The three W’s are a wish, a worry and a wonder. This skill can be combined with other communication skills, such as asking permission, expressing alignment, and reassuring that care will not stop. Vital Talk communication skills and tools offer an evidence-based communication skill set. There is a slide deck online posted on the American College of Physicians that does a decent job of covering many aspects of advance care planning, and palliative care with an emphasis on communication skills.
Before modeling use of the 3 W’s there is an important point to underscore. Any of the communication skills will fail to be helpful if the tone and attitude of the clinician does not demonstrate presence, and compassion. A distracted and hurried clinician may be communicating a great deal non-verbally and not be aware of how the patient is receiving the interaction. Our unconscious emotions may show up more than we know in our tone, our posture, movements and where we choose to position ourselves relative to the patient. Patients are vulnerable and it is natural for vulnerable people, unless unbearably ill in the moment, to be scanning others to try and discern the level of safety in the interaction. You have an ethical responsibility to manage your own emotions and thoughts as you prepare for an interaction of this serious nature.
Here are several examples of how the 3 Ws might sound using a few case examples.
Case A
Hazel is 82 and has pancreatic cancer, she is experiencing a great deal of pain and the team is focused on trying to help her become more comfortable but she is very fearful of narcotics and thinks she will become “junkie in the gutter” if she takes medicine.
“Hazel, I wish we could bring your pain under control without using the narcotics. You have tried several alternatives without making a dent in that pain. I worry that this pain is causing you misery and it could become unbearable, even though you have a great deal of strength to cope. I wonder how it would go if we did a test, where we gave you the medicine, at a low dose, for 24 hours and then you can tell us what you think.”
Case B
Sidney is a 17-year-old girl with Cystic Fibrosis. Her disease has steadily worsened over the last year and she has had a lot of side effects from the medications she takes. Her symptoms have resulted in multiple hospitalizations and each time she is admitted she is angrier. Her current goal is to go skateboarding across her state with her boyfriend.
“Sidney, I wish we could send you off on a skateboard to have big fun. We worry that your breathing is going to make that difficult, and it may not be as pleasurable as you are imagining if you are short of breath. I wonder if you and your boyfriend can try a shorter trip first to see how it goes.”
Case C
Aaron is a 45-year-old father of four children and has leukemia that so far has not responded to treatment. Over a year ago, before he became ill, he had promised his family a trip to Disney World and he wants to take the trip. He has dangerously low blood counts and is very fatigued.
“Aaron, I wish we could send you off to Disney World and I would ask you to ride Space Mountain for me. But I worry that the trip will be exposing you to a lot of people and your immunity makes that dangerous. Your fatigue is likely to make walking around a theme park tough. I wonder if there is another way to bring pleasure to your family without putting you into such a risky situation.
-Pat Justis, Washington State Department of Health