BACKGROUND

The value of asking the patient’s interpretation is most evident in the prognosis literature. In a study by Boyd et al., only 2% of surrogates stated that their own prognostic estimates were solely based on prognostic information delivered by physicians. Most combined some aspect of the physician’s judgement with their own perceptions of individual strength, will to live, unique history, individual observations of physical appearance, surrogate presence, optimism, intuition, and faith. Furthermore, studies have shown that surrogates’ personal estimates of prognosis are different, and generally more optimistic than what the physician communicates.

STEPS AND EXAMPLE

Notice how the clinician in this example does the following steps:

1. Ask: Begin by asking an open ended question about the patient’s/family members’ understanding of the medical illness, as well as their needs and concerns.
2. Tell: Next, tell the patient/family members information based on the the patient’s level of understanding discovered in the fist ‘ask’ (i.e addressing issues that do not seem clear to the patient/family, discussing any areas of misunderstanding). Use non-technical words, i.e. “spread” instead of “metastasized”
3. Ask: Lastly, either ask what the patient understood using a ‘teach-back’ technique and whether this information has changed their own views of the illness or prognosis.

Take a minute to think about what worked well in this example and what can be done differently.

PRACTICE PHRASES

• Ask: “So, tell me, how do you think things are going for your mom?” “What have other doctors told you about your prognosis?”
• Ask: “Given this information and what I have told you about how long I think he has to live, what do you think about your father’s prognosis?”

REFERENCES

1. Boyd EA, Lo B, Evans LR, Malvar G, Apatira L, Luce JM, White DB. "It's not just what the doctor tells me:" factors that influence surrogate decision-makers' perceptions of prognosis. Crit Care Med. 2010 May;38(5):1270-75.
2. Zier LS, Sottile PD, Hong SY, Weissfield LA, White DB. Surrogate decision makers' interpretation of prognostic information: a mixed-methods study. Ann Intern Med. 2012 Mar 6;156(5):360-66.

RESOURCES

- Vitaltalk.org ASK_TELL_ASK