There has perhaps never been greater awareness of the importance of serious illness communication, nor evidence to support its critical role in achieving effective clinical care. Despite this, trainees and practicing clinicians continue to report feeling underprepared for difficult conversations. Reassuringly, a new guidebook is poised to make talking with seriously ill patients more approachable than ever. Navigating Communication with Serious Ill Patients: Balancing Honesty with Empathy and Hope is the second edition of the original 2009 text by Back, Arnold, and Tulsky. This new edition includes three new authors, Carey, Wood, and Yang, and consolidates their decades of teaching experience as leaders of the educational nonprofit VitalTalk. This new edition triumphs in preserving the highly practical quality of the first edition, while providing updated communication frameworks and expanding its reach to a broader range of clinicians and clinical challenges.
What is the book’s central aim?
In the preface, the authors make their intention clear: to help clinicians combine their authentic selves with evidence-based skills, and therein foster more effective, meaningful conversations. To reach this goal, they are equally clear that this will take work – practice – on the reader’s part. Their central argument remains that clinicians can learn to communicate better, and doing so requires a process of observing effective skills, practicing, and receiving feedback. The text becomes a launch pad for readers to learn what works and then try incorporating skills into their practice. Additionally, the authors commit to remaining highly practical. While rooted in evidence, this is not a review – it is a playbook for one’s communication practice, and the authors serve as coaches along the way.
What is retained from the 1st edition?
Most chapters focus on a specific type of conversation and are organized around a common pitfall, roadmap to navigate the conversation, and “bottom line” point. This approachable chapter structure allows readers to identify the most important messages of the book and nicely reflects the authors’ position that effective communication need not feel nebulous or unattainable, but rather, is built on reliable frameworks which become, with practice, easier to employ. Additionally, the importance of responding empathically to emotion remains central – framed as the critical skill that allows clinicians to understand, align, and move forward with patients and families.
What is new in this 2nd edition?
Chapter 1 introduces that effective communication is built on individual skills, cognitive roadmaps, and clinician capacities. This updated vocabulary is then used throughout the book, allowing readers to categorize key elements of effective conversations. The authors have also added a new Chapter 2 covering Foundational Communication Skills – four must-have skills for most any conversation. With this foundation, the authors then introduce multiple updated conversation roadmaps, including “ADAPT” for discussing prognosis and “REMAP” for late goals of care. The new edition also covers more nuanced challenges reflective of modern practice, such as navigating prognostic uncertainty in the era of targeted cancer therapies and responding to requests for hastened death. The text even weaves in elements of the serious illness communication literature that extend beyond the traditional VitalTalk curriculum, including the prognostic awareness pendulum and expanded content on supporting positive coping.
The new edition also succeeds in incorporating a broader range of disease states, interprofessional clinicians, and patient demographics. While the first edition focused on physician practice, most often in oncology, the updated text incorporates physician assistants and nurse practitioners caring for patients with conditions such as multiple sclerosis and advanced pulmonary disease. Throughout the book, the authors also highlight how to adapt their methods when caring for patients from historically marginalized communities.
Are there any shortcomings?
Were there any limitations, readers may find some of the example dialogues to be “easy” or think – I wish it went that smoothly in real life. Consider the Chapter 6 dialogue demonstrating how to discuss treatment decisions with a patient with advanced heart disease. When the clinician uses the chapter’s skills, the patient quickly decides to “go with the LVAD” and appears ready to proceed with the intervention. While this may seem simple, we can also imagine it was done intentionally. Remember, the authors are using these dialogues to demonstrate specific skills, so some simplicity is necessary to ensure readers can identify the key skills and their effects on the conversation. Essentially, these are teaching tools, and sure – it’s always a bit messier in real life. That’s where the emphasis on practice comes in.
Here is what I appreciate most…
The authors’ highly approachable tone is among the book’s most striking and effective qualities. They consistently explain complex concepts with clarity and economy of words. Consider their description of emotional intelligence: “Although many of us learned in training that emotions are messy liabilities, … emotional intelligence, once acquired, gives us a whole additional realm of data that we use to understand other people. Not paying attention to our own internal emotional cues only makes communication with patients that much more difficult.” (222). Here, they leave the reader feeling that they too can understand and do this work. Equally, while the authors’ expertise is clear, their voice is consistently supportive, even humble: “These situations are really hard, and all of us have bad days from time to time and handle things imperfectly” (173). Like a coach, they normalize struggles and inspire the reader to keep trying: “If you are motivated, you can improve – and you’ll get to where you can use your skills instinctively” (223).
Summary
- The new VitalTalk book is likely to become required reading for trainees, practicing clinicians, and educators working with the seriously ill.
- Novice clinicians will learn foundational skills to use daily in practice, while seasoned communication educators will acquire new, succinct ways of describing more nuanced clinical challenges.
- The readers most likely to benefit from this book, regardless of career stage, are those willing to shift from reading to practice.
- The authors remind readers that only by deliberately practicing these skills can clinicians experience deeper connection and effectiveness with patients and families, the kind that make communication work so meaningful.
Author
Andrew Lawton MD, FACP, FAAHPM
Attending Physician, Section of Palliative Medicine
Northwestern Medicine & Feinberg School of Medicine (Chicago, Illinois, USA)
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: Faculty member at VITALtalk.
Twitter/X: @ALawtonMD
