Example: “On the one hand, I can hear this is hard to talk about and that you would rather have this conversation another time. On the other hand, I am worried that your dad’s body is very sick and that decisions need to be made now.”

3) Reflect and Affirm

Another fundamental skill in communication that will add to any therapeutic alliance is reflecting and affirming. This concept assures the patient that you are listening to their story and understanding their experience.

Example: “You’ve done so much to try to stay out of the hospital, and it’s just so disappointing to be back here again.”

4) Establish Urgency

As emergency medicine clinicians, we are under the impression that we are best at this skill. However, it can be difficult to relay a sense of urgency in many situations. Ending phrases with the statement, “We have to make a decision quickly,” can set the stage.

Example: “I expect your breathing only to get worse, we have to make a decision quickly.”

5) Responding to Hopes of Miracles

When patients respond with “trusting in a miracle,” or “my spirituality will bring me a miracle,” clinicians are often left speechless. Leading with affirmations such as “I can see your faith brings you strength,” followed by, “If a miracle was not possible, what would be most important?” may empower some clinicians to respond more appropriately.

6) Responding to Emotion (Imagining)

This step allows the clinician to respond to any emotions that arise during the interview. Often, patients are going through physical, emotional, or spiritual discomfort and this step allows for us to recognize their discomfort.

Example: “I can imagine this comes as a shock” or “I can hear how upset you are.”

7) Focus on What We Can Do

Many patients and family members arrive in the ED with expectations set from television dramas or third-party experiences that may not correlate to their current situation. Often, we need to reiterate the reality of their clinical presentation and focus on what is possible.

Example: “I think we should focus on treatments that would be helpful.”

8) Use “Yes and…” Statements

It is vital that your patient feels empowered through collaboration in their workup and treatment plan. Using “Yes and…” statements allows the patient to express their wishes while allowing the clinician to add on their concerns.

Example: “You want to go home, and I’m worried you could fall again, and I think you need to work with physical therapy to make sure it’s safe.”