Communication is controlled, consciously or unconsciously, by participants, who signal where they wish to go. Like choosing a fork in the road, one can choose to turn left or right. The other participant can choose to follow or ignore this lead. Being conscious of these choices and the other's response enhances communication. Choosing to address cognitive rather than affective content in an exchange is an example of such a choice. Another choice is whether to expand a certain conversational thread or to terminate it. A phrase suggesting expansion might be "Tell me more about that." Silence itself may suggest the opportunity for expansion or may be used to signal the end of a conversation thread. A terminating or finishing phrase might be "Let's talk more about that tomorrow" or "Yes, but let's get back to what we were talking about," to suggest a return to an earlier conversational thread. Standing up and offering one's hand suggests a termination as well. Skill is required to know when to expand a discussion, when to end it, and how.
Agendas arise to a large degree from a person's story line. We all attempt to "follow the plot" of a story of our own construction. If participants in a conversation have radically different story lines with different plots moving toward different endings, the tendency is to "force" the other along one's own story line. A physician following a story line of "doing an history and physical," for example, might impose this particular story line on a patient and family who may be working from very different story lines that may range from the complex ("I need to understand why this happened to me") to the most practical ("I need to go to the bathroom"). It is quite remarkable the extent to which patients and families will cooperate with such impositions. When the other does not cooperate with one's agenda, the choices are limited-to be more forceful (loud, angry speech, threatening, etc.), to cut off attempts at communication, or, as seems particularly common in clinical settings, to continue talking as if communication were happening when, in fact, people are talking past one another and, perpetuating the illusion of communication, as Shaw put it. To the extent that story lines are to come into sync, this process must entail an ability to recognize one's own agenda and an ability to suspend this agenda, at least temporarily, while attending to the agenda of the other. I now consider some of the more specific communication issues and skills in palliative care.
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Palliative Care Perspectives
James L. Hallenbeck, M.D.
Copyright © 2003 by Oxford University Press, Inc.
The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.