Recently, after what was to be a “routine” speech-language evaluation for a 3-year-old, I had no choice but to bring the word “autism” into the conversation with the parents. The toddler’s pediatrician had never raised concerns, even though the child said just a few words, avoided eye contact, demonstrated clear echolalia, and repeatedly throughout the day hit his head and threw his body against walls, along with other stimming behaviors.
Concerned about their child’s obvious delays compared to his peers, the parents sought a speech-language evaluation on their own. So while these parents knew something was going on, they didn’t expect me to recommend an assessment with a developmental pediatrician. When they asked why, I gave them my straightforward professional opinion—their child needed to be assessed for autism. (Note that SLPs with the relevant expertise can diagnose ASD, typically as a member of a team (see the ASHA Practice Portal and this Leader Live post). In some states, SLPs can independently diagnose ASD (check state licensure laws).
In our communication sciences and disorders professions, we deliver information across the spectrum of what may be considered bad news: Your lost hearing aid is no longer under warranty, your spouse’s stroke will affect her ability to speak for quite some time, your hearing test results suggest you should get an MRI. Audiologists and speech-language pathologists experience numerous scenarios in which we must break some sort of bad news.
Even when a diagnosis seems palatable or treatable to us, we can’t underestimate its impact. For example, diagnoses at our clinic—and in most speech-language and hearing practices—include articulation disorder and conductive hearing loss related to middle ear fluid. For us, discussing treatments for such common conditions seems simple. More than once, however, my audiologist partner and I encounter families who perceived these diagnoses as confusing, heart-breaking, and even life-altering.
An SLP shares why it’s important to get comfortable with breaking unpleasant news—and provides tips for tackling those conversations.
Use these insights from an audiologist, physician and SLP to show clients that you want and value their input into their own treatment.
Simulating Patient Communication Strategies
Stigma related to words such as “delay,” “deficit,” “disorder” and “loss” affects how people react to news. And most patients and their family members are unfamiliar with the speech, language and auditory systems and may never before have known anyone with a communication difference.
At our clinic, we recently reflected on this process using a model developed by physicians Michael Rabow and SJ McPhee on delivering delicate news to patients. The authors use a mnemonic—ABCDE—to provide hope and healing to patients receiving bad news:
- Advance preparation: Arrange adequate time and privacy for conversations, confirm medical and communication facts so you are prepared to answer questions, review relevant clinical data regarding the patient, rehearse and choose patient/family-friendly language, and emotionally prepare for the encounter with the patient.
- Building a therapeutic relationship: Identify patient preferences regarding the disclosure of news. Determine what and how much to share in the initial meeting. Invite multiple family members for additional eyes and ears to help the patient process information. Introduce yourself to everyone. Use comforting touch when appropriate. Schedule follow-up appointments so they have a clear plan of next steps.
- Communicating well: Determine the patient’s knowledge and understanding of the situation—for example, ask them what they already know about this diagnosis—and proceed at the patient’s pace. Use frank but compassionate sentences, avoid medical jargon or euphemisms, allow for silence and tears, and answer questions. Conclude each visit with a summary and follow-up plan, and ask the patient or family member to describe their understanding of the news.
- Dealing with patient and family reactions: Assess and respond to emotional reactions and empathize with the patient. Don’t argue with or criticize colleagues or their past diagnoses. The same goes for patients’ and family members’ thoughts or opinions.
- Encouraging/validating emotions: Offer realistic hope and a treatment plan based on the patient’s goals. Explore what the news means to the patient and family member. Make sure to deal with your own needs, as your emotional health is what supports the patient’s and family’s health.
My colleague and co-owner of our practice is an audiologist, and she likes to note that the above mnemonic should end with an “s” for “stop.” She spent many years telling parents their infant had a significant hearing loss and found one of the most effective strategies for delivering such news came from a talk by audiologist and professor Kris English. English encouraged clinicians to share the information and then stop talking.
Sometimes the best thing we can do is to let our patients and their families guide the conversation. Some of the most valuable lessons, thoughts and ideas have come from these moments of silence that have led to important and powerful conversations with patients and family members.