A Tissue, A Tissue – We All Fall Down

Anthony Herbert*

Division of Medicine, Lady Cilento Childrens Hospital, Queensland, Australia

*Corresponding Author:
Anthony Herbert
Director, Paediatric Palliative Care Service, Division of Medicine, Lady Cilento Childrens Hospital, Queensland, Australia.
E-mail: [email protected]

Received date: May 30, 2016; Accepted date: May 30, 2016; Published date: June 04, 2016

Citation: Herbert A. A Tissue, A Tissue – We All Fall Down. J Healthc Commun. 2016, 1:3. DOI: 10.4172/2472-1654.100019

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Most health professionals would consider it standard practice to offer a patient a tissue if the patient started crying during a consultation. In this context, it can be surprising that are tissue boxes are not always in the rooms of hospitals and clinics where such conversations occur. Some more advanced practitioners in communication will sometimes argue this should not be our sole response to a patient who is crying [1]. At the heart of such a clinical encounter with a patient who is crying is to determine what this means and how best to respond to their crying and distress. A flexible approach is required, and it may be more the intention behind handing a patient a tissue that is more important than whether a tissue is actually given or not.

One of the challenges with having to leave the room to find a box of tissues (if a tissue box is not already in the room) is that it becomes a barrier to you being with present with the patient in their distress. In one sense, it can allow you to escape from the patient’s distress. Alternatively, it can also be tempting to change the topic of the conversation to something lighter (e.g. speaking about a less intense topic e.g. medicines) or more technical (e.g. description of a medical investigation or procedure) and this should be avoided. Allowing the patient to cry, and giving them time to do this, shows the patient you are aware of their level of distress and that “It is okay to cry”.

A danger of giving the patient a tissue is that it can give you something to “do” [1]. This can prove a distraction from the real task at hand–which may be to just sit with the patient in their suffering. It may be preferable to have tissues available in the room, within reach of the patient, so they can access the tissues themselves without the health professional having to give them to the patient [1]. It is also important that when we give patient tissues, we do not imply the message non-verbally that we are asking them to stop crying. This is particularly important when the issues that is upsetting them is stigmatised or has some form of perceived shame associated with it. Until an emotion is expressed, it will be difficult to process the issues associated with it, or deal with other issues [2].

Crying allows a patient and family to release strong emotions. It may be more of a problem if a patient or their family are not expressing their emotions. Health professionals need to be comfortable to sit with a crying patient, and realize it is not necessarily them that have caused the patient to cry. More likely it is the difficult news or the situation that has led to the distress. Compassion in how health professionals communicate, and also in how they respond to strong emotions, will help to minimise the suffering that patients and families experience at such difficult times.

Staff may not need to say anything, but just be with the patient in their suffering [3]. A study of 127 Croatian General Practitioner (GP) trainees found that these doctors would allow their patients to cry [4]. Further, they gave verbal (81.9%) and non verbal (25.9%) support at this difficult time. Most of the trainees encouraged the patient to verbalize and describe the problem. The GP trainees felt it important to come to a mutually shared understanding of the problem, and a subsequent management plan. Reassuringly, more than 90% of trainees shared their emotion of sadness. Some GP trainees were not prepared or were surprised by patients who cried. In this context, less than 5 per cent of doctors reacted awkwardly, were indifferent or felt guilty about their patient crying. In this context it is helpful for the doctor or health professional to show compassion and empathy, but not to the point where the patient needs to start being a support for the health professional themselves.

This study outlined 5 steps in relation to communicating with a patient who cries [4]. Firstly, it is important to let the patient cry. If possible, it can be helpful to verbalize the emotions and facilitate expression of the problem which is causing the emotion. Not all patients will be willing or able to do this. The next step relates to mutual understanding and trying to find solutions. Again, it is not always possible to find a solution when a patient is suffering (e.g. in the context of an incurable illness or severe trauma). Ongoing contact with the patient and the health professional’s own reflections on their personal experiences of strong emotions will also be of benefit to the patient in the longer term.

In relation to cancer survivors, responding to emotions has been identified as one of the six core functions of patient-centred communication. In a survey of 1794 cancer survivors in the United States of America, survivors reported suboptimal patient-centred communication in the domain of responding to emotions in 49% of cases [5]. The need for better training for health professionals in how to respond to emotions has been identified [5]. Such training can involve simulation, actors, “teaching on the run” in a clinical context and the use of video based clinical vignettes. The Oncotalk® program gives a number of strategies which can be used including “Responding to Emotion” and “Responding to Anger” [6]. In relation to responding to emotion there is the possibility of showing respect to the emotion, or alternatively “naming the emotion”. These are outlined and demonstrated on their website.

The SPIKES schema of “breaking bad news” also provides a number of strategies around handling emotions in an empathic manner [2]. This includes observing for emotions that the patient is experiencing. The clinician can then identify the emotion being experienced by the patient by naming it to oneself. Using open questions can further clarify what the patient is thinking or feeling. Trying to identify the reason for the emotion is helpful. This may be connected to “difficult news” but if unsure, ask the patient. After giving the patient time to express their emotions, it can be helpful to let the patient know you have connected the emotion with the reason for the emotion by making a connecting statement.

An example of a connecting statement [2]:

1. Doctor: I'm sorry to say that the x-ray shows that the chemotherapy doesn't seem to be working [pause]. Unfortunately, the tumour has grown somewhat.

2. Patient: I've been afraid of this! [Cries]

3. Doctor: [Moves his chair closer, offers the patient a tissue, and pauses]. I know that this isn't what you wanted to hear. I wish the news were better.

It is important that a health professional can just stay with the patient while they cry and be with them. A period of time may allow the patient to process the emotions and to continue on in the consultation. Continuing to make empathic responses until the patient becomes calm can also be helpful [2]. Alternatively, it may also be necessary to reconvene the meeting at a later stage. The time constraints of the health professional will also determine how long they can spend with the patient. In this context, it is important the health professional allows sufficient time to meet with the patient when they know they will be discussing difficult issues. Alternatively, it can be helpful to have another team member present during such discussions, as this increases the chance of one health professional being able to stay for a longer period of time to support the patient and their family. Having other family members or support persons present during such clinical meetings, will also provide another emotional support to the family before, during and after the consultation. This will also include assistance in allowing the distressed patient to travel home in a safe and supported manner if they are an outpatient.

Health professionals also need to be able to deal with their own discomfort when a patient cries [1]. Health professionals need to be able to be comfortable with the expression of emotions and to just let them be. This is in contrast to the perceived need to “fix” the problem which is causing the emotional distress. “Constantly checking in with ourselves, rather than moving on auto-pilot to offer a tissue for instance, can sometimes reveal that what we are doing is more about attending to our own needs and discomfort rather than theirs [1]”.

Phrases that are Helpful when a Patient is Crying

• "Take your time" [3]

• "You may not need to say anything. Just allow silence"

• “If a hand would help, I’m here” [1]

• “I’m sorry this is so painful for you" [3]

• “I can see that this news is upsetting for you" [2]

• “You let it all out. It’s best to have a good old cry" [3]

• “It’s OK. Have a tissue" [3]

• “It’s not surprising that you find talking about this so distressing (This is an example of a validating statement)" [2,3]

• “What would you find helpful right now?"

• When giving the patient a tissue: “Please know I’m giving you this NOT so you stop crying, but so you can feel comfortable crying as for as LONG as you need to” [1]

• Clinicians can also use empathic responses to acknowledge their own sadness or other emotions e.g. “I also wish the news were better” [2]

Practical Things you can do to Assist a Patient who is Crying

• Make sure they have privacy

• If you know the patient well enough, touch may be helpful e.g. reaching out a hand at some point, palm up and half-way. The patient is then welcome to take it [1]

• Offer them a tissue (provided you don’t do this in a way that shows you are uncomfortable with them crying, or that you do not have the time to be with them)

• Offer to get them a glass of water (or cup of tea)

• Make sure they can travel home safely if they are an outpatient, or they have sufficient support on a ward (e.g. nursing staff, social worker, relative) if they are an inpatient

• Make sure their seating is comfortable

• Consider whether a referral to a colleague would be helpful (e.g. pastoral care, social work, volunteer service)

• Consider the temperature and ventilation within the room

In conclusion, depending on the situation and context, it may or may not be appropriate to offer the patient a tissue. In the ideal situation, the room you are meeting with the patient in, will have a box of tissues, and the patient will be able to reach for the tissues themselves. This can allow you to then provide silence and a safe space for the patient to cry in an unrushed manner. However, you could give the patient a tissue, as one means of acknowledging the strong emotions being expressed. It can be done in a way that is supportive, and allows them to continue crying for as long as they need. From a practical perspective, it can allow the patient to cry without being distracted by tears [1]. However, it is important that tissues are not handed to a patient in order to stop them crying quickly, or if there is a suggestion to the patient, the health professional is uncomfortable with the patient expressing strong emotions. Responding to a patient 's distressing emotions in a meaningful way will reduce the patient’s isolation, express solidarity with them and validate their feelings or thoughts [2]. This will improve the therapeutic alliance and result in better treatment outcomes.


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