Orange (2006) advocates for clinicians to restore compassion to a central role in the patient–clinician relationship (p. 7). She goes on to observe that in everyday English, “compassion” often connotes “pity or sympathy” and thus compassion could also imply the act of “being-nice-to-patients” (p. 14). However, the IMROC's conceptualization of compassion goes beyond this everyday understanding. In keeping with Orange's interpretation, the IRMOC draws on the etymology of the word. The Latin origin of compassion, as Orange reminds us, is suffering with.

Orange (2006) notes that, complementarily, the Latin origin of the word patient is patior: to suffer, or undergo. Thus, “a patient is one who suffers, who bears what feels unbearable” (p. 15). In relationship to the patient, who is bearing what feels unbearable, the clinician's compassion is thus “a sufferingwith, a bearing together” (p. 15). The author concludes that compassion is “a way of being-with” and is “both process and attitude” (p. 15). Orange advises, if “we are not too intent on naming pathologies and defenses or being right, but instead relentlessly seek to understand and accompany the sufferer, an implicitly interpretive system emerges” (p. 15). By seeking to understand and accompany—to suffer with—the patient (the sufferer), the clinician can help mitigate remaining echoes of paternalism and objectivity, and attenuate clinicians' tendency to “name pathologies,” focus exclusively on physiology, and maintain the illusion of clinical distance. In this way, compassion can guide clinicians as they facilitate communication about ACP and EOL care.

Compassionate Communication

In the foreword to his book, Knapp (2007) notes that therapeutic communication skills are “universal principles among health and human service providers” (p. xi). They are effective ways of listening and responding in clinical relationships (Hammond, Hepworth, & Smith, 2002). These skills have been posited for inclusion in training curricula for nurses (Kluge & Glick, 2006), doctors (Back, Arnold, & Tulsky, 2009), social workers, and other helping professionals (Wolvin & Coakley, 1985). From a psychotherapeutic view, Orange (2011) has advocated a “readiness to listen and learn from the voice of the other [the patient] —as a clinical philosophy” (p. 15). However, there has been historically a lack of clinical training in these skills.

Many clinicians provide exquisitely compassionate care and sensitively engage in communication with patients. Yet the literature demonstrates that this is not the experience of many patients or their loved ones (Tulsky, 2004). At the same time, therapeutic communication skills have been widely identified as crucial to building clinician confidence in that such skills can enhance ACP by augmenting clinicians' interpersonal competence and increasing patient trust (Rodriguez et al., 2011; Skirbekk, Middelthon, Hjortdahl, & Finset, 2011). Improved therapeutic communication skills have also been shown to reduce professional health care providers' anxiety (Back et al., 2009; Fried, Bradley, O'Leary, & Byers, 2005). Moreover, Levinson (1994) and Roter (2000) propose that clinicians improve their communication skills as a way to reduce malpractice suits. Schaffer and Norlander (2009) offer eight principles that underlie therapeutic communication in the health care setting. Together, these principles provide a supportive framework for clinicians to draw upon when communicating with patients and their advocates and loved ones. These principles can help clinicians skillfully facilitate communication about ACP. Schaffer and Norlander's principles have been adapted here, in conjunction with other authors' recommendations, to the particular imperatives of ACP:

■ Ensure privacy and adequate time for ACP discussions.

■ Assess patients' and their loved ones' and advocates' understanding of disease processes, treatment options, and effects of treatment. Respond by providing accurate information about diagnosis, prognosis, and effects of treatment simply and honestly while avoiding euphemisms and medical jargon. Give broad, realistic (not overly optimistic) time frames for possible effects of diseases and treatments in order to help the patient and his or her advocates take full advantage of “relevant and accurate information about the medical details of various clinical conditions and treatments” (Ditto, Hawkins, & Pizarro, 2005, p. 494) as they formulate and complete ADs.

■ Encourage expression of feelings and elicit patients' values, beliefs, and care goals as guides for formulating ACP (Doukas & McCollough, 1991).

■ Be empathetic and embody both a process and attitude of compassion (Orange, 2006).

■ Arrange for follow-up. This final point is particularly noteworthy in ACP situations.

Follow-up in ACP is crucial because ACP is not a one-time event. Advance care plans should be revisited whenever patient's care needs, desires, and circumstances change.

An important additional component to the principles offered by Schaffer and Norlander is found in the SPIKES Protocol (Baile et al., 2000), which encourages clinicians to ask open-ended questions to reach increased understanding. Clinicians often mistakenly believe that asking open-ended questions and cultivating deeper understanding requires more time than is available. However, Stewart, Brown, and Weston (1989) found that this is not the case if clinicians follow basic communication principles, including paying attention to the patient's emotional schema, listening actively rather than controlling the discussion, and communicating empathetically.

It is also important for clinicians to recognize nonverbal communication cues—what Stolorow, Atwood, and Orange (2002) have identified as “unconscious nonverbal affective communication” (p. 85), such as a glance away, a change of focus or facial expression, a shift in posture such as leaning forward, or a subtle turn away. It is vital for clinicians to explore with
the patient what these nonverbal signals might mean—that is, engaging with the patient in dialogue, with the aim of discovering the meaning of the unspoken. No less in importance, Orange (2006) advocates for “close and compassionate listening” (p. 15). An attitude of compassion affirms the “human worth of the patient” and conveys to the patient, “You are worth hearing and understanding” (p. 16). These skills, individually and collectively, can help clinicians participate relationally and engage compassionately in dialogue with patients to help formulate their ACPs. In so doing the clinician can engender and convey, as Orange advocates, both a process and an attitude of compassion.

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