7.1.2 Hospitalists Need Skills to Address Their Unique Needs in Discussing Serious Illness

Hospitalists are in many ways well positioned to discuss care preferences with seriously ill patients. They work in teams and coordinate with multiple services and disciplines. They are not constrained to a clinic schedule, so may be able to build trust by visiting patients in multiple short segments throughout the day, or in longer segments of time if needed. After a discussion, they can follow up in a short time frame, compared to waiting for a clinic visit weeks later.

Hospitalists also face unique challenges in meeting patients’ communication needs. They often meet patients for the first time in the hospital, and may only follow them for a few days. Hospitalists often have daily schedules that are less predictable than a routine clinic day. They have to quickly establish rapport and build trust, since they are often discussing serious information even during the first encounter [1, 3]. The communication section of this book offers skills and strategies to meet the specific communication needs of hospitalists.

7.1.3 What Patients and Families Want in Hospital Communication about Serious Illness

Empirical research illustrates that patients want clear, honest information about their disease process and treatment options [8]. However, they do not want to discuss more information than they are ready to hear [9]. Most patients want to know realistic information about prognosis; yet, a significant minority do not want this information [8, 10]. Patients want clinicians to convey empathy and support hope [10]. They want to establish relationships with clinicians who see them as individuals [9] and want to trust clinicians with whom they discuss end-of-life concerns and prognosis [11]. Though hospitalists may worry that their limited relationships are a barrier, research indicates that seriously ill patients want and may even prefer to discuss end-of-life care preferences with hospitalists [12].

Based on this evidence, we suggest three goals for communicating with seriously ill hospitalized patients: (1) conveying desired information clearly, (2) supporting patients and families emotionally, and (3) helping patients and families make decisions that are consistent with their goals. The communication section of this book provides practical evidence-based advice to meet these goals. In this chapter, we detail the general principles and core skills involved in four main domains of hospital communication: opening the encounter, responding to informational concerns, responding to emotional cues, and handling the special situations of discussing bad news, responding to families who say “don’t tell,” and balancing truth telling with hope.

7.2.4 Eliciting Concerns and Setting the Agenda

Eliciting concerns is an important beginning to any interaction [16] and can be especially important in discussions of serious illness. Most patients have concerns at hospital admission, yet many are not addressed in encounters with hospitalists [17]. It is especially important to begin discussions of serious illness, such as goals of care discussions or family meetings, by eliciting patient concerns.

Concerns are most effectively elicited with open-ended questions and active listening. Questions like “How are you coping with all of this?” let the patient know that the clinician is interested in the patient’s concerns [18]. The phrase “tell me more,” for example, “Tell me more about what information you need at this point?” or “Tell me more about what you mean by that,” can be helpful to elicit concerns, particularly if the clinician feels that there is misunderstanding [15].

Once concerns have been elicited, the clinician and patient can set a collaborative agenda for the discussion. For example, “I would like to ask you some questions about the treatment you’ve had so far, and then we can discuss your concern about your chemotherapy treatment delay. Does that sound okay?”