| Key elements of serious illness communication | Barriers during telephone or video visits | Strategies to address barriers during telephone and video visits |
| Preparing | Unclear communication preferences or language discordance | Assess the patient's ability to participate, preferred language, prior documentation on legal proxies and wishes, and which loved ones to include |
| Poor internet connection or inexperience with technology | Engage volunteers to help set up technology in the hospital; invite family members to join a few minutes before the meeting; if there are several family members, designate 1 or 2 as primary spokespeople; participants should mute if not talking, or leader should mute others | |
| Hearing impairment | Speak slowly, start sentences with the person's name, silence hospital devices, use hearing aids, use pocket talkers if available, and avoid yelling or exaggerating one's voice | |
| Vision impairment | Ensure the patient's use of glasses and good lighting | |
| Mask obscuring clinician's face | Clinicians and participants can call from private locations with masks removed | |
| Clinical distractions | Take a deep breath before starting conversations, and silence cellphones or pagers | |
| Building rapport and trust | Difficulty in building rapport or trust when interactions are remote | Communicate early and often, and encourage storytelling by patients and families to build connection (eg, "Tell me about life before coronavirus." "I'm glad you have pictures in your room, can you tell me about them?") |
| Lack of continuity due to transitions in clinical providers or shift work | Include staff who regularly work with or have a previously established relationship with the patients (eg, nurses, primary care physician, or clinical liaisons) | |
| Disappointment with telecommunication | Use "I wish" statements (eg, "I wish I could be there in person to support you.") | |
| Clinicians may appear distracted | Look at the camera (rather than the screen) and give brief verbal responses ("Yes." "Go on.") | |
| Having the conversation | Conversations can be disorganized or difficult to initiate over the telephone or video | Consider the agenda and limit meetings to 1 or 2 top priorities |
| Consider a communication framework (eg, CALMER [Check in, Ask about COVID, Lay out issues, Motivate to talk about what matters, Expect emotion, Record conversation]); keep the framework on a separate screen as a reference during conversations | ||
| Ask permission to discuss difficult topics or to transition to a new topic | ||
| Check for understanding by referring to persons by name, using summarizing statements, or orienting back to patients | ||
| Responding to emotion | Limited nonverbal emotional support, such as touch or silence | Listen and watch for verbal and physical signs of distress (eg, crying, long pauses, repeated questions); pause frequently to check for understanding or permission to go on; when using silence, indicate you are present and listening by nodding |
| Impression of being cold or robotic | Acknowledge that these are extraordinary times and use NURSE (Name, Understand, Respect, Support, Explore) statements |
