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Some "never-words" should not be used in conversations with seriously ill patients, according to a group warning against language that shuts down patient questions, offends, or limits decision-making.

A physician may say, "Your mother needs to be intubated" or "she needs a transplant," which can effectively shut down a patient or family's ability to consider other paths or options. In phrases like, "We can continue treatment, or we can just do supportive care," "just" implies a value judgement, where one course of treatment is "suboptimal," explained Rana Lee Adawi Awdish, MD, of Henry Ford Hospital in Detroit, and colleagues.

Therefore, "need" and "just" may be considered "never-words" in certain contexts, the group asserted in a perspective paper. The authors had conducted a literature review on best practices for difficult patient conversations and surveyed 20 clinicians within their professional networks to ask what words or phrases they would never use with a patient.

Awdish and colleagues advocated for alternative phrases that can instead invite open conversations that center patient and family, better convey wanting to provide care, offer realistic and humane support, invite further dialogue, and avoid implying that sheer will can overcome an illness.

For example, one alternative to a "need" statement could be, "Her heart is getting worse. May we talk about what that means and what to do next?" This phrasing, the authors wrote, "signals openness to shared decision making, rather than issuing a unilateral directive. More thoughtful, intentional communication redistributes power back to the patient."

The word "just" can be removed all together, they said.

Awdish's group provided more examples of "never-words" and alternative language:

• "There is nothing else we can do" can become "Therapy X has been ineffective in controlling the cancer, but we still have the chance to focus on treatments that will improve your symptoms and, hopefully, your quality of life."
• The phrase "withdrawing care" can become "We can shift our focus to his comfort rather than persisting with the current treatment, which isn't working."
• "Do you want us to do everything?" can become "Let's discuss the available options if the situation gets worse."
• "Everything will be fine" can become "I'm here to support you throughout this process."
• Instead of "fight" or "battle" with regards to illness, use "We will face this difficult disease together."

Having prepared phrasing readily available can help clinicians lacking sufficient time to iterate shared goals throughout the continuum of care for each patient, the authors suggested.

For a clinician with good communication skills, "the conversations are quicker and more meaningful than if they're not skilled," commented Robert Arnold, MD, of the University of Pittsburgh, who is experienced in teaching communication skills for difficult patient conversations.

"I think physicians who take care of of seriously ill patients want to do a good job, and I think that we should just give them the training and support that will promote their doing a good job," said Arnold, who is also on the board of VitalTalk, an organization that teaches communication skills to clinicians.

"My general view is that we should focus on what we want people to do, rather than what we want people not to do," he told MedPage Today. "Because if we spend all our time talking about what we don't want them to do, from an educational point of view, that's what they'll remember."

"You may teach certain phrases and yet you need to modify them so they fit your personality," Arnold suggested. "I've said the wrong things before -- I've probably said some of those 'never say' phrases, and yet, if you say them from a place of trying and caring, sometimes it goes better than you would think."

He recalled a time when he told a patient they had "failed" something. In response, the patient "looked at me and he said, 'I didn't do it. It was the medicine. Your medicine didn't work.'"

"I said, 'Yeah, you're right,'" Arnold continued. "We had a long-term relationship, and it was okay, and he trusted me enough that he could tell me when I said stuff that he thought was stupid."

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