Beyond the NURSE Acronym: The Functions of Empathy in Serious Illness Conversations.

Abstract

Empathic communication, defined as both responding to emotions and actively appreciating another's world view, is associated with better outcomes for patients and families, including decreased anxiety and depression, and improved coping 1 Kelley JM Kraft-Todd G Schapira L Kossowsky J Riess H. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2014; 9: e94207https://doi.org/10.1371/journal.pone.0094207 Crossref PubMed Scopus (420) Google Scholar , 2 Hoffstädt H Stouthard J Meijers MC et al. Patients’ and Clinicians’ Perceptions of Clinician-Expressed Empathy in Advanced Cancer Consultations and Associations with Patient Outcomes. Palliative Medicine Reports. 2020; 1: 76-83https://doi.org/10.1089/pmr.2020.0052 Crossref Google Scholar , 3 Neumann M Wirtz M Bollschweiler E et al. Determinants and patient-reported long-term outcomes of physician empathy in oncology: a structural equation modelling approach. Patient Educ. Couns. 2007; 69: 63-75https://doi.org/10.1016/j.pec.2007.07.003 Crossref PubMed Scopus (186) Google Scholar , 4 Flickinger TE Saha S Roter D et al. Clinician empathy is associated with differences in patient-clinician communication behaviors and higher medication self-efficacy in HIV care. Patient Educ. Couns. 2016; 99: 220-226https://doi.org/10.1016/j.pec.2015.09.001 Crossref PubMed Scopus (68) Google Scholar , 5 Hojat M Louis DZ Markham FW Wender R Rabinowitz C Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Acad. Med. 2011; 86: 359-364https://doi.org/10.1097/ACM.0b013e3182086fe1 Crossref PubMed Scopus (678) Google Scholar . Despite this, clinicians who have not undergone formal communication training typically focus on information exchange and miss patients’ emotional and social cues. To address this gap, we use the acronym NURSE (Name, Understand, Respect, Support, Explore) 6 Fortin AH Dwamena FC Frankel RM Smith RC Smith's Patient-Centered Interviewing : An Evidence-Based Method. 4th ed. McGraw-Hill Education, New York2019 Google Scholar ,7 Back AL Arnold RM Baile WF Tulsky JA Fryer-Edwards K. Approaching difficult communication tasks in oncology. CA Cancer J Clin. 2005; 55: 164-177https://doi.org/10.3322/canjclin.55.3.164 Crossref PubMed Scopus (430) Google Scholar to teach trainees how to respond to patient emotions. When used effectively, these skills communicate caring and help patients and families navigate their emotions and cope with their circumstances, both of which ultimately help with decision-making. However, we worry that some learners may not progress beyond this model, and may even see these empathic statements as a tool to get emotions to settle down and let the patient can make the “right” decision. This suggests that we - the teachers - need to do a better job explaining the way that emotions and empathy function in the clinician-patient/family interaction. Emotion and decision-making theory 8 Lerner JS Li Y Valdesolo P Kassam KS. Emotion and decision making. Annu. Rev. Psychol. 2015; 66: 799-823https://doi.org/10.1146/annurev-psych-010213-115043 Crossref PubMed Scopus (1081) Google Scholar ,9 Conte B Hahnel UJJ Brosch T. From values to emotions: Cognitive appraisal mediates the impact of core values on emotional experience. Emotion. 2022; https://doi.org/10.1037/emo0001083 Crossref Scopus (1) Google Scholar , as well as our clinical experiences, lead us to conclude that skilled empathy, beyond resolving emotion so the conversation can move forward, helps us in these discussions in at least four additional ways. Empathy helps us uncover and understand patient values, to appropriately pace the conversation, to facilitate healthy grieving, and, ultimately, transforms how we approach our work. Below we describe these four functions of empathy in an encounter in which we meet with a patient with serious illness or their family to discuss medical decisions. . We focus on the hospital setting, where we meet families in crisis and must build a connection quickly. However, these skills may apply to a wide variety of clinical encounters.