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How to Have Difficult Conversations with Patients and their Families

by Bijal Shah

How many times are we as physical therapists put in a position where we have to tell patients and their families bad news? We might have to tell families that their loved ones cannot go home or explain why we don't recommend they live alone. We may be the ones to break the news that our patients won’t be able to drive or feed themselves. We might have to explain why impulsivity or memory deficits will jeopardize a patient's independence.

Yes, these are very difficult and emotional conversations. They are not fun to have. However, the conversations we have with patients and their families are of critical importance. Most patients, particularly if they are elderly, are protective of their independence. In their minds, they are safe - according to them, any unsafe incidents are just accidents. Patients don’t want to hear that they have to leave their private homes and move in with family, or that they have to say goodbye to driving and give up their favorite car.

Here are some tips that I have learned about having difficult conversations with patients and their families.

Know your patient

This is the MOST important thing. You need to know what your patients value in life, what their purpose is, and why they want to get better. The majority of the time your patients will tell you “I want to go home” when you ask them what their goals are. When your patients tell you this it is important to find out WHY. What do they want to get back to at home? Maybe it’s cooking, gardening, being able to attend bingo again, or even just sitting on bar stool. It is important to identify your patient's’ goals and know what they are working toward while they are in rehabilitation.

It is also important to clearly communicate your own goals as a physical therapist by explaining the purpose of your chosen treatment techniques. When you work with your patients on a daily basis, they need to know that you are on their team. The exercises you prescribe are given to them in order to help them achieve their goals. We should educate our patients about the individual effects of all exercises. We can educate patients on what part of the body their exercises work on and why they are related to their goals.

Develop a rapport with patients and their families

This tip mainly applies to inpatient rehabilitation. Whenever my patients achieve one of their goals, I pick up the phone and call their wife, daughter, son, or primary emergency contact. They always appreciate it.

This serves two purposes. First, this is happy news and family members are thrilled to hear that their loved ones are improving. Second, opening this line of communication allows you to develop a rapport with your patients’ families.

I have noticed that after I start sharing patient experiences with family, the family members start to feel more comfortable with me. As a result, they are more likely to share important information that can assist with discharge planning. Having open conversations with family members also helps me get to know my patients better. Therefore, when I need to have those difficult conversations, with either patients or family members, I am better prepared.

Listen and try to understand the other side

This can be little tricky. Having the patience to listen to your patients and their family members is time-consuming. Sometimes you may feel as though it doesn’t get you anywhere. However, this is when your patients and their families will provide you with critical information.

Now as a clinician you are not going to change a patient’s family dynamic, but you can educate and share your expertise in order to improve long-term patient outcomes. Patient education is not always smooth though. While your conversations may be well intended, it is important to be mindful of the possibility that patients and their families can become argumentative. Perhaps you are not telling the family what they want to hear, or they disagree with your professional opinion.

Also remember that it is normal for the family to resist you if you have to give bad news. It is OK. Remind both the patient and their family of all that the patient has achieved up until this point. Patients will benefit from a patient education model in which you show them what is right with them, not just what is wrong with them!

Also point out that your recommendations are coming from a safety standpoint. Show the family and patient why it may not be in the patient’s best interest to live alone or drive. Going through these steps and walking your patients and their families through your rationale allows them to understand and accept the situation at hand.

Explain and educate

You are a clinician, right? As a physical therapist, your job consists of prescribing exercises and developing plans of care. This is what I thought as a new grad too. However, after I started working I began to realize how much time I spent educating patients, families, other members of the interdisciplinary team, and even sometimes my own co-workers.

I am not a professional teacher, but I am constantly educating and explaining - it can be about the importance of body mechanics, exercise, energy conservation, muscle work in daily activities, reasons for muscle soreness, pathology of illness or disease, etiology of disease, compensatory movements, and so on.

Admit your mistakes

When you are having difficult conversations with patients and their families, it is best to be honest about your mistakes. If you neglected to consider an important piece of a patient’s history, then be upfront about your shortcoming. If you did not concentrate on a particular activity, then explain to the family how you will correct your error. Honesty is always the best policy when it comes to patient care.


If you promise your patients and their family members that you will follow up with something, then please make sure you actually do it. If you told them you will contact them in a week, mark it on your calendar so that you don’t forget to be in touch. This will improve your overall credibility and also help you gain the trust of your patients and their families.

Have fun

Have fun with what you do and SMILE. Treat your patients with respect and deliver happiness on a daily basis (even with those difficult patients). Loving what you do brings passion to your work and transfers to the patient experience. Your patients will benefit from your passion for their health. In return, they will show you much appreciation and respect.

Remember to respect patient differences

I want to stress that every patient and family is unique. We must keep this in mind when having difficult conversations with our patients and their loved ones. By utilizing a patient-centered approach, along with excellent physical therapy skills, we can turn the difficult conversations into successful outcomes.


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