Four core communication skills are “Ask-tell-ask”, recognize and respond to emotion, ask permission to move forward, and “Tell me more…” “Ask-tell-ask” is asking what the patient or surrogate knows about the medical situation, telling them the headline (information and meaning), and asking what they are taking away from your conversation. Recognizing and responding to emotion, both verbal and nonverbal, can allow patients to discuss additional medical information, builds connection between clinician and patient, and can clarify what is important to the patient. Responding to emotion may be nonverbal or verbal (e.g., NURSE statements), and may include simple or complex reflections or “wish statements”. Asking permission to move the conversation forward signposts that there is a transition, allows patients control, and helps you judge if they are ready. Finally, “Tell me more…” helps clarify informational needs or allow a deeper view into a patient’s reasoning or emotional space, giving the clinician guidance on where to direct the conversation. In telemedicine, communication skills need to be adapted as some of the in-person nonverbal skills are less effective or impossible.

The VitalTalk roadmap for talking about serious news is GUIDE (Get ready, Understand, Inform, Demonstrate empathy, and Equip patient for next steps). Getting ready includes planning the details of the meeting, including why and how the information is to be shared. The next step is understanding what the patient expects from the visit and what they have been told so far. Prior to giving information, the clinician should ask permission to share what they know. The news should be shared using a headline containing both data and what it means for the patient’s life. Afterwards, the clinician should demonstrate empathy by recognizing and responding to emotion. Equipping the patient includes discussing next steps, summarizing, and checking for shared understanding. There may also be challenges of patients receiving potentially too little or too much information when families say “don’t tell” or due to asynchronous electronic results delivery respectively. How much patients want to know and how and when they get information can be clarified through preparatory discussions. Finally, medical errors are another form of serious news that require an apology along with the headline.