Author: Cailin Gramling
Posted: September 2019

A compassionate silence is defined as: “A 2+ second pause in speaking that follows a moment of gravity (an expression of emotion that appears unpleasant to the person experiencing it (e.g., fear and sadness) or information that is shared with an identifiable affective cue indicating that the speaker perceives the message to be unfavorable (e.g., prognosis)), in which the person who speaks immediately following the pause acknowledges the gravity of that moment or makes a statement that offers to continue the expression of emotion (e.g., ‘‘It’s a lot to take in, isn’t it?,’’ ‘‘Can you tell me more?’’). In order to fully understand an episode of such a silence, it needs to be examined within its surrounding environment. Following is a qualitative analysis of the 5 minutes preceding and following a compassionate silence.

Conversation Context: This is the second conversation between a 49 year-old woman with the palliative care team. From her self-reported questionnaire, she rated her Quality of Life as 7 out of 10, her physical distress as ‘Quite a Bit’, her emotional distress as ‘Moderate’, and as having low trait optimism. She felt ‘Moderately’ heard and understood by her care team.

Transcript Preceding the PauseTranscript Following the Pause
  • Patient: “Because it’s swollen. It’s pushing-”
  • Clinician: “That’s how we know that we punch ourselves or stick ourselves or something, right, when we cut ourselves cutting vegetables in the kitchen or something. But definitely there could be a nerve component inside and [name] makes a very good point because – and with the swelling in the lymph nodes you have – we have nerves in that area. And if it’s swollen and it’s pushing on those nerves then.”
  • Patient: “Yeah, it’s swollen.”
  • Clinician: “Then that’s what’s shooting that, you know those.”
  • Patient: “Yeah, it feels like that. It feels like it wants to burst-
  • Clinician: “Right, the burning pain, the shooting pain.”
  • Patient: “Yeah.”
  • Clinician: “You know those are very characteristic terms used for neuropathic pain.”
  • Patient: “Hopefully, well like you said a couple of them disappeared in the past couple of weeks. They just melted and [sound effect].”
  • Clinician: “The lymph nodes?”
  • Patient: “Well the-”
  • Clinician: “Or the lesions?”
  • Patient: “The lesions and I’m just hoping that the rest will follow suit. And.”               
  • Clinician: “Yeah so between that, I mean the radiation has a long half-life.”
  • Patient: “Yeah.”
  • Clinician: “Uhm, so it could be radiation effects still, or it could be the chemotherapy effect.”
  • Patient: “Yeah.”
  • Clinician: “Yeah.”
  • Patient: “Okay.”

  • Patient: (deep sigh)
  • Clinician: “A lot going on.”
  • Patient: “I’m really tired of [crying]. I’m tired of crying about it. I’m tired of it all.” 
  • Clinician: “I know, I wish there were things I could say differently.”
  • Patient: “I’m just going to go through it.”
  • Clinician: “Are there things that you can – that you think would help make it a little less hard for you to go through?”
  • Patient: “Well I do – I do have a lot of support from my church and from friends and family. I just have to keep my head on straight and look at the right things and think about the right things. Think positively.”
  • Clinician: “It’s okay not to though.”
  • Patient: “In my head.”
  • Clinician: “It’s okay to have those moments.”
  • Patient: “Well I mean I do and when I feel sorry for myself and start crying. But I mean I’m choosing to think positively about it. That the chemo’s going to work and it will bind all this back down again like we did before. So this is where you have to go in your head. Yeah. In the meantime, yes, it does suck. Ah.”
Topic of Conversation
Preceding the Pause
Topic of Conversation
Following the Pause

During the 5 minutes before the Pause, the clinician is explaining the treatment options for neuropathic pain, and asking the patient about her symptoms. The conversation revolves around levels and location of pain and the subsequent pain management. Medications are suggested for future use, and the conversation leans toward the effects of previous sessions of radiation. The entirety of the 5 minutes discusses pain and pain management.

During the 5 minutes following the Pause, the focus of the conversation pivots towards individual experience and emotions, as well as the contemplation of personal values. The patient expresses frustration, and cites the support of friends and her church as making the process easier for her. The patient expresses a positive outlook as being a primary aim. There is no further mention of treatment from the clinician during this time.

Process of Conversation
Preceding the Pause
Process of Conversation
Following the Pause

During the 5 minutes before the Pause, there are two conversation speakers. The clinician is talking more than the patient. The clinician speaks on average more words per conversation turn, as well as dominating the information flow within the conversation. There are several occurrences of overlapping speech.

During the 5 minutes following the Pause, the patient speaks on average longer per turn. The patient initiates the direction of the conversation and dominates information flow. The clinician adds minimal information to the conversation. Instead the clinician reiterates and supports the patient’s statements, with a few prompting questions. There are no occurrences of overlapping speech.

Summary: In this conversation, the Compassionate Pause served as a transition point for the conversation. Prior to the Pause, the content of the conversation was primarily focused on the logistics and pain management. The clinician led the conversation, dominating information flow and length of turns. During speech surrounding the Pause, apparent emotion was expressed, both verbally and through cadence of speech. Following the Pause, the conversation focused on personal values and emotion. The patient spoke more words on average per conversation turn than the clinician, and initiated the conversation topic.