Introduction    Listening to, recognizing, and responding to patient emotions is an essential skill for physicians who care for dying patients.  We often think of this skill as innate—either we have the skill as an attribute of our personality, or we don’t.  In fact the skill of responding empathetically to patient emotions can be learned.  Here are eight tasks that guide you in responding to patient emotion:

1. Listen to the patient.  Listen – do not interrupt while the patient is talking.  Patients and families facing end-of-life decisions want an opportunity to talk with their doctor about what they are thinking and feeling.

2. Listen to yourself.  Be aware of your own emotions.  Your feelings of sadness, anger, anxiety, fear or happiness are often the first clue that a patient is communicating an important emotional message.  Avoid the trap of quickly acting on your emotions.  For example, if you find yourself feeling angry, do not tell the patient you are angry; instead use your feeling of anger as a cue to find out more about what the patient is saying. See Fast Fact # 203 on Managing One’s Own Emotions as a Clinician. 

3.Reflect thoughts, feelings and behavior.  Reflection means re-stating what a patient has said using their own words and phrases.  Reflection 1) tells the patient that you are listening and care, giving permission to discuss sensitive topics; 2) allows the patient to listen to their own thoughts, heightening their self-awareness; and 3) allows the patient to confirm, correct or amplify upon your understanding. 

 Example 1, Reflecting thoughts:

• Patient:  This is a tough decision…I just can’t decide whether I want to enter a hospice program or continue with chemotherapy.
• Physician: You’re having a hard time deciding between hospice and chemotherapy.

 Example 2, Reflecting emotions:

• Patient:  I’ve been feeling run down and discouraged. I’m a little overwhelmed.
• Physician: You have been feeling discouraged and overwhelmed ….

 Example 3, Reflecting behavior:

• Patient begins to cry. 
• Physician: I see that you are crying….

4. Affirmation & respect.  Patients and families take a risk when they share their emotions; affirm and support the patient.   Examples: Thank you for sharing your feelings and thoughts. Or, I’m glad that you are talking with me about your feeling. Or, I can do a better job as your doctor when I know how you are feeling.

5. Empathic curiosity.  Be curious and request more information:  I’d like to know more about this… Or, Please tell me more about the sadness you are feeling.

6.Summarize/paraphrase.  Restate the patient’s story in your own words.  In contrast to reflection, paraphrase and summary involves interpretation and condensation of the patient’s narrative. An effective comment is brief yet captures essential meaning and emotion. We have been talking for awhile about how things are going for you.  Let me see if I can summarize what you have said, then you can let me know if I’m on track…

7. Make a plan.  Sometimes a patient simply wants to talk about their feelings; other times, action may be important.  Possible action steps include making changes in how you and the patient communicate, helping the patient identify sources of social support, and changing the plan of care.  Find out what the patient is expecting—How can I help? Or, What, if anything, would make a difference for you?

8. Offer Follow-up.   I would like to check in with you next week and see how things are going.  In the mean time, please let me know if you need to talk before then, OK?

See Fast Facts: Delivering Bad News (#6, 11); Dealing with Anger (#59); Responding to Emotions in a Family Meeting (#224).

References

1. Egener B. Empathy.  In: Behavioral medicine in primary care: a practical guide. Feldman MD, Christensen JF, eds. Stamford, Connecticut: Appleton & Lange: 1997: pp8-14.
2. Cole S, Bird J. The Medical Interview: The Three Function Approach.  Second Edition. St. Louis, Missouri: Mosby; 2000.

Version History:  This Fast Fact was originally edited by David E Weissman MD.  2nd Edition published August 2005; 3rd Edition May 2015. Current version re-copy-edited March 2009; then again May 2015.