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that matter to the patient, detected via the cues (whether they are worries the patient came with or worries resulting from new information given), allows the concerns and needs of the patient to be identified and addressed appropriately.


Which cues? Gathering information It isn’t always feasible or practical to explore every cue but it is important to work with key cues that help to elicit the patient’s thoughts, feelings and concerns. There is evidence that the acknowledgement and exploration


of the first patient cue (verbal or non-verbal) is crucial because there is a 20 per cent decrease in cues provided by the patient if the first cue is not acknowledged or explored. Subsequent cues to work with are the strongest ones (which healthcare professionals tend to avoid). If in doubt, summarise the cues and ask the patient to prioritise. Working with the strongest cues and first cue (verbal or non-verbal) will optimise disclosure of concerns.


Giving information Working with cues is also important when giving information and negotiating decisions with the patient. Acknowledgement of a patient’s cues increases the amount of information the patient is able to recall and increases their ability to make decisions. Cues are a useful way of gauging patients’ reactions to what


we say. These cues might include nods which may suggest agreement or understanding, but could also include frowns, agitations, blank expressions or reduced eye contact, all of which may imply confusion or distress with what is being said, or disagreement with a decision.


Key communication skills To be sure of their meaning, cues need to be acknowledged, clarified and explored (ACE) using the skills below. Using skills in context, i.e. to acknowledge and explore cues,


significantly increases the disclosure of significant information from the patient and is key to a patient-centred approach.


Skills to acknowledge • Reflection • Paraphrase • Summary


Skills to clarify and explore •


information is given. Being empathic throughout is crucial.


Handling difficult questions Difficult questions or demands are often best treated as cues. Answering difficult questions may lead to breaking bad news or giving uncertain information. Typical questions can be “How long do I have?” “I am going to die, aren’t I?” Is it bad?” The key principle is to first acknowledge the importance of the question, then explore the question before giving information that addresses it (“explore before explain”). By exploring the question, the patient’s perceptions and concerns can be identified which will allow the question to be answered appropriately.


Breaking bad news Bad news needs to be given in a way that allows the person to understand and manage what is being said to them and in a way that allows them to express their fears and concerns before any information and advice is given. This means it needs to be delivered slowly in small chunks and with compassion. The doctor also needs to actively elicit the patient’s new concerns and feelings (being guided by the patient’s cues) before moving into information giving and discussing and negotiating treatment options.


Improving skills Learning to communicate effectively through experience alone has been shown to be ineffective when compared to other methods. Although a sound knowledge base and observation of good practice may facilitate change, experiential workshops which give participants a chance to practice, will optimise and maximise the ability to acquire, hone and maintain new skills.


Open focused questions


• Educated guesses


Showing empathy and being supportive Being empathic helps the patient to feel understood and cared for, and acknowledging emotions (cues) significantly increases information recall and enables the patient to process decisions more clearly.


Empathic statements: examples • I can see how upset you are. • You sound upset, am I right? • It sounds overwhelming. •


Summary of useful patient centred skills • Actively elicit patient’s perspective and all concerns (gather information)


• Verbally acknowledge concerns by summarising and empathising


• Obtain permission to give information • Pause frequently when giving information • Obtain permission to give further information • Check for new concerns and acknowledge • Negotiate a plan • Empathise throughout


You say you are coping but I am getting the sense that you are finding it really hard. (Pause)


Difficult situations Managing difficult communication situations normally refers to handling strong and difficult emotions exhibited by the patient or relative but it can also mean being asked difficult questions, or when patients or relatives make inappropriate demands. In all these situations the key is to work with the cues. Strong emotions need to be acknowledged, not ignored or minimised, and the concerns driving the emotion elicited and explored before any


Further reading Assessing Patients with Cancer: the content, skills and process of assessment, Cancer Research UK Publication: (2nd ed 2008) maguireunit@christie.nhs.uk


Silverman J., Kurtz S., Draper J. (2008) Skills for communicating with patients (2nd edition), Radcliffe publishing: Oxford


Dr Claire Green, Nicky Schofield and Alison Fellows are trainers with the Maguire Communications Skills Unit, The Christie School of Oncology, Manchester


Summary A patient-centred approach using a structure for the consultation (“gather before give”), and facilitative skills linked to cues will: optimise disclosure of patient concerns, allow patient preferences to be heard, increase the likelihood of the patient understanding and recalling information, and participating in treatment decisions. A patient-centred approach is the key to best practice. It will increase the likelihood of the patient feeling satisfied with their care and feeling they have been treated as an individual with their wishes respected. It will also allow doctors to deliver tailored care with less risk of non-concordance with treatment.


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