Background During serious illness communication, each person – clinicians, patients, family, caregivers – constructs and interprets silence differently (1). Yet, therapeutic silence is more than just the absence of speech – it is a communication tool that has been associated with improved decision-making, deeper clinician-patient encounters, and better patient-reported quality-of-life when employed deftly in serious illness communication (2,3). This Fast Fact presents expert opinion on how to incorporate and respond to silence in serious illness communication.

Silence – two sides of the same coin   During the emotional dynamics inherent to serious illness conversations, clinicians may worry silence will be interpreted as them not knowing what to say or do and, thus, a sign of failure. Such “awkward silences” can evoke temporary feelings of discomfort or disapproval (4). Yet, more broadly, silence offers therapeutic opportunities to integrate and reflect on information. It also facilitates space for questions and eliciting care preferences and values (4-6).

Silence as an intentional clinical tool   When leading serious illness conversations, silence is a crucial element of the dialogue and should be utilized intentionally to convey empathy, affirmation, respect, and safety. While the published evidence is not robust, experts promote that silence can (7-9):

• Serve as a pause to slow down the pace of a serious illness conversation.
• Allow patients and caregivers to process clinical information before moving ahead in discussions.
• Allow patients and caregivers time to elaborate on their thoughts or perform further introspection.
• Convey non-abandonment by demonstrating the clinician’s awareness of the emotionally difficult situation, their willingness to process the situation, and attention to the patient’s needs before offering clinical advice to what are often complex and challenging clinical decisions.
• Demonstrate presence in the “here-and-now” of the conversation and the patient’s processing.

Conversely, when clinicians needlessly interrupt, patients may feel rushed and inhibited from expressing their immediate concerns and symptoms (10-12). This can strain the therapeutic relationship, foster mistrust, and leave patients feeling dismissed or rejected (13,14).

Silence as a challenge   The practice of silence within the patient-clinician relationship is challenging, especially in serious illness care (7,15). Clinical emergencies, rapid responses, and symptom crises demand swift action and clear, concise communication. Additionally, time pressures from competing clinical demands may compel clinicians away from utilizing silence despite its potential value. Mastering the skill of “being silent” and “being with” requires discipline and practice (7,15). There remains a clear need for education and training to incorporate silence as part of serious illness communication (7).

Tips for employing therapeutic silence in serious illness conversations   Several online resources dedicated to improving serious illness conversations include the effective use of silence, e.g., Ariadne Labs (https://www.ariadnelabs.org/serious-illness-care/), VitalTalk (https://www.vitaltalk.org/), and Care Learning (https://carelearning.org.uk/). Additional tips include (4-16): 

• Remind others that they can take their time in expressing thoughts and emotions. Be intentional to avoid filling in the pauses of the patient’s speech. “Take your time. I’m not going anywhere.”
• Sit by the patient instead of standing over the patient if possible. See Fast Fact #514.
• Pause for several seconds before responding when a patient shares vulnerable information (e.g., they are tearful or expressing their health worries). Intentional use of silence can create space for therapeutic nonverbal expressions (i.e., facial or hand gestures, gentle touch), and may also bring to light elements of the conversation that were previously unspoken or overlooked.
• Slow down the overall pace of speech. To do so, utilize “ask-tell-ask” communication principles when sharing key content; allow for a couple moments of quiet when transitioning between major points of the agenda or conversation.
• Leverage silence to build nonverbal alliances with others in the room – e.g., make eye contact, smile, nod in understanding (as culturally appropriate). Observe the nonverbal behaviors of others.
• Intentionally lengthen your exhale when engaging in emotionally intense communication encounters.

Responding to silence   When patients, families, and/or clinicians encounter unexpected silence during a serious illness conversation, it is often perceived as awkward. Despite the short-term social discomfort elicited by silence, it also provides insight into how the patient and their loved ones are processing clinical information. Instead of fighting against silence by filling it in with idle conversation or by trying to move the conversation ahead too quickly, observe the silence and internally reflect on what it may signify about the patient and the encounter. If needed, an appropriate verbal response to prolonged silence can be “I can only imagine what you must be thinking. What thoughts are going through your mind at the moment?” or “I’m sure you can see that I don’t know what to say right now to make this clinical situation easier for you.”

Summary Without silence, communication may be perceived as impersonal, inauthentic, detached, and/or rushed. The integration of intentional silence can provide many benefits in serious illness care.

References

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Authors’ Affiliations: 1IRCCS San Raffaele Scientific Institute, Milan, Italy; 2Memorial Sloan Kettering Cancer Center, New York, New York, United States; 3Oregon Health & Science University, Portland, Oregon, United States. *denotes co-first authors.
Conflicts of Interest: None to report.
Version History:  Originally edited by Sean Marks MD; first electronically published in May 2025.