When Sen. John McCain announced his cancer diagnosis, the internet was flooded with messages of support and encouragement: “You can beat this!” “You’re a fighter!” “You’re a survivor.” Hopeful, upbeat messages about health care are everywhere — ads for medications, health plans, hospital networks, and elsewhere. These often show smiling patients, interacting happily with physicians and other practitioners, laughing with friends and family, and celebrating positive outcomes. Although such messaging is designed to inspire confidence in patients and encourage them to place their trust in the product or provider, they also can lead to unrealistic expectations, anger, and damaged relationships. It is important for practitioners and caregivers to balance cheerleading with realistic and focused support to help patients deal with serious diagnoses, disappointments, and outcomes that fall short of goals. Mary Lou Dallam, a woman in her 70s battling lung cancer, appreciates people’s efforts to be positive. “I know they mean well and genuinely are rooting for my recovery,” she said. However, she finds misplaced optimism frustrating. For example, she said, “When I’m in the hospital and sick from chemo, I know that I look awful. Telling me that I look great doesn’t help because I know it’s not true. I would prefer that people focus on something else and not make up compliments or words of encouragement that are just patently untrue or unrealistic.” She prefers not to pretend that everything is great when it isn’t, and she appreciates the opportunity to talk honestly about her feelings. Tatyana Shteinlukht, MD, a geriatric psychiatrist based in Massachusetts, understands why people tend to be overly positive. “You cannot all of a sudden spill the whole truth about bad news or a negative diagnosis. You have to be sequential, start slow, and not make any promises or present a definitive prognosis, as it depends on the individual course of illness in a particular patient,” Dr. Shteinlukht said. For those who are in denial, she said, “Start with the picture they want to see and gradually over time walk them to a more realistic view.” For example, consider the patient who strives to go home from the nursing home after a hip fracture but who is likely too sick and frail for that to happen. During the first meeting, Dr. Shteinlukht suggested, talk about what they enjoy about their home and what could make their stay in the facility more pleasant and comfortable. In the second meeting, talk about where they are in their recovery and where they need to be before they can go home. “Slowly go into more detail about what they are capable of and what skills and abilities they are likely to recover,” Dr. Shteinlukht said. For instance, if they will be unable to drive, you can help them realize that they need to reside someplace where there is transportation. “You can’t be unrealistically optimistic. However, you do have to be completely realistic all at once. You need to slowly walk them from point A to point B — from the picture they imagine to a more realistic one. You have to explore with your patients the benefits of ... adjusting to a new reality.” Maureen Nash, MD, a geriatric psychiatrist and internal medicine physician who serves as medical director of Providence ElderPlace, a Program of All-Inclusive Care for the Elderly in Oregon, agrees that it can be helpful to break down the situation into steps. The practitioner has to walk a fine line between encouraging false expectations and dashing the person’s hopes. “You can say, ‘This is the plan. We’ll see how you do in therapy; and we’ll reassess goals based on your progress. We’ll take it a day at a time,” Dr. Nash suggested. It can be challenging to determine how much “reality” a patient wants or can handle. Tools such as the Physician Orders for Life-Sustaining Treatment (POLST) paradigm can help promote conversations about what the patient wants and encourage family discussion so that everyone can get on the same page. “This gives you an opportunity to sit with someone and really hear what he or she is saying,” said Joshua Schor, MD, CMD, medical director of New Jersey-based Daughters of Israel. He added that legal standards such as the Patient Self-Determination Act “also gives you some legal scaffolding to rest on when families don’t want to give up or refuse to accept mom or dad’s desire to pursue palliative care over aggressive treatments.” “You don’t want to get too far ahead of where they are in their understanding of illness and the likely future,” Dr. Nash said. She suggested paying attention to verbal and nonverbal cues as you talk to residents and family members. People provide clues with their body language (nervous laughter, crossing arms, or looking down) and facial expressions (appearing confused, grimacing, or frowning) when the practitioner has perhaps given them a bigger dose of reality than they are ready to digest. Regularly checking in with people to determine their understanding of the illness helps direct the conversation. None of this is to say that positivity is never appropriate. According to David Smith, MD, CMD, president of Geriatric Consultants in Brownwood, TX, “The positive message is important, but it needs to be crafted individually for each person so that it isn’t just delivering false hopes.” It can be hard for families to accept their loved one’s illnesses and limitations. As a result, they may be unable to face reality and unable to abandon — or tone down — their need to be cheerleaders. When this happens, said Dr. Shteinlukht, “My job is to find out why they think the way they do, and I have to do some cognitive restructuring.” She starts, she said, by trying to determine what experience their feelings are based on. “They might say, ‘Well, I had a friend in that situation.’ At this point, we can talk about the differences between the situations,” Dr. Shteinlukht said. “I admit that this takes time. It helps if you have a longitudinal relationship with the family.” Especially with a diagnosis such as dementia, said Beverly Chang, MD, a geriatric psychiatrist in private practice, “It is a progressive terminal illness, and I don’t like to give false hopes about the diagnosis. Instead, I focus on quality of life issues, how to slow the progression, and how to manage the disease as it advances.” Again, ensuring that these patients have a completed advance directive or POLST paradigm form is a priority. Particularly for diseases such as cancer, there are many treatments that are tremendously expensive and may have limited value or may be harmful for frail elders. However, sometimes families or patients want everything possible done. “My approach is always to sit down with them and discuss the risks and benefits,” said. Dr. Shteinlukht. She admitted that not every practitioner can do this; however, she suggested that other team members, such as social workers or even clergy, can have these conversations. “In situations where family members refuse to accept comfort measures, I lay out the prognosis and encourage them to focus on palliative efforts and maximize their loved one’s quality of life. I try to absolve them of making difficult decisions,” Dr. Chang told Caring. “It always goes back to what the patient wants.” If family members are being overly optimistic, Dr. Smith said, “I would visit the patient and ask, ‘How do you feel about what you daughter said the other day?’ If the patient says he or she agrees with her, I would talk about other, more practical approaches.” If the patient thinks the daughter is being unrealistic, he said, “I would say that I know your daughter means well, but I also know you want me to shoot straight with you.” Don’t be surprised if families disappear or make themselves scarce after a practitioner has a serious talk with them regarding their attitudes about their loved one’s condition or limitations. “Sometimes they will come back after they’ve had time to digest everything and say, ‘You were right,’” said Dr. Shteinlukht. “It can be challenging. The majority of people listen to themselves and their own experiences. They will trust what you say when they believe you are on the same page. You have to have a lot of patience.” Of course, there are times when some cheering and encouragement is acceptable and even important, noted Dr. Schor. Physical therapists are a good example. “They focus on minute-by-minute, hour-by-hour functional cheerleading,” he said. They target specific tasks, and they encourage and support patients to accomplish these. However, if they start making unrealistic promises or are overly optimistic about a person’s chance of cure or recovery, team leaders need to step in and help them understand that this is not part of their role. In fact, it can do more harm than good. “I lay out the prognosis and encourage [the family] to focus on palliative efforts and maximize their loved one’s quality of life. I try to absolve them of making difficult decisions.” “We don’t want to be the voice of doom, but if we cheerlead, we are ignoring reality and ultimately doing the patient and family a disservice,” Dr. Schor said. It may seem harmless to be a cheerleader for a family member or friend with an illness or other medical issue. However, it can cause a surprising amount of harm. “It can lead the patient to feel alone and isolated if they want to talk about their illness and what could happen and his or her family insists on cheerleading all the time,” Dr. Shteinlukht explained. Sometimes it is helpful to encourage family members to consider what they would want if they were in their loved one’s shoes. “When you do this, they often become more realistic because their thinking isn’t clouded by their feelings about the patient,” she said. Delivering false hope, even when it is well intended, can have tremendous repercussions. “If you deliver false hope to patients who desperately want to believe it, they might pursue treatments and tactics that won’t result in positive outcomes and may even increase pain and suffering. This wastes time, energy, and money, takes resources away from potentially beneficial palliative therapy, and diminishes quality time with loved ones,” Dr. Smith noted. “Delivering false hope in a Pollyanna fashion to someone who is pragmatic tells that person that he or she can’t talk to you honestly about their fears and concerns.” If the practitioner is overly optimistic and turns a blind eye to cheerleaders surrounding the patient, the result can be destructive as well. “You can lose credibility if they are trusting you with their health and they come to view you as a liar,” Dr. Shteinlukht said. As the rise of accountable care organizations, bundled payments, and value-based medicine continues, practitioners and facilities will increasingly need to be realistic about the risks and benefits of various treatments, as well as lengths of stay and when it might be safe for a patient to leave post-acute care or return to the community. In this new world, there is a place for optimism and encouragement. However, there is increasingly little or no place for unrealistic expectations, unnecessary or excessive treatments, and cheerleading that potentially can hurt patients more than it helps them. Ultimately, Dr. Smith said, even when family and friends are cheerleading in a potentially detrimental way, it is important to realize that people usually have the patient’s best interests at heart. “By reframing the conversation and bringing it back to what is best for the patient and in line with his or her wishes, loved ones will usually do the right thing," he said. Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, PA, and a communications consultant for the Society and other organizations. Mary Lou Dallam considers herself fortunate to have a large network of friends and family to support her as she battles cancer. She also knows what helps and doesn’t help when a person is ill, hurting, and uncertain about what the future will bring. She suggested a few ideas that practitioners can pass along to family and friends. •Instead of asking how you can help, be specific. “I don’t want to put anyone on the spot, and I may not be able think of something quickly or on the spur of the moment,” said Ms. Dallam. “Offer to do or bring something that you are comfortable with. If you cook, offer to bring food. If you have a car, offer rides to the doctor. If you like to shop, offer to get groceries or other items. If you’re a pet lover, offer to help with pet sitting.” This keeps the patient, who already has a full plate, from having to brainstorm about what others can do to help.•If you don’t know the person’s spiritual beliefs, ask if they would mind if you prayed for him or her.•Try to arrange visits with other friends and family so that the patient isn’t overwhelmed at some times and left alone at others. If possible, find out when the person prefers company.•If you visit a patient and he or she clearly is unwell (such as after chemotherapy or a tiring physical therapy session), take the cue. Offer to get the person water or juice, then excuse yourself and offer to return at another time.•Let the patient take the lead regarding what and how much he or she wants to talk about his or her health, condition, or prognosis. — Joanne Kaldy