Mastering Serious Illness Communication: An Interview with Dr. James Tulsky

For this month’s newsletter, I interviewed Dr. James Tulsky about serious illness conversations. Dr. Tulsky is an internationally recognized leader in clinician–patient communication and supportive oncology. He is the Poorvu Jaffe Chair of the Department of Supportive Oncology at Dana-Farber Cancer Institute and Chief of the Division of Palliative Medicine at Brigham and Women’s Hospital.

A professor of medicine at Harvard Medical School, Dr. Tulsky’s research focuses on improving communication and quality of life for patients with serious illness, particularly those with advanced cancer. He is also a founding director of VitalTalk, a nonprofit organization dedicated to teaching clinicians the communication skills needed to discuss prognosis, goals of care, and what matters most to patients facing serious illness.

Understanding Serious Illness Conversations

Janet: Welcome, Dr. Tulsky. Many oncology clinicians struggle with the concept of serious illness conversations. To start, what exactly is a serious illness conversation?

Dr. Tulsky: A serious illness conversation is any discussion with a patient that aims to achieve a few key goals. First, it clarifies what the patient understands about their illness. Second, it helps them recognize what to reasonably expect going forward. Third, it explores what matters most to them in the context of living with this illness.

I often describe these conversations as “in-the-moment goals-of-care decision-making.” They go beyond delivering bad news. For instance, telling a patient their scan shows disease progression is important, but the deeper question is what that progression means for their life and whether it changes the decisions they want to make about their care.

Once you understand those pieces, the goal is to make recommendations that align the treatments you have as an oncologist with the patient’s values and priorities. And this may not align with what you might do personally or for someone in your family.

When Clinicians Should Have Them and Who Should Be There

Janet: When should oncologists have these conversations, and who should be present?

Dr. Tulsky: These conversations can happen at many points along the cancer journey. Early in treatment, care is often fairly algorithmic, with both clinicians and patients focused on the next evidence-based step. But moments arise when the trade-offs between benefits and burdens become more significant. That’s when understanding a patient’s values becomes essential.

These moments aren’t limited to end-of-life care. They occur whenever decisions depend on what matters most to the patient, such as when treatment options involve meaningful trade-offs or the illness enters a new phase.

In terms of who should be present, the patient is primary. Beyond that, it’s important to ask who they want involved. Some prefer family or friends; others choose to speak alone and share information later.

From the clinician side, another member of the care team, such as a nurse, social worker, or palliative care clinician, can be helpful, particularly if the conversation is complex or emotionally charged. But the most important thing is making sure the patient feels supported and that the people present are those they want there.

What Makes a Serious Illness Conversation a Successful One

Janet: At the end of a serious illness conversation, what tells you the conversation has been successful?

Dr. Tulsky: A successful conversation is one in which the patient gains a clearer understanding of their situation and feels genuinely heard. Trust grows when patients feel the clinician sees them as more than just a disease, taking into account their priorities, family, and what matters most in their lives.

Another important piece is emotion. Many clinicians feel uncomfortable when strong emotions arise, but I actually see emotion as data. It tells you that the patient heard what you said and that it matters to them. When clinicians respond empathically to those emotions, it helps patients process the information more clearly.

A good conversation usually ends with a recommendation. After understanding what matters most to the patient, the clinician can say something like, “Given what you’ve told me is important to you, here’s what I would recommend we do next.” The key again here is that the recommendation reflects the patient’s values rather than simply what the clinician might choose personally.

Why These Conversations Are So Difficult for Oncologists

Janet: When I was a practicing oncologist, I found these conversations awkward or difficult. Why do you think that is?

Dr. Tulsky: There are a number of reasons. First, oncologists care deeply about their patients, and nobody enjoys being the person who brings news that may cause distress. That alone can make these conversations emotionally challenging.

Another reason is that clinicians often haven’t been given a clear framework for how to conduct them. In oncology, we have well-defined algorithms for diagnosing and treating disease. But when it comes to communication, many clinicians feel like they’re improvising each time. Even experienced physicians may have conducted many of these conversations yet still feel uncertain about how to structure them.

When clinicians have a framework and some practical skills, the conversations become much less intimidating. They begin to feel more manageable and often more meaningful for both the clinician and the patient.

An Introduction to VitalTalk

Janet: That leads nicely to VitalTalk. Can you explain what it is?

Dr. Tulsky: VitalTalk is a nonprofit organization that focuses on teaching clinicians communication skills for serious illness conversations. It was founded by a group of physicians who were deeply involved in research and teaching around clinician–patient communication and wanted to improve the quality of those interactions.

We started primarily in oncology, but the work has expanded across many areas of serious illness. VitalTalk now provides training for clinicians across the United States and internationally. Over time, tens of thousands of clinicians have participated in these programs, and we’ve also trained faculty who then teach these skills at their own institutions.

Specific Vital Talk Techniques

Janet: Can you share some of the specific techniques that VitalTalk teaches?

Dr. Tulsky: We teach both individual communication skills and broader frameworks for guiding a conversation.

For example, a simple skill is asking permission before discussing the future. A clinician might say, “Would it be all right if we talked a little about what the future might hold?” That kind of question helps patients feel respected and gives them a moment to prepare for the discussion.

Another skill is reflecting back what the patient has said. When you summarize or repeat their words, it helps confirm that you understood correctly and signals that you are really listening.

In addition to these skills, we teach frameworks that help clinicians navigate the overall arc of a conversation. One example is the REMAP framework, which helps clinicians move through a discussion in a structured way—from understanding the situation and responding to emotion to identifying the patient’s values and developing a plan that reflects what matters most to them.

An Introduction to the REMAP Framework

Janet: I’m fortunate enough to have been trained in the REMAP framework, and it’s incredibly helpful. Can you go into a bit more detail about what it is?

Dr. Tulsky: REMAP is simply a way to remember the steps in a serious illness conversation. It gives clinicians a structure, so they don’t feel like they’re improvising.

The R stands for Reframe. This is where the clinician signals that the situation may be different now. In oncology, patients often move through several lines of therapy over time. A reframe helps them understand that something important may have shifted. A clinician might say, “I’m worried that we may be in a different place with your illness now.” That prepares the patient to think about the situation in a new way.

The E stands for Expect and respond to Emotion. When patients hear difficult information, there is almost always an emotional reaction, even if it’s subtle. We encourage clinicians to acknowledge that emotion with an empathic statement such as, “I can see this is really upsetting,” or “This isn’t the news you were hoping for.” Addressing the emotion helps patients absorb the information more clearly.

The M stands for Map out the patient’s values. Once the patient understands the situation, the next step is to explore what matters most to them. I often ask questions like, “Given what we’ve talked about, what’s most important to you right now?” or “What are you hoping for?” and “What are you worried about?” These questions help the clinician understand the patient’s priorities before making recommendations.

The A stands for Align. Here the clinician reflects back what the patient has said to make sure they understood correctly. For example, you might say, “It sounds like spending as much time as possible with your family is the most important thing right now.” This step confirms understanding and helps the patient feel heard.

Finally, the P stands for Plan. After understanding the patient’s values, the clinician offers a recommendation that reflects those priorities. Instead of simply asking what the patient wants to do, the clinician might say, “Given what you’ve told me is most important to you, here’s what I would recommend we do next.”

Benefits of VitalTalk Training

Janet: Beyond the specific techniques you describe, what do clinicians gain from participating in a VitalTalk training session?

Dr. Tulsky: One of the most important things clinicians gain is the realization that these are learnable skills. Many people assume communication is something you either naturally do well or you don’t. But like any other clinical skill, it can be taught and improved with practice.

In our courses, clinicians watch demonstrations, practice with each other, and receive feedback. The sessions are very interactive, and people often discover that once they have some language and a framework, these conversations become much easier and more satisfying.

Many participants tell us that after the training they try a technique with a patient and immediately notice the conversation going more smoothly. That experience reinforces the idea that these skills can make a real difference.

Additional Benefits to Clinicians

Janet: Is there anything I didn’t ask you today about this topic that would be helpful for oncology clinicians to hear?

Dr. Tulsky: One thing I would emphasize is that these conversations don’t necessarily require a lot of additional time. Clinicians often worry that they won’t be able to fit them into a busy clinic schedule. But sometimes even a brief empathic response can make a meaningful difference. Research suggests that responding to emotion may add only seconds to an encounter while significantly increasing patients’ trust in their clinician.

The other point is that, like any clinical skill, communication improves with practice and feedback. When clinicians have opportunities to learn these skills with colleagues and reflect on their experiences, their confidence tends to grow over time.

Ultimately, these discussions can be some of the most meaningful interactions we have with patients. They allow us to connect treatment decisions with what truly matters in a person’s life, which is really at the heart of good medical care.

I will be posting the full video interview with Dr. Tulsky on my website in the coming weeks. I’ll let you know when that happens. And to learn more about VitalTalk, please visit their website: VitalTalk.org.

I also offer a variety of additional resources about effective communication with patients and their families under the Communication and Special Topics sections on my website.

I hope you found these insights helpful. Please consider sharing this with colleagues who might benefit, and feel free to leave a comment with your reflections or questions. Thank you for being here.