As outlined above, physicians tend to be most comfortable addressing cognitive aspects of communication. Dealing with the emotions that arise in others and in oneself is considerably more difficult. Why is this so? Some emotions are simply hard to deal with for practically anyone - anger and sorrow, for example. Clinicians face an additional barrier, or handicap. Doctors (as well as nurses, social workers, and others) are professionals, and with this professional role comes a lot of baggage. We are scientists. We are in charge, and we are rational. To a degree, this is all true, but we are also human. Our humanity may be viewed by some as a weakness, a failing in our professional role. However, this humanity is central to the relational aspect of communication with our patients and their families. In a crisis patients and families want the professional. They want clear thinking, and they want our professional skills. They also want a human being with whom they can relate.
Patients and families often try to talk our language. They try to speak "doctor-talk" requesting an IV when the subtext is really "I'm feeling desperate, please help me!" They, too, may be more comfortable dealing with the cognitive aspects of communication and may avoid emotional issues. Choosing when to address the emotional subtext is an art; there are times to do it and times not to do so. It is safe to say that most physicians do not do it enough and lack the skills to know how to address the emotional subtext.
One way of addressing emotions in another is simply to name what you see or think you see: "You seem very angry." Here, you are inviting the other person to raise what has been a subtext to the text.
In hearing a sad story, one might reflect "How sad." Such a statement reflects a feeling shared by speaker and listener as well as the mood in the room and in this subtle way differs from naming. It is also an empathetic response (see below on empathy). Identifying the mood draws attention to a common emotional context and the relationships among participants as an aspect of communication.
Addressing affect does not mean just bringing it out in the open; it is not simple catharsis. Affect can be explored cognitively. One can expand the conversation by inviting further exploration of an emotion: "Where do you think your sadness is coming from?" or "What is it that makes you so angry?" An empathetic statement is also an effective way to invite exploration: "It must be really hard to see your dad like this."
Now we're on scary ground. "Getting emotional" suggests a loss of control that threatens our professional roles, and we will be considered poor clinicians if we routinely "lose it" with our patients. How can we authentically share our emotions and yet be true to the maxim that in the clinician-patient relationship, the needs of the patient (and family) come first? We must acknowledge that, as human beings, we will sometimes lose it. It cannot be helped. If a doctor told me he or she had never "lost-it," I would worry about that doctor.20 Either that doctor is a saint or has built such thick calluses around his or her emotions that I would wonder if accessing those emotions were even possible. Saints are in short supply, so we should consider sharing our emotions from a therapeutic perspective: how could sharing our emotions be helpful to the patient (and family)?
If the emotional subtext of a conversation is completely ignored or suppressed, the situation becomes increasingly unreal and dishonest. This can have a very negative effect. At a time when patients and families are struggling with their emotions, we should not serve as models by running away from ours. Difficult as such emotions can be, bringing them out in the open in a manner that still demonstrates professionalism can simply acknowledge a tension between the doctor and the other that must be dealt with if a relationship is to exist and flourish. It is possible to model being angry, for example, without "losing" it and at the same time express a desire to be helpful: "I'm angry at you because you often demand this or that. It is hard for me to help you when I always feel on the defensive."
What about sharing other emotions, such as grief? We may think behaviors such as crying are undignified. Although people from different cultures likely have different values about this, consider how you might feel if a physician shed a few tears when pronouncing a loved one of yours. Would you consider it unprofessional or a tribute?
Technically, empathy refers to an intimate connection with another person such that one experiences the other's emotions as one's own. In seeing someone cry, we cry. In seeing someone in pain, we experience pain. I will leave it to philosophers to argue whether we really can experience someone else's suffering. What is clear is that we can find a certain resonance with the emotional states of others. When we respond to a person empathetically, we display verbally and nonverbally this resonance - or at the very least our effort to resonate with that person's experience. Most difficult discussions in palliative and end-of-life care offer numerous opportunities for empathetic responses.19 Empathetic responses address the affective aspect of communication but go beyond naming or sharing one's own emotions, as discussed above. The emphasis is on resonance. Many empathetic responses require no words, being best communicated nonverbally. For example, our voices may choke up. We may stand silently by a grieving widow as she sobs by the bedside of her now deceased husband. We may use physical touch, such as holding a hand just a second longer than is customary. Occasionally we may hug, although judgment must be used as to who is a "hugger" and who is not. Even how we cover a patient after an examination may display empathy or lack thereof. Listening, we stay in contact with the other. When pain or sorrow arises, we may change position or furrow a brow. Verbally, we may express at least an effort to understand the hardship of the other. To the family member keeping vigil, one might say, "You must be exhausted. Did you sleep last night?" When a relative comes from far away and seems surprised at how a loved one has changed, "How long has it been since you've seen your father? This must come as quite a shock." A more directly empathetic statement (but not necessarily better) might more overtly reflect your resonance with the other's state: "I really feel for you. I share your sadness," or simply, "How sad." One last piece of advice-if you do offer an empathetic response, makes sure it is genuine. False empathy is worse than no empathy at all.
<<< Previous Next >>> [ Go Up ]
Palliative Care Perspectives
James L. Hallenbeck, M.D.
Copyright © 2003 by Oxford University Press, Inc.
The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.