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Communication and Relational Skills

Charles F. von Gunten, MD, PhD; Frank D. Ferris, MD; Linda L. Emanuel, MD, PhD

JAMA. 2000;284:3051-3057.

Physician competence in end-of-life care requires skill in communication, decision making, and building relationships, yet these skills were not taught to the majority of physicians during their training. This article presents a 7-step approach for physicians for structuring communication regarding care at the end of life. Physicians should prepare for discussions by confirming medical facts and establishing an appropriate environment; establish what the patient (and family) knows by using open-ended questions; determine how information is to be handled at the beginning of the patient-physician relationship; deliver the information in a sensitive but straightforward manner; respond to emotions of the patients, parents, and families; establish goals for care and treatment priorities when possible; and establish an overall plan. These 7 steps can be used in situations such as breaking bad news, setting treatment goals, advance care planning, withholding or withdrawing therapy, making decisions in sudden life-threatening illness, resolving conflict around medical futility, responding to a request for physician-assisted suicide, and guiding patients and families through the last hours of living and early stages after death. Effective application as part of core end-of-life care competencies is likely to improve patients' and families' experiences of care. It may also enhance physicians' professional fulfillment from satisfactory relationships with their patients and patients' families.

Author Affiliations: Center for Palliative Studies, San Diego Hospice, San Diego, Calif (Drs von Gunten and Ferris); the Education for Physicians on End-of-Life Care (EPEC) Project, the Interdisciplinary Program on Professionalism and Human Rights, Northwestern University Medical School, Chicago, Ill (Dr Emanuel).

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