Imagine sending a page to the palliative care service that reads: “Patient is 4.5 billion years old with recent history of fever and nonhealing wounds, now in multisystem failure. Request consult for IDT support, symptom management, and goals-of-care conversation.” While tongue in cheek, there are clear parallels between communicating with patients about serious illness and communicating with patients about climate change. In both cases, our palliative care colleagues’ serious illness communication skills can make a meaningful impact for both our patients and the planet.
The World Health Organization (WHO) has named climate change the greatest health threat we face as a species. Climate change is unparalleled in scale and urgency as a cause of preventable and inequitable human suffering. Human activity is making the planet’s serious illness worse and must drastically change to mitigate harm. As we have seen countless times caring for patients with serious illness, the seemingly insurmountable scale of the illness triggers the human fight-flight-freeze response. It paralyzes our ability to engage in complex decision-making as individuals, while current social systems and structures incentivize apathy and the denial of responsibility. The first way any of us can begin to overcome these challenges and mitigate suffering is by showing up, fully present, to listen to what our patients are telling us.
As with serious illness, patients want to talk about climate change. Wildfire smoke plumes and displacement, extreme heat waves and power grid failures, hurricanes and other storms that cause more severe and more frequent flooding are all no longer once-a-generation events. Planetary serious illness is here. Patients recognize that it is no longer some hypothetical, psychologically “safe” distance in the future. When serious illness hits, what we know is that patients seek help and supportive communication from their physicians. They want to know how illness impacts their health today, and how they can expect that to change going forward. They seek validation of their emotional responses, which often include fear, disbelief, or a sense of grief and loss. And they want to know what they can do, how they can retain some semblance of agency in the face of an illness that feels huge and threatening.
Experts in climate change communication have found that there are several key elements which facilitate productive conversations. These include attuning to and seeking to understand the nonverbal communication elements of climate change discussions, maintaining a nonjudgmental approach, and creating space where every voice can be heard and every emotion can be felt. Many physicians incorporate these serious illness communication skills in their practice already. When the patient leaning over their knees and staring at the floor shakes their head and whispers, “I didn’t realize it would get this bad so fast,” we recognize the nonverbal signs of emotional processing. Rather than hitting the patient with reams of data, we recognize that in this moment the patient needs emotional connection, not intellectual correction.
Real physician voices, twice a week
Free, and one click to unsubscribe.
When climate change comes up in conversations with patients, there are several serious illness communication tools we can adapt. Open-ended questions such as “What’s most important for you when you think about climate change?” help the patient direct the conversation to the things that matter to them, rather than imposing our own assumptions from the start. When patients mention their worry about how much wildfire smoke is harming their grandchild’s asthma, we can align with their concerns and shared values.
A powerful communication technique is called “social norming,” when we provide reassurance that the patient in front of us is not the only one who has faced this situation or worried about this illness before. Whereas we might frame a choice between technological dependence and withdrawing life-sustaining treatment by describing both as choices made by “many loving families,” we can frame a conversation about climate change interventions as “Many people who say the health of the climate and future generations are important to them tell me this is a change they feel is manageable in their own lives. I wonder what you think about that and how it feels for you?”
Lastly, palliative care providers (at least these two authors) are sometimes perceived as comical in their frequent use of “wishes and worries” when discussing serious illness with patients. Applying wishes and worries to climate change communication, we might say something like, “I wish the situation were different. I worry that we will see more of those dangerous extreme heat days. I wonder how we can plan to prepare for them together?”
Some of us do better with more prescriptive acronyms and mnemonics as we approach the edge of our communication skill comfort zone. If that resonates, consider modifying the ADAPT tool from VitalTalk, a popular serious illness communication training program.
Figure 1. Modifying the VitalTalk ADAPT tool for discussing prognosis
| Criteria | Palliative framing | Planetary health framing |
|---|---|---|
| ASK what the patient knows, what they want to know | What have other doctors told you about your prognosis, or the future? | What have you heard about the current state of our planet’s health, or its future? |
| DISCOVER what information about the future would be useful for the patient | For some people, prognosis means numbers or statistics about how long they will live. For other people, prognosis means living to a particular date. What would be more helpful for you? | Some people want the latest research updates and scientific evidence. Others prefer to hear about the big picture. Which would be most useful to talk about now, given what you already know? |
| ANTICIPATE ambivalence | Talking about the future can be a little scary. If you’re not sure, maybe you could tell me how you see the pros and cons of discussing this. | Planetary health can feel a little scary to talk about. If you’re not sure, maybe you could tell me how you see the pros and cons of discussing it. |
| PROVIDE information in the form the patient wants | The worst-case scenario is [25th percentile], and the best-case scenario is [75th percentile]. | Climate change is one of the biggest health threats of the 21st century, and will have the greatest impact on the health of our most vulnerable patients, like children and elderly people, people experiencing disadvantage, or people with disabilities or chronic illness. |
| TRACK emotion | I can see this is not what you were hoping for. I wish I had better news. | I wish this wasn’t the case. It sounds like you aren’t surprised to hear this, but it is still upsetting. |
Fundamentally, palliative care is dedicated to addressing suffering, minimizing it when possible, and when it isn’t, helping those we care for find ways to cope. Our patients are seeing the health impacts of climate change show up in their own lives and they increasingly bring their concerns to our attention. Communication tools are flexible and adaptable, whether we are addressing a patient’s serious illness or the planet’s.
Daniel Mahoney and Christian Archer are palliative care physicians.
