What do you do when a patient takes a long time to answer your questions? Do you push them along? How do you handle the situation when your time is limited?
There is a lot of waiting involved for oncology patients. It begins right from the start. They go to the doctor because something is wrong, and wait to hear the diagnosis. “You have cancer.” Further testing requires waiting. Surgery requires blood work, and waiting to be scheduled. They wait for treatment planning. If they go for a second opinion, they wait for an appointment, wait while they consider which doctor to select. If they have surgery and need to chemotherapy after, they wait until a certain amount of healing occurs before they start. They wait for results, wait for side effects to manifest, wait for them to lessen, wait for medication to work, or wait for the need for them to go away. Waiting becomes a way of life. Time is measured by the next milestone. “I see the oncologist next week,” “I start my second round of chemo tomorrow,” “I am scheduled for a follow up CT in 2 months.” The waiting seems endless. I tell patients there is real time and there is medical time and the two should not be confused.
Busy nurses, including me, feel like there is never enough time. Any time spent waiting keeps me from the next item on my list. I can’t X out a task until I get to it, I can’t get to it until the waiting is over. I am often a bit impatient. I expect those tasks to fit into the time I allotted for them. But communication with patients is another matter entirely. By nature it is more organic, hard to quantify, timeless. When I talk with patients, their real issues and concerns may be embedded in a long story; one that I may not have planned to have the time to listen to. Sometimes, with the best of intentions, I try to hurry a conversation along, even filling in words when there is a pause. The clock is always ticking.
Mr. Sanders was a college professor, perhaps by profession a person inclined to talk and be listened to. Direct questions never elicited a direct response and hurrying him along only seemed to slow him down, like a child being hurried to get dressed and ready for school but who keeps sitting down and making it impossible. If I asked how he was doing he always answered the same way, “That’s a loaded question.” To answer, he had to navigate the provenance of his response, “Well, last night at 9 pm I had a dose of morphine …” It was 11 in the morning, but he ran through all of the night’s events to answer a relatively simple question. More than one of his nurses and doctors commented on how irritating it was. One nurse thought he was “delirious” because he would not answer the question that was asked. There was a meandering style to his conversation. He might start with a litany of events before answering, or he might begin way out in right field with a seemingly unrelated story that finally arrived at an answer to the question. His personal autonomy was linked to his ambling conversational style. Interrupting him was not an option, pulling up a chair and settling in was.
In an article in Psychotherapy Networker, Ronald Siegel, references an acronym he recently learned and now uses with his patients: WAIT, or why am I talking?1 It reminds him not speak unless there is purpose to what he is about to say. WAIT reminds me not just to wait, but to ask myself if what I am thinking of saying should be said. It also allows the time between comments to expand, and in so doing, end up in the right place. That may sound like double talk but it is surprisingly effective.
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Do you think WAIT is a practical tool?
Can you think of a time when WAIT might help you in your conversation with a patient?
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There are many times when I have to bite my tongue to keep from hurrying a conversation along. Waiting is often very uncomfortable. With Jack, the husband of a young woman dying of metastatic breast cancer, I actively reminded myself to WAIT as he described his sorrow. They both knew she was dying, but they had arrived at this point sooner than he or his wife thought they would. He needed to talk it out. He couldn’t wait, so I had to. I needed to quietly wait to hear what he needed to say, wait while he cried, wait while he talked about how unbelievable the situation was, wait as he tormented himself wondering if he had handled the conversation with his children appropriately. Wait as he gathered his composure. But waiting was not just about time. WAIT is about processing. When I talk without stopping to ask myself why I am speaking, I run the risk of missing an important interaction.
Jack and I were in the hallway outside his wife’s room. His wife had slipped away mentally and was actively dying. But a young heart can take a long time to stop beating. Essentially, we were waiting for her to die. We stood face to face, and I thought it might be more comfortable if we were in a quiet place. But if I interrupted, he would lose his momentum and we might sacrifice this important moment. The dynamic with Jack was different from the one with Mr. Sanders, but it was similar too. Both needed me to wait while they spoke. I thought of Siegel’s article as we stood in the hall. This was not a two way conversation. I did not need to fill in the spaces with words. And because I didn’t, the conversational pauses detoured into the place Jack needed to be.
Active listening implies action. I wanted to fix things for Jack, meaning I wanted to help him get where I knew he was heading. But he didn’t need me to give him directions. He needed me to stand by as he found his own way. And to do that, I needed to WAIT.
Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.
1. Siegel B. Can we afford it? [Wisdom in Psychotherapy]. Psychotherapy Network. 2013;March/April:18-25.