Category: Communication Skills

How to say the hard things. These posts focus on practical phrasing, frameworks, and conversational mastery across teams, patients, and families.
Examples: Worst First, REDE in Hospice, How to Talk About Prognosis

  • Racing to a Good Day

    Racing to a Good Day

    How Hospice Teams Drive Meaningful Moments at the End of Life

    Introduction

    Pancho just wanted one last lap around the track.

    His heart was failing. I worried about the risks, the meaning, the safety, the weight of the request. At IDG we planned a way forward: a car show and a vehicle that could give rides to anyone able.

    We brought a racing UTV to the nursing home. A lightweight off-road vehicle, open-sided with roll bars, easy to enter and safe at low speed. Residents gathered outside, smiling as the engine rumbled. We ran slow laps in the cleared parking lot.

    He came outside, placed a hand on the hood, and whispered: “Fun.” That single word became the memory staff return to again and again. The ride wasn’t only his wish. It became a shared joy for the whole facility.

    Hospice often begins with one simple question: “What would make today a good day?” The question anchors dignity therapy, which helps patients reflect on meaning and legacy (Chochinov, 2007), and aligns with person-centered outcomes research, which emphasizes tailoring care to individual values.

    The answer might be woodworking or card night. Often, it’s simply not being alone. Sometimes, it’s the thrill of the racetrack.

    When hospice is done well, “a good day” is not chance. It’s created by a team, an IDG, working together to make meaning possible. That’s what we were racing toward when Pancho touched the hood and whispered his truth.

    The Power of the Team: Who Shows Up, and Why It Matters

    In hospice, care is never the work of one. It belongs to the interdisciplinary group (IDG). Each brings a distinct lens. Together, they steer the day toward peace.

    When it works, it sounds like:

    • A chaplain singing hymns bedside because the patient once led worship
    • A social worker securing additional aide coverage from a payor
    • A massage therapist easing agitation so meds aren’t needed as often
    • A nurse finding a way to get a patient to her daughter’s backyard wedding
    • A PA signing off and attending a boating trip for a patient with special needs

    These moments rarely appear in the chart, but they shape what families remember as the why in “why hospice, why now”.

    Moments That Made the Day: True Stories of Wishes Come True

    • The Home Prom: A young woman with Huntington’s disease never got to go to prom. So her ECF team helped her pick a dress. Family decorated the commons. Staff showed up in suits. She danced the night away.
    • The Final Adventure: A patient with two young children shared one wish: to create joyful memories at the zoo. The social worker and volunteer coordinator made it happen with help from our hospice foundation. A dolphin encounter and dinner. A weekend full of laughter.
    • The Almost Missed Moment: We nearly missed a patient’s final porch visit because the DME vendor canceled last minute. The aide called three suppliers. The social worker drove 40 minutes to secure backup equipment. By nightfall, the patient sat under the stars with his brother. No chart could capture what that moment of mobility and freedom meant to the family. 

    These weren’t mapped routes. They were turns we took because someone asked, ‘Can we?’—and the team found a way. These moments answered the question: What would bring peace today?

    These moments remind us that presence is the foundation of care, even when wishes can’t be fully realized. The National Hospice and Palliative Care Organization (NHPCO) offers resources to help teams navigate such challenges (nhpco.org).

    The Good Day Loop: A Practice Worth Repeating

    Good days don’t happen by accident. They happen when teams stay curious, responsive, and reflective. The Good Day Loop offers a rhythm for everyday care:

    1. Ask  — What would make today a good day?
    2. Act — Try one thing, big or small.
    3. Reflect — What worked? What was missed?
    4. Care Plan — Document it. Build on it.
    5. Share — Who made it possible? What did it teach?

    Quarterly Prompt for IDGs: Pick one good day story each quarter. Review it as a team. Teach it to new staff. Share it in a Legacy Round to build culture from lived examples.

    Example: A nurse documented that a patient wanted to sit outside. The next week, the chaplain arranged music in the garden. What began as a line in the chart became a shared act of care.

    Each Role, One Voice

    Like driver and pit crew, each move depends on trust, timing, and a shared direction.

    Closing Reflection: We Don’t Just Witness Good Days. We Build Them.

    Hospice doesn’t always mean a ride around the track. Sometimes it’s motion brought to stillness. Sometimes it’s joy in a parking lot. Sometimes it’s presence when the plan falls apart.

    Ask the question. Let the answers guide care. Some answers lead to joy. Some to stillness. Some to nothing at all. But asking still matters. Showing up still matters.

    As Blog #1 reminded us: Think with the End in Mind. As the BigR reframes: focus on the high-leverage moments that build legacy. Good days in hospice are not accidents. They are the legacy of an IDG that asks, acts, and adapts together.

    Three Key Insights

    • The question “What would make today a good day?” is a compass for meaningful care.
    • IDG members bring unique and essential tools to make moments matter.
    • Hospice’s greatest impact is often in the non-medical moments it protects and makes possible.

    Two Actionable Ideas

    • Hold quarterly Legacy Rounds where each team member brings one story, one moment, or one line from a patient that brought meaning.
    • Add a “Good Day” section to routine IDG documentation: what mattered, what was tried, what was noticed. Remember: You are not just documenting decline. You are helping someone live. Ask the question. Make the moment. Share the story.

    One Quote

    “In hospice, good days don’t happen by chance. They’re driven by presence, steered by trust, and tuned by teamwork.” — Brian H. Black, D.O.

    Bibliography

    • Chochinov, H. M. (2007). Dignity and the essence of medicine: the A, B, C, and D of dignity-conserving care. BMJ, 335(7612), 184–187. https://doi.org/10.1136/bmj.39244.650926.47
    • National Hospice and Palliative Care Organization. (2024). Standards of Practice for Hospice Programs. Retrieved from https://www.nhpco.org

    Glossary

    Dignity Therapy – A structured interview method that helps patients reflect on meaning, purpose, and legacy at the end of life.

    Person-Centered Outcomes – Research and practices that measure success by how well care aligns with the individual patient’s values, not just clinical metrics.

    Good Day Loop – A repeatable hospice practice framework of asking, acting, reflecting, documenting, and sharing patient-centered goals to create meaningful days.

    Today Was a Good Day – A Hospice Synopsis phrase highlighting that small, values-driven interventions can define the impact of hospice care.

    IDG Storyboard – A practice tool for capturing, teaching, and passing on good-day stories within the interdisciplinary group to shape culture and morale.

    To Do: Future Project

    The Good Day Tracker – A companion tool for IDGs to record, reflect, and share “good day” moments. Includes:

    • Printable template for quotes, wishes, follow-through notes
    • Weekly prompts for IDG morale and inspiration
    • Integration into onboarding and staff storytelling efforts

  • Managing Expectations in Hospice

    Managing Expectations in Hospice

    The Underrated Skill That Impacts Everything

    Written by

    Brian H. Black D.O.

    in

    ,

    When It Doesn’t Seem Like Enough: A Story in Two Voices

    “It was awful,” she said. “I had to give the meds. And no one was there. We were alone.”

    In those final hours, Nicki wasn’t just grieving. She was the caregiver, the one holding the morphine. She felt guilty, afraid to do it wrong, and overwhelmed with her own swirling questions.

    The triage team dispatched a nurse. But for Nicki, in that moment, it wasn’t enough. She had some information, but no clear forecast of what to do if the meds didn’t work. No one had explained that “on call” could mean support was an hour away.

    She wasn’t clinically unsupported, but her grief was compounded by uncertainty.

    On the other side of that same midnight story:

    “I got the page and headed out immediately. Triage said the caregiver was worried, so they gave some tips on dosing existing meds. The GPS said 47 miles to go.”

    Susan, the on-call nurse, dropped everything. She drove at the upper end of the speed limit and arrived promptly. She offered her full presence. But the patient had just died. She felt the brunt of arriving “too late.”

    Sometimes, this is a staffing problem. But much more often, it’s a systems problem. Hospice was designed for intermittent presence—but the public expects immediate on-site availability.

    Especially in rural areas, hospice teams cover wide territories with limited resources. One nurse may manage three counties. That’s the clinical reality. But the caregiver’s memory will often be based on one question: Was someone physically there when it mattered most?

    This situation was a failure in expectation alignment. To avoid this, we need to establish and review clear plans much earlier in the course of care. 

    Expectations Unspoken

    A 2021 study found nearly 50% of caregivers felt hospice didn’t meet their expectations. This is largely because they didn’t know what hospice actually included, how often support would arrive, or what their role was supposed to be. [1]

    I asked in a recent informal LinkedIn poll, “What is the biggest knowledge gap in hospice?” One answer stood out at nearly 50%: managing expectations.

    This insight came from seasoned clinicians, team leads, and front-line hospice staff. They tell me is this: trust doesn’t break from poor care. Trust frays when expectations remain unspoken.

    Families can’t understand what we never clearly said.

    The Gap Between Assumption and Reality

    Every person walks into a hospice consult with different expectations for the journey ahead. Few actually know the terrain they’re about to face.

    Families often think of hospice as a full service rescue mission. Instead, they often receive a simple well-meaning map and a comfort kit—just before a long, unfamiliar hike.

    • Many patients quietly hope they’ll get better soon: “That’s why I have hospice experts.”
    • Clinicians may assume families understand the limits of the benefit—a defined Medicare offering with clear regulatory edges.
    • Families often expect a panacea: constant nursing, instant relief, and full-day presence from admission through aftercare.
    • Referring providers or marketing teams may unintentionally set expectations we simply can’t meet.

    Across the board, assumptions differ. Mismatched expectations can’t all be true. What begins as a misunderstanding often ends as mistrust, just when families are looking for someone to help carry the weight.

    Forecasting Trust: Conversations That Prepare

    Managing expectations isn’t a script. But it should be!

    We call them Two-Minute Forecast Scripts—brief, teachable conversations that help families understand what hospice care truly includes and what to expect next. Delivered near the end of a visit, these Two-Minute Forecast Scripts clarify symptoms to watch for, explain roles, and build trust by previewing expectations until the next visit.

    These clinical tools are vital. When IDG teams train, model, and consistently use these scripts, they see success in real time. These scripts do more than inform. They turn communication into confidence and prepare families for what’s next. 

    This is how we deliver clarity as care.

    Research emphasizes that “Proactive communication that clarifies the scope and limitations of hospice services is critical to mitigating caregiver distress and fostering trust in the care process.” [2]

    “We’ll be here for you” sounds comforting. But families need specific orientation over vague reassurance. Imagine instead:

    “We’ll always be here for you—by phone, with guidance, and for urgent visits when needed. Call us early if the shortness of breath starts again anytime. Here’s how that works with your family regarding the meds for this weekend…”

    This isn’t about simply under-promising or over-delivering. Preparation itself is a form of presence. And the clarity that follows stays long after the visit.

    From Words to Practice

    Here are a few simple ways IDG teams can start today:

    • Reframe vague language (“We’ll be here” → “Here’s how we respond…”). That’s care planning in action, clear guidance with a timeline that families can trust.  
    • Include expectation alignment at every admission—and during any change in condition.
    • Share a simplified written care plan that outlines visit frequency, symptom response, and who does what and when. Review it with the family to ensure understanding.

    When we lead with clarity as care, we equip patients, families, and facilities with the expectations and tools they need – before a mismatch becomes a crisis.

    “Clarity is care. Simple, clear, honest communication is one of the most eloquent forms of clinical intervention.” Brian H. Black D.O.

    3 Key Insights

    Mismatched expectations are one of the leading causes of distress in hospice care.

    • Families don’t need perfection but they need clarity of expectations. It’s how we give care.
    • Managing expectations is a clinical skill. It is one we can teach, support, and systematize.

    Two Actionable Ideas

    • Use forecast scripts and simplified care plans to create clear, shared expectations.
    • Train IDG teams to revisit expectation alignment regularly—not just at admission.

    One Compassionate Call to Action

    Let’s stop assuming families know what hospice means. Try a forecast script of your own. Walk them toward what comes next with compassionate clarity.

    Bibliography

    [1] Kehl, K. A., Kirchhoff, K. T., Kramer, B. J., & Hovland-Scafe, C. (2021). Caregiver perceptions of the quality of hospice care: A prospective cohort study. American Journal of Hospice and Palliative Medicine, 38(3), 258–266. https://doi.org/10.1177/1049909120963600

    [2] Head, B. A., & Faul, A. C. (2013). Development and Validation of a Scale to Measure Satisfaction with End-of-Life Care. Journal of Palliative Medicine, 16(9), 1093–1100. https://www.liebertpub.com/doi/10.1089/jpm.2013.0062

  • Never Words in Hospice

    Never Words in Hospice

    “There is nothing more we can do.”

    Written by

    Brian H. Black D.O.

    in

    Words That Close the Door

    I walked into the doorway to ICU bed 3 when I heard the dreaded phrase.

    “There is nothing more we can do.”

    The attending, trying to introduce me as the palliative consultant, intended to help. But his words sparked fear in the patient.

    The room was quiet and reflective, but tension immediately rose. I watched the patient’s daughter glance down, hands clenched, bracing for impact. That one sentence changed the energy in the room. An emotional door closed—and I hadn’t even sat down yet.

    Not only was that phrase untrue—it caused harm. Postulating the answer as “nothing” closes the door and locks it, isolating the patient and family from hope, connection, and choice.

    Language Isn’t Neutral: It Builds Trust or It Breaks It

    Clinicians face one of the highest-stakes conversations in medicine when sitting with someone who is seriously ill. In hospice, these conversations often happen in an ICU or a living room, where you’re not just discussing medical options. You are honoring hopes and dreams that may be about to be cut short.

    Too often, we mean to comfort or clarify but do the opposite. Never-Words, as defined by Awdish, Grafton, and Berry in their 2024 Mayo Clinic Proceedings [1] paper, are phrases that take away choice, frighten, or unintentionally sever connection. They are not just poor phrasing. They are missed opportunities for trust, clarity, and dignity.

    This post reviews the seminal article by Awdish et al., adds hospice-specific insights, and offers practical replacements for common Never-Words. It builds on Think with the End in Mind to support Clarity First dialogue.

    What Are Never-Words?

    “Never-Words” are phrases that clinicians should avoid in serious illness conversations. 

    They often:

    • Shut down dialogue
    • Impose authority over patient agency with declarative communication
    • Sound reductive or dismissive

    Examples include:

    • “There is nothing more we can do.”
    • “You failed treatment.”
    • “We will withdraw care.”
    • “He needs a transplant.”

    Why They Harm

    Never-Words reinforce power imbalances in emotionally charged moments. They suggest judgment, finality, or abandonment. Take the question: “Do you want us to do everything?”

    It sounds like collaboration—but it conceals a failure to lead. In asking it, we dodge our duty to name prognosis and give informed consent. It’s moral abdication, disguised as respect.

    In busy hospital settings with fragmented care, harmful phrases persist because no one owns the language. EMRs default to jargon. New clinicians receive little coaching on how to speak at the bedside.

    We need to normalize communication training. We need to model better language.

    Patients hear more than words. They hear tone. They feel intention. And when the words land poorly, they linger. They echo. “Patient failed treatment” might land in the chart, but it isn’t respectful to the patient or family.

    The profession needs to own the language and cannot allow a prognostic burden shift. We need to own the lack of role modeling, poor EMR defaults, and poor word choices.  

    There is a chance to do better in the moment and implement clear teaching moving forward.

    Practical Alternatives

    Never-WordAlternative PhraseWhy It Works
    “There’s nothing we can do.”“We can shift our focus to comfort and quality of life.”Conveys continued presence and care
    “She failed treatment.”“The treatment hasn’t had the effect we hoped for.”Removes blame from the patient
    “Withdrawing care”“We’re continuing care that aligns with what matters to them.”Reframes as a shift, not a stop
    “Do you want everything done?”“Let’s talk through what care would be most meaningful.”Avoids false binaries; invites shared decisions
    “He needs a transplant.”“His heart is worsening. May we talk about what that means?”Shares concern and invites exploration

    Print this table for your next IDG meeting or keep it handy to guide your language.

    Hospice Perspective

    Far too often in the ER and even in hospice IDG meetings—I hear the phrase “He is a DNR.” It always stops me cold. No one is a code status. Reducing a person’s full narrative to a three-letter shorthand flattens nuance, erases deliberation, and risks signaling finality. It is also dehumanizing.

    A better option? “Mr. Smith has chosen a DNR order to prioritize comfort. It is noted on file.” That framing reflects a choice made with thought, intention, and context. In hospice, where identity and dignity reign, this isn’t a matter of semantics. It’s a matter of respect.

    The Never Words article struck a nerve for me. Families often remark, “Those words still haunt us.” Language lingers. Your choices can echo and impact grief long after you leave the room. It creates moral residue for clinicians too. There are many reasons why language matters.

    I’ve seen how phrases like “comfort only” or “withdraw care” can send families into emotional free fall. I’ve also seen language bring calm, restore clarity, and invite collaboration. Words shape tone. Tone shapes trust. And we need more trust in medicine. Trust that we will work together and never abandon the patient. Trust that there is a doctor, a nurse, a social worker, a chaplain, an aide, a volunteer, and more. Trust that there is a whole team available.

    When we say, “Let’s talk through this together and consider all options” it shifts the dynamic from detachment to solidarity. That’s the essence of hospice. We comfort. We show up—deliberately and consistently.

    Vision That Lights the Way

    If we want families to see the paths ahead, we have to illuminate them. That means guiding families through goals-of-care discussions with empathy to ensure they feel supported. We have to help them understand why hospice may be the best option—not the last option.

    In our prior post, Hospice is not a Place, It’s a Promise, we discussed how hospice prioritizes showing up for patients. Avoiding Never-Words builds on that foundation by ensuring our language honors choices and uplifts patients.

    Hospice is about showing up. It’s understanding the patient’s voice—and honoring their decisions. Now is the right time.

    To avoid Never-Words, training programs should include role-playing serious illness conversations and reviewing phrases like those in the table above. New providers can practice these during on-boarding to build confidence.

    It all begins with recognition—and learning to carefully craft powerfully positive words.

    Three Key Insights

    1. Never-Words are rarely intentional—but they still cause harm.
    2. Better phrases build trust, agency, and clarity.
    3. Communication training should be standard in serious illness care.

    One Actionable Ideas

    • Review your own scripts and swap out one habitual Never-Word this week and seek out other resources like VitalTalk or the REDE Model.
    • Practice walking back a phrase that didn’t land well: “That came out wrong. Can I say that another way?”

    One Actionable Item

    Speak as though your words will echo—because for many families, they do. Share Never-Words with your team at IDG. Bring up this topic at your next staff meeting. Link to this Blog. Let’s learn together!

    Glossary

    • Never-Words (new): Harmful phrases that sever connection in serious illness conversations, often unintentionally.
    • Language Shift (new): The practice of replacing default or harmful clinical phrases with language that builds trust, clarity, and compassion.
    • Words That Heal (new): A Hospice Synopsis communication principle promoting language that honors patient dignity and supports informed, shared decisions.
    • IDG (existing): Interdisciplinary Group – the full hospice team that includes physicians, nurses, social workers, chaplains, aides, and others.
    • DNR (existing): Do Not Resuscitate – a medical order indicating no CPR or advanced cardiac life support if breathing or heartbeat stops.

    Quote

    “Speak as though your words will echo, because for many families they will.” — Brian H. Black, D.O.

    Bibliography