by Kim Smart, RN, JD, PhD
In the fast-paced world of health care, where time is critical and emotions can run high, the words we choose can make or break patient safety and satisfaction. But are we always mindful of how our communication impacts care? Research has consistently shown that physician communication plays a critical role in health care outcomes and satisfaction (1). In particular, clear and compassionate communication is essential when addressing difficult topics such as serious diagnoses and end-of-life care. The movement to advance clear communication and post-event disclosure programs and the development of Apology Laws are founded on awareness that open, transparent communication helps to reduce patients’ anger and may decrease the inclination to file a lawsuit (2). The use of an apology allows emotional healing to commence and trust to be regained (3).
What Are “Never Words”?
Risk professionals have long known that the right words can foster patient safety and promote an environment of trust and transparency. There are words that can tarnish that trust and create a chasm in understanding between patients and health care providers.
In our current medical system, the application of the scientific method results in an objective, narrow focus that feels cold and emotionally detached (4). This leaves little room for the subjective, human expression of suffering. For the seriously ill patient, in particular, the impact of “never words” can be profound.
In the medical field, “never words” are words that add no benefit to the conversation and could cause emotional harm (5). Words that convey absolutes, such as “always,” “never,” or “no risk,” are words that imply certainty where uncertainty may exist (5). Because we are humans working with humans and there are immeasurable variations, these words may create unrealistic expectations. These words and phrases typically convey absolutes and are not possible in the inherently uncertain and complex nature of medical care. For example, phrases like, “You’re lucky it’s just stage 3” or “There’s nothing more we can do” overwhelm patients, evoke fear and suggest hopelessness. These words fail to account for the human experience of suffering and can inadvertently close down productive discussions about the next steps.
There is a delicate balance a provider needs to strike to honestly disclose information about complex treatments and expectations to a patient who is experiencing fear, physical pain, grief and other intense emotions. The provider may revert to the objective, dehumanizing language of the scientific method, offering cold, textbook narratives and declarative statements.
The patient and their loved ones are listening intently to every word and phrase, trying to make sense of the medical jargon and the experience in the context of the patient’s life. Even excellent physicians struggle to have these difficult conversations, and despite a growing recognition of the need for compassionate communication, old habits come to the fore.
While there is no universally accepted list of “never words,” the following examples illustrate terms and phrases that risk damaging the doctor-patient relationship, and alternatives that convey greater empathy:
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Instead of this:
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Consider this more empathic statement:
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You’re lucky it’s just stage 3 (or disease X).
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You have stage 3 cancer. Let’s talk about the treatment options.
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There’s nothing more we can do.
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The treatment we have been using has not been effective; let’s talk about things we can do to help control your pain and improve your quality of life.
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You should prepare for the worst.
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I’m concerned that she is not responding to treatment. Let’s explore the possible next steps.
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You’re not going to get better.
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I’m concerned about the possibility that you may not get better. Let’s talk about your options.
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I’ve never seen this before.
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I have asked Dr. Y to consult on your case–she has significant expertise in treating patients with this disease.
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It’s just part of the disease process.
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I understand how frustrating this must be, and while this may be a common symptom of the disease, we have strategies to help manage it.
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This is just the way it is.
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I know this situation is challenging, but we’re here to work with you and explore the available treatments and solutions.
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You need to be realistic.
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It’s important for us to acknowledge the challenges ahead, but we will also focus on the steps we can take to improve your care and comfort.
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Why didn’t you come in sooner?
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I understand it’s been a tough journey getting here, and I’m glad you’ve come in now so we can address your concerns and get you the care you need.
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I’ve already explained this.
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I want to make sure you fully understand everything. Would you like me to go over anything again, or is there anything you need more clarity on?
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There is nothing I can do for your pain.
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I know you’re in pain, and while we may not have a cure for the pain, let’s work together to find ways to manage it and improve your quality of life.
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I wouldn't be too hopeful.
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I understand this diagnosis may feel overwhelming, but together we’ll develop a personalized plan to support your health and work toward the best possible outcomes, using the resources and options available to us.
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Let’s just wait and see what happens.
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I believe it’s important to monitor your progress, but we can also set up follow-up plans to track any changes and adjust treatment if needed.
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We can try radiation or we can “just” provide comfort care.
The word “just” minimizes the value of comfort care and its choice as a valid approach.
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We have two main options: radiation, which may offer some benefit, or comfort care, which is focused on your quality of life and symptom management. Let’s discuss what’s the best approach for you.
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You “need” to have surgery to remove that tumor.
The word “need” becomes a directive and eliminates the patient’s autonomy.
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Surgery is one option to consider for your treatment, but I want to make sure you have all the information you need to make an informed decision about what’s best for you.
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The Impact of “Never Words” on Communication
Many seasoned clinicians intuitively develop effective communication skills through years of practice, despite the lack of formal training (6). Yet, there are moments when language can inadvertently cause harm. This is particularly true in high-stakes settings such as emergency departments, where frenetic activity, stress and urgency can sometimes lead to the use of phrases that can damage trust or create unnecessary distress for patients (7). The patient may hear from the provider phrases such as: “that patient was sicker than you,” or “He’s back in the ED again? I’ll go get rid of him,” or “the other doctor was wrong.”
What Can Risk Professionals Do?
Given time constraints that make it difficult for health care providers to engage deeply with every critically ill patient, risk professionals can help providers develop and practice an elevated vocabulary from a perspective of compassion that can ease their discomfort and equip them to avoid further harm to their patients. One way to approach this is through group exercises that encourage providers to reflect on the words and phrases they use that may cause distress to the patient and/or family.
Alternative statements may look like those found in Box 1: “Never words” and the more empathic alternatives above. Brainstorming alternative statements in this way and getting feedback from others in the process is an effective way to test and practice empathic alternatives. Incorporating these discussions into grand rounds, in-service training, or other learning opportunities can help raise awareness of harmful language and empower providers to develop more compassionate responses.
Conclusion
The importance of compassionate communication in health care cannot be overstated. Risk professionals play a pivotal role in guiding providers to recognize and avoid “never words,” which can harm the trust and emotional well-being of patients, particularly those facing serious illnesses. By fostering an environment that prioritizes empathetic and thoughtful language, risk professionals can help ensure that providers communicate in a way that promotes patient safety, emotional healing and improved care outcomes.
References
- Safran, D. G., Taira, D. A., Rogers, W. H., Kosinski, M., Ware, J. E., & Tarlov, A. R. (1998). Linking primary care performance to outcomes of care. Journal of Family Practice, 47, 213-220.
- Saitta, N., & Hodge Jr, S. D. (2012). Efficacy of a physician's words of empathy: An overview of state apology laws. Journal of Osteopathic Medicine, 112(5), 302-306.
- Saitta, N. M., & Hodge, S. (2011). Physician apologies. The Practical Lawyer, December.
- Guidi, C., & Traversa, C. (2021). Empathy in patient care: From 'Clinical Empathy' to 'Empathic Concern.' Medicine, Health Care, and Philosophy, 24(4), 573–585. https://doi.org/10.1007/s11019-021-10033-4
- Hazan, A., & Haber, J. (2016). Mindful EM: Five Things Physicians Should Never Say. Emergency Medicine News, 38(10), 23.
- Windover, A. K., Boissy, A., Rice, T. W., Gilligan, T., Velez, V. J., & Merlino, J. (2014). The REDE model of healthcare communication: Optimizing relationship as a therapeutic agent. Journal of Patient Experience, 1(1), 8-13.
- Awdish, R. L. A., Grafton, G., & Berry, L. L. (2024, October). Never-Words: What Not to Say to Patients With Serious Illness. Mayo Clinic Proceedings, 99(10), 1553-1557. https://doi.org/10.1016/j.mayocp.2024.05.001
Author biography
Kim Smart, RN, JD, PhD. With over 40 years of experience in health care, law, risk management, compliance, and leadership, Kim currently serves as the Chief Strategy and Implementation Officer at MD For Accuracy, a physician-led global specialty practice. Her background spans clinical risk management, health care law, public health, and education, where she developed innovative programs to improve outcomes, reduce litigation, and ensure regulatory compliance. She also has extensive experience in policy reform as a former Deputy Commissioner and Medicaid Director for Alaska, and continues to contribute as an educator, speaker, and mentor, with a focus on fostering transparency, improvement, and patient-centered care.