Given clinical and human realities, there are numerous factors that can hinder the advance care planning process, including health care system influences, deficient communication skills, and various psychological barriers. Meaningful advance care planning discussions are borne out of a trusting relationship between the patient and clinician, something that takes time to nurture and cultivate. Health system issues, including professional time limitations on visits with patients and families, and patient engagement with multiple providers can impede a professional’s capacity to build rapport and trust (Kolarik et al., 2002; Tulsky, 2005). Clinicians may lack specific training in communication skills and the willingness to broach and maintain discussions about potentially sensitive, emotionally charged issues with patients and families. The overuse of medical jargon can also interfere with patient education, comprehension, and meaningful, clear discussions (Limerick, 2002; Reisfield & Wilson, 2003). Finally, patients and families may be reticent to ask clarification questions, not wanting to appear ignorant or to step outside the expected role of the “good patient.”

Psychological barriers, including fear and anxiety, can also influence the quality of advance care planning discussions. Clinicians may be concerned about causing psychological harm or destroying patient and family hope through frank discussions about diagnosis and prognosis (Morrison, 1998; Steinhauser, Christakis, Clipp et al., 2001). Patients and families can also become emotionally stressed during discussions that convey bad or sad news, and their abilities to process and respond to information can be limited. Finally, patients, families, and clinicians all have a set of unique experiences related to illness and dying, and those previous experiences can influence expectations about and willingness to address such issues in the present, thereby affecting communication quality (Lee, Back, Block et al., 2002; Moore, 2005a). Despite these challenges, clinicians can develop communication strategies to engage patients and families in the advance care planning process.

The development of a trusting relationship with patients and families is integral to high-quality medical care, especially at end-of-life (Tulsky, 2005). The quality of the patient-clinician relationship trust and rapport can be enhanced by encouraging patients to share their concerns and questions using active listening, demonstrating respect, talking in an honest and straightforward manner, being sensitive when delivering difficult news, and maintaining engagement about advance care planning issues with the patient and family throughout the disease process (Moore, 2005b; Quill, 2000; Tulsky, 2005; Wenrich, Curtis, Shannon et al., 2001). Encouraging questions and open discussion of concerns is facilitated by active listening skills. Active listening and avoiding the tendency to interrupt can give patients and families the sense that the clinician truly cares and is invested in understanding their perspectives.

Active listening involves the use of open-ended questions and appropriate reflection back about the content of the speaker’s message. For example, to begin a dialogue, a provider can ask an open-ended question such as, “What do you understand about your illness at this point?” (Moore, 2005a; Norlander & McSteen, 2000; Tulsky, 2005). This can provide an assessment of the patient’s knowledge base about the illness and any salient concerns he or she may currently have. Once an open-ended question is posed, it is important to allow sufficient time for patients to respond and to avoid the tendency to interrupt. To ensure that the message content is understood and convey that the provider is really listening, reflecting the main ideas and feelings of the patient’s statement can be helpful. For example, a clinician may say in response to a patient’s dialogue, “You’re really concerned about the side effects of your current medication, but you are afraid that if you don’t take the drug, your condition will worsen. Let’s talk about some options.” Reflection used in conjunction with open-ended questions can help clinicians learn about what is most important to their patients and promote patient-centered care.

Some advance care planning discussions can be emotionally charged, and providers need to develop skills that manage this affect (Tulsky, 2005). Discussions fraught with emotion are often difficult for providers. Not all concerns uncovered during palliative care discussions have solutions (e.g., finding meaning in the illness experience, fear of dying, being overwhelmed with caregiving responsibilities). Whether or not such painful emotions are expressed, many patients and families coping with advanced illness experience them regardless, and opening up dialogue about difficult emotions can reduce the isolation they are apt to feel (Lo, Quill, & Tulsky, 1999). Lo and collegues (1999) remind clinicians that they “do not have sole responsibility for responding to the patient’s suffering” (p. 747). Referring troubled patients and families to a social worker, psychologist, member of the clergy, or another mental health professional can be helpful and appropriate.

When patients and families do become emotional, Tulsky (2005) suggests that providers:

Direct discussion and validation of emotion without false reassurance or premature advice giving can be effective in diffusing emotionally charged clinical discussions.

Trust and respect are further cultivated when providers communicate in a straightforward and honest, yet sensitive, manner. Evidence suggests that a vast majority of patients want to be fully informed about their illness and what to expect about their physical condition (Jenkins, Fallowfield, & Saul, 2001; Steinhauser et al., 2001; Wenrich et al., 2001). In one study, patients and family members ranked honest and straightforward discussion as one of the most important aspects of patient-provider communication in end-of-life care (Wenrich et al., 2001). They wanted physicians to be willing to discuss dying and to balance honesty and sensitivity. This is a formidable challenge to providers in palliative care but one that is important to quality advance care planning discussions. The Wenrich study indicated that poor communication “[s]temmed from being too blunt, not picking an appropriate time and place to provide bad news, and giving the sense that there was no hope” (p. 872).

One way of balancing hope and honesty in the context of ongoing advance care planning discussions is to frame discussions with patients in terms of ‘hoping for the best yet preparing for the worst’ (Back, Arnold, & Quill, 2003). Patients’ hopes can be discussed while anticipation of and preparation for future health states and treatment scenarios are explored. Such discussions can start by clinicians articulating hope and preparation early in the course of treatment and then revisiting the topic throughout the disease trajectory. Patients can be asked, “Could you tell me more about what you are hoping for? That will help me do a better job for you” and “What are your concerns if things do not go as we hope?” (Back et al., 2003). Supporting and validating the patient’s hopes, fears, and other emotions that result from such discussions are important. It is also important to note that what patients and families hope and prepare for can change during the disease trajectory. For example, during the early stages of the disease, hope may be invested in cure. As the disease progresses and attempts at cure show little success, providers can explore other hopes of the patient and family and what preparations need to be made.

Finally, it is important that health care professionals be aware of their nonverbal behavior and the context in which communication occurs with patients and families. Self-awareness of one’s nonverbal communication is the first step in making needed changes. Practitioners should assess how they carry themselves when interacting with patients and families. Do they have an open posture that invites discussion (e.g., avoiding crossed arms)? Do they make appropriate and consistent eye contact? Environmental issues, such as privacy and avoiding outside interruptions, need to be considered, particularly when sensitive issues are addressed. The setting and the manner in which a message is conveyed can be powerful and have the potential to affect overall communication quality. Box 4-1 provides suggestions related to rapport-enhancing communication strategies.