Background Using personal narratives in clinical care can increase patients’ hope and sense of peace (1), decrease distress (2), and help them feel valued (3,4). Narrative interventions can be performed across healthcare settings and by any interdisciplinary team member including physicians, nurses, social workers, and chaplains. Though similar, dignity therapy is a specific type of psychotherapy performed by trained psychosocial clinicians. This Fast Fact will provide a framework to discuss narrative approaches to serious illness care that can be incorporated into clinical practice. This framework is largely based on experience with the My Life, My Story program within the Veterans Affairs healthcare system (5).

Applying narrative approaches in clinical practice: A narrative history does not replace a typical medical history, but it can enhance the delivery of patient-centered care at any stage of illness (6). We recognize this can be time-intensive and may be most feasible in longitudinal care settings or long hospital stays. Some programs have used an asynchronous digital approach, with the patient answering online questions and reviewing and discussing with their care team later (7). Importantly, narrative histories should be easily accessible to all care team members through the electronic health record (EHR) so that they can be easily reviewed as staffing changes.

Example questions and tips for narrative history-taking 

• Invite the patient to participate. Explain that some patients find it helpful to share more about themselves with their care teams and have stories about their lives written down for them and their support systems to keep. Explain that doing so may help their care team provide better care to them.
• Let the patient know they can talk about whatever they want and avoid anything they do not wish to share. Be mindful of trauma-informed care principles while engaging the patient in narrative history-taking (see Fast Fact #487 and Fast Fact #488).
• Consider starting with childhood experiences or asking the patient where to begin.
  • Some people like to start by talking about their childhood, but if there is another time you’d like to begin with instead, we can start there.
  • What was growing up like in your family? What do you remember from your childhood?
• Transition to important points in careers and/or relationships if applicable.
  • What did your career path look like?
  • Who are important people in your life? How did you meet your significant other?
• Finish with lessons learned and exploration of values.
  • What are you most proud of? What things are most important to you?
  • What advice would you give to others? What are you hopeful for? 
  • What else is important to say? Or What else do you want others to know about you?
• Offer to read the story back to the patient and once a draft is created, invite editing to ensure the narrative is how they want it. This does not have to be done on the same day.
• Thank them for sharing their story and this experience with you.
• Recognize that some patients may not be interested in participating fully. Principles of narrative history taking can also be applied to smaller portions of the person’s experience, clinical story, or even a specific healthcare decision and might be served with a simple question: Can you tell me more about that? Exploration in a finite life space may be more comfortable for patients (8).

Underlying principles of narratives approaches to clinical care – The 6 R’s Framework  

• Reframing: situate the underlying illness and a patient’s way of relating to it within the broader context of their life. Clinical example:  A young woman with ovarian cancer is hesitant to take opioid analgesics. Through a narrative approach, the clinical team learns the importance of her role as a mother and makes medication changes that prioritize the skills needed for her to serve this role well.
• Relationships: Seek understanding of the patient’s important relationships and identities. Doing so can enhance patient-clinician bondedness (9) and help clinicians understand the reasoning underlying their patients’ care preferences (10). Example: A young man with refractory heart failure has limited social support, apart from a trusted aunt who lives out of state. A narrative approach allows the team to identify that important relationship and involve her in care conversations.
• Reflecting: Via open-ended questions, close listening, and reflecting back patient responses, clinicians can accompany them as they search for meaning amid their terminal illness experience; this may foster better adaptation to their health situation and a fuller sense of peace (11-16).
• Recommendations: Taking a narrative history can facilitate the identification of the patients’ care goals and values more organically, which can then be incorporated into goal-concordant treatment recommendations. Example: An older adult woman has advanced leukemia and a limited prognosis. As they consider further chemotherapy, a narrative approach allows the clinical team to understand her key goal of having time at home with her grandchildren. They recommend home hospice care.
• Remembrance: Documentation allows patients to create something tangible for themselves and their loved ones. In the My Life, My Story program, after patient approval, a copy is uploaded into the EHR and printed copies are given to patients and family members to honor the story they shared.
• Resilience: Clinician burnout is common, especially in serious illness care (17,18). Narrative approaches can promote clinician resiliency by highlighting humanism in clinical care and increasing clinician empathy towards patients (19,20).

References 

1. ‌Wise M, Marchand LR, Roberts LJ, et al. Suffering in Advanced Cancer: A Randomized Control Trial of a Narrative Intervention. J Palliat Med. 2018;21(2):200-207. doi:10.1089/jpm.2017.0007.
2. White, M, Epston D. Narrative Means to Therapeutic Ends. 1st ed. Norton; 1990. 
3. Charon R. What to do with stories: the sciences of narrative medicine. Can Fam Physician. 2007;53(8):1265-1267. 
4. Ringler T, Ahearn EP, Wise M, et al. Using Life Stories to Connect Veterans and Providers. Fed Pract. 2015;32(6):8-14. 
5. Nathan S, Wershof Schwartz A, Topor D. My Life, My Story: A Narrative Life History Activity to Humanize the Veteran Patient Experience. In: Cases on Instructional Design and Performance Outcomes in Medical Education. IGI Global; 2020:70-91. 
6. Laskow T, Small L, Wu DS. Narrative Interventions in the Palliative Care Setting: A Scoping Review. Journal of Pain and Symptom Management. 2019;58(4):696-706. doi:https://doi.org/10.1016/j.jpainsymman.2019.06.009.
7. Cercato MC, Colella E, Fabi A, et al. Narrative medicine: feasibility of a digital narrative diary application in oncology. Journal of International Medical Research. 2022;50(2):030006052110455. doi:https://doi.org/10.1177/03000605211045507.
8. Salana K, Maty S, Hage R. A Whole Other Story: Interpreting Narrative Medicine. Global Advances in Health and Medicine. 2021;10:216495612110318. doi:https://doi.org/10.1177/2164956121103188.
9. Wittenberg E, Ragan SL, Ferrell B, et al. Creating Humanistic Clinicians Through Palliative Care Education. J Pain Symptom Manage. 2017;53(1):153-156. doi:10.1016/j.jpainsymman.2016.11.004.
10. Tulsky JA, Steinhauser KE, LeBlanc TW, et al. Triadic agreement about advanced cancer treatment decisions: Perceptions among patients, families, and oncologists. Patient Educ Couns. 2022;105(4):982-986. doi:10.1016/j.pec.2021.08.001.
11. Wise M, Marchand LR, Roberts LJ, et al. Suffering in Advanced Cancer: A Randomized Control Trial of a Narrative Intervention. J Palliat Med. 2018;21(2):200-207. doi:10.1089/jpm.2017.0007.
12. Kreuter MW, Green MC, Cappella JN, et al. Narrative communication in cancer prevention and control: a framework to guide research and application. Ann Behav Med. 2007;33(3):221-235. doi:10.1007/BF02879904.
13. Carlick A, Biley FC. Thoughts on the therapeutic use of narrative in the promotion of coping in cancer care. Eur J Cancer Care (Engl). 2004;13(4):308-317. Doi:10.1111/j.1365-2354.2004.00466.x.
14. Kleinman A. The Illness Narratives. Basic Books; 2020. 
15. ‌Frank AW. The Wounded Storyteller : Body, Illness, and Ethics. The University Of Chicago Press; 1995.
16. Ezzy D. Illness narratives: time, hope and HIV. Soc Sci Med. 2000;50(5):605-617. doi:10.1016/s0277-9536(99)00306-8.
17. Pessin H, Fenn N, Hendriksen E, et al. Existential distress among healthcare providers caring for patients at the end of life. Curr Opin Support Palliat Care 2015;9(1):77e86.
18. Kamal AH, Bull JH, Wolf SP, et al. Prevalence and predictors of burnout among hospice and palliative care clinicians in the U.S. J Pain Symptom Manage 2016;51(4):690e696.
19. Schoonover KL, Hall-Flavin D, Whitford K, et al. Impact of Poetry on Empathy and Professional Burnout of Health-Care Workers: A Systematic Review. Journal of Palliative Care. 2020;35(2):127-132. doi:10.1177/0825859719865545.
20. Winkel AF, Feldman N, Moss H, et al. Narrative Medicine Workshops for Obstetrics and Gynecology Residents and Association With Burnout Measures. Obstetrics & Gynecology. 2016;128:27S33S. doi:https://doi.org/10.1097/aog.0000000000001619.

Authors’ Affiliations: Brigham and Women’s Hospital, Boston, Massachusetts; Dana-Farber Cancer Institute, Boston, Massachusetts; Veterans Affairs Boston Healthcare System- West Roxbury Campus, Boston, Massachusetts.
Conflicts of Interest:  None to report.
Version History:  Originally edited by Sean Marks MD; first electronically published in September 2024.