issues, issues with relationships. So good palliative care is really delivered alongside curative life-prolonging other supportive therapies at any stage and along the course of a serious illness.

Dale Shepard, MD, PhD: I guess that's a great explanation of palliative care, but a lot of people mistakenly think hospice. So just quickly differentiate what hospice is in comparison.

Laura Shoemaker, DO: Sure. Sure. Hospice is always palliative care. Palliative care isn't always hospice. So, hospice is that part of conservative comfort-focused care nearer to the end of life when time might be short. Palliative care, on the other hand, like I said earlier, is delivered along the trajectory at any stage of a serious illness, alongside curative treatments, alongside disease-modifying or life-prolonging therapies. At all times when we're doing palliative care and hospice, we're wanting to focus on the patient and their loved ones and what they need to improve the quality of their life and reduce suffering.

Dale Shepard, MD, PhD: Excellent. So, we're going to talk about having difficult conversations, delivering bad news, some tips and thoughts about that. As a palliative care specialist, what are some of the things that most often encountered in terms of the need to deliver bad news?

Laura Shoemaker, DO: Sure. Well, I think the conversation really depends on the unique experience of that patient. So oftentimes, I have no idea what we're going to be talking about during any specific visit or encounter. So, it really starts from a place of inquiry wherein I'm trying to understand their unique story or experience of that illness. Once I do that, and I can ask about what their experience has been, it takes us to all kinds of different places. Sometimes we talk about symptoms, the burdens of either the disease itself or oftentimes, the treatments for the diseases bring a lot of symptoms.

Sometimes we're talking a lot about the emotional journey, the stress, how do you cope? A lot of times we're talking about how they apply their unique values, preferences and goals as they navigate the relative benefits and burdens of the disease, treatments that are available to them at different courses of the disease. Then sometimes we're also talking about time, when time is uncertain, or time might be short. So prognostic conversations come up and again, we try to think about those things together within the unique framework of that individual's experience, their preferences, their goals, their values. So, lots of things come up. We never know where we'll end, so we start with a place of wanting to understand first.

Dale Shepard, MD, PhD: Which is fantastic because I think it's safe to say that as physicians, we talk too much, and we don't listen enough. For these difficult conversations, I'm suspecting that's the case.

Laura Shoemaker, DO: Absolutely. So, we do, we talk too much. I think it's important to ask first before we tell anyone anything. I think it's important to listen more than you talk, and I think to be ready, if you're talking about serious things or bad news as it's often called, there's going to be emotion there. Emotion is normal. I tell a lot of my patients and families, "If you weren't emotional, that would be strange. That would be abnormal." So, there's a lot of emotion here. So being ready for the emotion and responding to the emotion when we encounter it, when we're talking about serious things.

Dale Shepard, MD, PhD: I guess when you say respond to the emotion, I think one thing that oftentimes troubles physicians having these conversations is how they handle their own emotion and how much of our emotions we can share with patients during those conversations. What are your thoughts on that?

Laura Shoemaker, DO: Yeah, I think you're right that that might be a barrier. Just being comfortable with emotion, whether it's ours or someone else's, that's not something that comes naturally to everyone. Most of us either unintentionally or intentionally need to develop some comfort around the expression of emotion and the experience of emotion as you sit with someone who's facing a serious life-changing or potentially life-threatening diagnosis. So, I think you acknowledge for yourself, again, that it's normal to have emotion when the stakes are high and to give yourself some grace and some space to feel authentic emotion.

I think what most patients and families want is really our attention and our presence as we're trying to support them navigating something that's really challenging. So, if my intention around my emotions is not to hide them or avoid them or pretend, they don't exist, but in a professional way to acknowledge when something's sad, acknowledge when something's scary, also acknowledge and celebrate when you can find joy during sad and scary times too along the way and share in that. That's how I manage my emotions is I just try to share in the emotion in a way that's authentic for me.

Dale Shepard, MD, PhD: I still remember spending time in the hospital as a resident or a fellow and somebody gets a new cancer diagnosis, and the primary team is hovering around the nurses' station and they're like, "Have you told them? Have you told them? Have you told them?" It's this, quite honestly, it seems like fear on their part to have those discussions. How do you work with, as in a team approach, whether it's with oncologists or other specialists, to make sure that the right people are having those difficult discussions at the right time?

Laura Shoemaker, DO: Wow, that's a complicated question. I think when I think about the collegial relationships and the collaborative relationships that we have with the oncologists, the nurses, the other members of the care team, I think you bring empathy and listening and space to them as well. So, part of my role too, I think, is being a member of the team as any of us is to support that team. So, acknowledging with the oncologists, with the other clinicians, this is hard, this is scary, this is potentially sad. What we're going to talk about with this patient and their family today is life changing.

We can try to imagine for ourselves if we were sitting on the other end of that conversation how that might feel. So again, acknowledgement, putting a space there so that the clinical team can process that. As far as making sure the right person has the conversation, I think there's lots of people who can be the right person to have the conversation. I think someone who's willing to bring presence, partnership, honesty, and ready to sit with and respond to emotion, anyone who's willing and able to do those things is the right person to have the conversation regardless of what their professional title is.

Dale Shepard, MD, PhD: Makes sense. You've mentioned empathy a few times. I'll ask it in a silly way, but can you learn empathy? If so, how?

Laura Shoemaker, DO: That's a great question. I think you can learn empathy. I think what we're talking about, empathy, I think, is two parts. A lot of times people say, "Oh, it's putting yourself in someone else's shoes, imagining what it would be like to live someone else's experience." Yes, that's the creative imaginative part of empathy. Most of us have feelings and have experienced joyful things, sad things, scary things in our lives, so we can access those emotions even if we haven't lived the same experience that's led to the emotion. So, I might not have lived with a cancer diagnosis yet; however, I have experienced other things in my life that have been scary or sad or uncertain, so I can access that emotion. Then the second part of empathy is expressing it.

So, I think the first part, most everyone has access to it if you imagine it in that way. The second part sometimes comes naturally, expressing the empathy. If it doesn't, that's something absolutely you can teach because empathy is expressed both non-verbally and verbally. A non-verbal expression of empathy is giving someone your full attention, looking them in the eyes, asking first, listening to their response, not talking over them. Those are things that, again, if they don't come naturally, you can certainly learn to do and make part of your clinical practice. I think verbal expressions of empathy as well can be taught. Many of us, when we think about empathy, we think immediately about validation.

So, things like, "Oh, anyone would feel that way if they were in your situation," and validating empathy can be really appropriate, ineffective. There are other ways to verbally express empathy too. So, seeing emotion, calling out emotion is empathy. Acknowledging the impact of the emotion, what it's like to feel scared or worried or excited, and then supportive statements too, just letting people know they're not alone in it. That might sound something like, "I can hear you're going through a really difficult uncertain time. Please know you're not alone in this. I'm here to help you figure this out." So those kinds of verbal expressions of empathy that let the other person know that you're not only trying to share that emotion with them, but you're letting them know really is what brings the whole thing together.

Dale Shepard, MD, PhD: Makes sense. You've talked before about learning these behaviors. Here at Cleveland Clinic, I know there's a number of communication courses and ways to try to teach caregivers to have conversations. Is there anything you can let us know about some of those efforts to train people to have those conversations?

Laura Shoemaker, DO: Yeah. Years and years ago, we had a center, and I think we still do have the center, but it developed a really excellent framework for really enhancing our communication generally with patients and families. A lot of that was around verbal expressions for empathy. That was called the Center for Excellence in Healthcare Communication. They taught a lot of the things that I just reviewed. The four different kinds of empathy, for example, supportive statements, acknowledging statements, validating statements, emotion naming, those are all part of the core curriculum. I didn't come up with these myself. The other place I think where we teach clinicians how to connect with others in a relationship-centered way is our Center for Excellence in Coaching and Mentoring. We talk about relationship-centered communication in that course. We talk about deep listening, expressions of empathy, helping people reflect by reframing situations so we can navigate both clinical and professional challenges.

Dale Shepard, MD, PhD: One thing that I always find difficult is the environment and the setting at which to give bad news, have difficult conversations. One thing that comes to mind is discussions around you may find something in a lab or a CT scan, for instance, or get a biopsy result and the patients at home. How do you navigate bad news, difficult discussions when you can't necessarily have the person in a room with you? Do you bring them in? It always seems a little wonky to say, "I need to have a serious conversation with you, but I'll have it once you're here," because then that just generates anxiety. So, any guidance to people about situationally, how you deal with those sorts of times when you can't necessarily just have everything right there at the right time when you want to have that conversation?

Laura Shoemaker, DO: Yeah. I think ideally, as we get to know patients and families, we ask them questions about, "How do you like to receive communication? Are you a big picture person? Are you a detailed person? You need to be in the weeds on everything? Are you someone who likes to receive information alone and share it with your loved ones? Are you someone who likes to have a loved one with you as you receive information?" So, if we can get to know people in that way, then it sets us up in the future. When we find ourselves in predicaments, when important and potentially serious information needs to be shared, we already know what their preferences are, and we can try to facilitate that kind of situation. If you don't know, I still don't think it's wrong to ask.

My very early medical school communication courses, they talked about the warning shot. I think the warning shot still works. So, if you're calling someone on the telephone, letting them know that you're wanting to talk with them for a few minutes about some of the information you've received, pause. Wait to hear what their response is. "I already looked at the report, doctor, I know what you're going to tell me," or maybe they say, "Oh, my goodness, I thought we weren't going to talk about this until we see each other in the office." So, it's putting out there why you're calling and then stopping talking and listening for the response.

You can learn a lot about where someone is. Then you might say something like, I have some potentially concerning, serious, worrisome, whatever word you want to put to the information that I'd like to talk with you about today. Am I catching you at a good time?" Pause. Listen. Then also too, I would inquire potentially about, "As we start this conversation, where are you? Who's with you? Is there someone else you'd like to have join the conversation?" So again, just approaching it slowly, sharing information one piece at a time with a little bit of a warning shot as you go along and pausing along the way, because if we just stop talking, oftentimes, patients will tell you everything you need to know about how to navigate that situation.

Dale Shepard, MD, PhD: I guess how have these situations and your ability to control, not control their knowledge of information, but their ability to set the stage changed with our new policies with electronic medical records? Oftentimes, people know their biopsies or their CT scans before I do.

Laura Shoemaker, DO: Yeah.

Dale Shepard, MD, PhD: Has that made an impact on your ability to effectively have difficult conversations?

Laura Shoemaker, DO: Yeah, you're right. It does introduce, for many of us, a different kind of dynamic in the way the order in which the information is shared. I think we both remember a time when the doctor was the holder of all information until it was decided by the doctor shared, and we don't live in that space anymore. I think that's okay. I think we need to have sensitivity, again, about the variety of ways that people like to have information. So, for some people to be able to click on that result and open it up themselves, that actually is better for them. For some people, that might not at all be, quote, unquote, "better."

So, I think having sensitivity around that, again, asking about how they like to receive information and being ready that you might not know what the patient knows or doesn't know already, so to start with, "Help me understand what you know now. What information do you already have?" I'll often say, "What have the doctors told you about your cancer, your heart failure, your illness?" So, start by asking to find out where the patient is and then you can meet them there and fill in the gaps. I think too, just remembering to expect emotion and respond to the emotion that's invariably going to be there.

Dale Shepard, MD, PhD: It sounds like, from what I'm hearing, that really, of course, communication is key. But not having delivering bad news as an event, as a moment in time, as a single conversation, setting expectations, learning about people, having continued conversations is really the key. Does that seem like a takeaway?

Laura Shoemaker, DO: Yeah, I think so. I think it's just the relationship centered nature of communication and information. Things are a lot easier to navigate when there’s relationship around them, so where there’s trust, where there’s shared expectations, where there’s some familiarity with each other, “I know a little bit about you, a little bit about me. We’re in this together.” I think the relationship piece of that is really important. I love your comment about communication’s not just one event. You don’t just drop a bomb unexpectedly. You help people be prepared for what’s coming, and you’re there for the fallout too after that.

Dale Shepard, MD, PhD: Excellent. Well, you've provided us some great insights today. Appreciate you sharing your insights with us.

Laura Shoemaker, DO: Thanks. It's my pleasure to be here.

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