Best of Heme 2025: Patient Conversations – Navigating Complex Cases
Presented by:
Beth Faiman, PhD, RN, MSN, CNP, BMTCN®, AOCN®, FAAN, FAPO
Conference:
Best of Heme 2025
Introduction
Effective communication is essential in hematologic oncology, where patients face complex diagnoses and evolving treatment options. At the 2025 Best of Heme Conference in Vail Colorado, Dr Beth Faiman, a nurse practitioner specializing in hematologic malignancies at Cleveland Clinic, discussed communication strategies for navigating difficult patient conversations. Her presentation focused on shared decision-making, empathetic communication techniques, and methods for discussing significant and treatment impacting prognostic information with patients.
Key Components for Effective Patient Communication
Dr Faiman outlined some of the key components for effective navigation in complex cases, which include identifying any existing challenges in provider-patient communication and implementing strategies to enhance shared decision-making. She also noted the importance of applying empathetic communication techniques, such as the “Ask-Tell-Ask” method and the “NURSE” mnemonic to help improve discussions around a patient’s overall prognosis, treatment options, and end-of-life care decisions.
Case Example: Navigating a Complex Diagnosis
Dr. Faiman illustrated some of the potential patient communication challenges using the case of a 48-year-old male with no significant past medical history, who was referred to hematology for unexplained anemia. The patient, attributing his fatigue to work and parenting stress, underwent a workup revealing:
Hemoglobin: 10.3 g/dL (low)
Monoclonal IgA Kappa paraprotein: 0.18 g/dL
Peripheral blood plasma cells: 12.6%
Serum Creatinine: 1.8 mg/dL (elevated)
Normal serum calcium and albumin
The patient initially received a diagnosis of monoclonal gammopathy of undetermined significance (MGUS) with a plan for further anemia evaluation. Additional rapid testing, however, revealed a plasma cell leukemia (PCL), a diagnosis necessitating immediate treatment. Dr Faiman noted the some of the unique challenges of this case stemming from the transition from informing on an initially optimistic, low-risk diagnosis to a more time-urgent discussion for a life-altering diagnosis.
Shared Decision-Making in Oncology
Dr Faiman described the concept of shared decision-making (SDM) as a collaborative process between clinicians and patients, to ensure that the prescribed course of treatment aligns with the patient’s overall values and goals. She noted that SDM is particularly critical in the case of hematologic cancers, where options include standard therapies, clinical trials, as well as stem cell transplant considerations.
She noted the four key elements of shared decision-making with patients:
Two-way information exchange: Wherein the provider presents medical options, and the patient shares their own personal preferences.
Consensus-building: Wherein the provider helps the patient weigh benefits and risks.
Mutual agreement: Wherein the patient and provider come to an agreement and decide on a course of action.
Ongoing reassessment: Where the provider recognizes that patient preference may evolve as the disease progresses.
Dr Faiman noted some of the benefits of shared decision-making with patients, including reducing decisional regret, strengthening patient-provider-trust, and improving treatment adherence. She further noted that SDM can help the patient and provider to navigate high-stakes decisions, for example, deciding between a transplant versus a non-transplant pathway. In the case described, for example, Dr Faiman noted that SDM was critical as the patient transitioned from the relatively simple prospect of passive monitoring for his MGUS to a more aggressive myeloma-directed therapy.
Empathetic Communication Strategies
Dr. Faiman emphasized the concept that communication is not just about what is said, but how it is conveyed to the patient. She noted that empathic communication strategies help to foster trust and enhance patient engagement, particularly for patients facing serious life-altering diagnoses.
The “Ask-Tell-Ask” Approach
Dr Faiman emphasized the benefits of the “Ask-Tell-Ask” approach, a framework designed to ensure that patient receives information in a digestible manner. Step one is to ASK, with a question like "What do you understand about why you are here today?" This helps to inform the clinician about how much the patient already understands. Based on that, the second step is for the provider to TELL, providing the patient with concise, plain-language explanations of the diagnosis and next steps. The third step is to ASK again, to assess the patient’s understanding, with questions like "What questions do you have about what I just shared?" In the plasma cell leukemia case example, the provider started with an MGUS discussion but had to pivot to discussion of an aggressive malignancy and an aggressive course of treatment. She noted that using Ask-Tell-Ask helped to manage the significant emotional impact for the patient associated with such a shift.
The NURSE Mnemonic
Dr Faiman also described her use of the NURSE mnemonic, a framework that can help clinicians understand, acknowledge, and validate patient emotions, by first 1) Naming the emotion with phrases like: "I can see that this news is overwhelming for you..." then, 2) offering Understanding their emotion: "I imagine this was not what you were expecting today..." Third, Dr Faiman noted it is important to 3) Respect and validate the patient’s emotion with phrases like: "You’ve handled this situation with a lot of strength.", then 4) offer Support for the patient with phrases like: "We’re here to help you every step of the way." Lastly, she noted the importance of 5) Exploring any lingering concerns or unanswered questions, with questions like: "What concerns you the most about this diagnosis?"
Applying Empathy in Oncology
Dr Faiman noted several instances where empathetic communication is particularly important for patients with cancer, for example when delivering bad news (e.g., regarding a relapse event or an imminent treatment failure), when discussing the overall burden of treatment burden versus its potential benefit, when managing patients who decline more aggressive care, and lastly, when managing expectations in patients who might express an otherwise unrealistic hope.
End-of-Life Conversations in Hematology
Dr Faiman noted that navigating end-of-life discussions can be difficult, particularly for patients dealing with indolent, or relapsing hematologic malignancies who may not recognize or appreciate the significant prognostic shifts in their disease. Some of the relevant barriers to prognostic awareness which Dr Faiman cited were a resistance of patients to acknowledge their declining health, a hesitation of clinicians to initiate the conversation about the patient’s change in status, as well as a patient families’ desire to protect the patient from any bad news. When navigating these kinds of discussions, Dr Faiman suggested several strategies:
Introduce options for palliative care early in the course of treatment, rather than only at disease progression.
Explore the patient’s feelings by asking open-ended questions such as: "What do you understand about your illness?" and/or "What are you hoping for with this next treatment?"
Emphasize a focus on quality-of-life issues with the patient, with phrases like: "We want to ensure you feel as well as possible for as long as possible."
Take steps to reinforce the goals of care at critical decision points in treatment, with questions like: "If your disease progresses despite treatment, what would be most important to you?"
Dr Faiman emphasized that early conversations regarding end-of-life issues can improve quality of remaining life, reduce emergency interventions, and ensure more patient-centered care.
Role of the Multidisciplinary Team
Given the complexity of hematologic cancers, Dr Faiman emphasized an essential role of the multidisciplinary team in optimizing patient outcomes. Some of the key team members and their roles include the oncologist/nurse practitioner to lead discussions on treatment, the nurse/nurse navigator, to reinforce information and provide emotional support, the oncology pharmacist to educate the patient on treatment side effects and drug interactions, the oncology social worker to help the patient navigate financial burdens and coping strategies, and a financial counselor, who can assist with insurance reimbursements and cost concerns. In this regard, for the case example provided, Dr Faiman noted the role of the pharmacist in providing education on treatment side effects and expected response, the social worker in connecting the patient with financial resources for chemotherapy costs, as well as the physician and nurse working together to manage logistical aspects of urgent treatment initiation.
Conclusion
In view of the increasingly complexity of diagnosis, treatment, and survivorship issues for patients with hematologic malignancies, Dr. Faiman’s presentation highlights the critical role of communication and optimizing the patient-provider relationship. By incorporating shared decision-making, empathetic dialogue, and a multidisciplinary approach, clinicians can dramatically improve the patient’s overall experience and help to enhance treatment outcomes.
Quick Summary
Communication challenges are common in hematologic oncology due to the alterations in treatment course and the evolving nature of their disease.
Shared decision-making helps to enhance provider trust and patient adherence to their treatment.
Ask-Tell-Ask and the NURSE mnemonic are effective tools for helping to deliver difficult and disappointing news.
Prognostic discussions should start early, especially in relapsing cancers.
Collaboration with a multidisciplinary team helps to ensure holistic patient support.
Speaker Disclosure Information: Dr Faiman reported no relevant disclosures for this presentation.
You can see the full presentation on Navigating Complex Cases by Dr Faiman on our YouTube channel here. Dr Faiman’s presentation starts at 39:25.