Over the last decade I have observed the ever-changing landscape of geriatric medicine, with delirium remaining a prevalent and challenging issue for patients, families, and healthcare teams alike.
For a significant period, the full understanding of delirium experiences, their psychological impact on patients, their family members, carers, and healthcare providers, was noticeably insufficient.1 The distress linked with delirium is not merely confined to the period of the delirium episode; it may persist over the course of months or even years and is related to enduring psychological illness. Notably, such distress is not exclusive to the patients; family members or caregivers who witness a patient’s delirium can also experience profound distress, occasionally exceeding that of the patients themselves.1 The severity of delirium distress is gauged through various assessment tools. Nonetheless, only a handful of these tools have been validated and implemented in research and clinical settings, and a consensus is yet to be reached on the choice of tool to be used. Efforts to alleviate delirium distress primarily emphasize the provision of information about delirium to both patients and their family members, before, during, and after the episode.1
Amidst the myriad of complexities in delirium management, one crucial element that warrants attention is the way we communicate. The concept of “Humble Inquiry,” as proposed by the late MIT Sloan School’s Edgar Schein,2 offers a valuable framework for improving care for older patients with delirium, as well as strengthening relationships between families and healthcare teams (Figure 1).
Humble Inquiry is the art of asking questions to which we genuinely do not know the answers, while also expressing genuine curiosity and concern.2 It is crucial to underscore that while Humble Inquiry’s principles are universally applicable, the nuanced application in varied healthcare settings, is what truly harnesses its transformative power in patient care: it is a powerful tool for fostering trust, understanding, and collaboration in any context (Table 1). In the realm of delirium care, this approach enables healthcare providers to better comprehend the unique experiences of patients and their families, leading to more individualized and effective interventions.3
For patients with delirium, Humble Inquiry can provide essential insights into their cognitive, emotional, and social needs.4 By asking open-ended questions and actively listening, healthcare providers can gain a deeper understanding of the patient’s perspective, allowing for more personalized and compassionate care.3 This not only benefits the patient but can also alleviate the emotional burden on family members, who often struggle with feelings of helplessness and frustration.4
Involving families in the care of delirious patients is essential, as they can provide valuable information about the patient’s baseline mental state, preferences, and medical history.5 Practicing Humble Inquiry with family members can help healthcare teams develop a more comprehensive understanding of the patient’s condition and facilitate a collaborative approach to care.4 By empowering families to contribute their knowledge and insights, healthcare providers can foster a supportive environment that promotes optimal patient outcomes.
In addition to its benefits for patients, families, and healthcare teams, Humble Inquiry has broader implications for the field of geriatric medicine. By fostering a culture of curiosity and open-mindedness, we can encourage the development of innovative solutions to the challenges of ageing and promote a more inclusive and equitable healthcare system. In this way, Humble Inquiry can serve as a catalyst for change, inspiring new ways of thinking about and addressing the complex needs of older adults.4
Moreover, Humble Inquiry can enhance communication and collaboration among healthcare teams themselves.6 By encouraging open dialogue and shared decision-making, this approach can help break down hierarchical barriers and promote a culture of mutual respect and continuous learning.6 In the context of delirium management, effective teamwork is critical to ensure timely diagnosis, appropriate interventions, and seamless transitions of care.7,8
Despite the promise of Humble Inquiry, it is essential to acknowledge the potential barriers to its implementation in clinical practice. Time constraints, heavy workloads, and the pressure to adhere to established protocols may hinder healthcare providers’ ability to engage in genuine, curiosity-driven conversations with patients and their families.9 Overcoming these barriers will require a concerted effort from healthcare organizations, professional societies, and policymakers to create a supportive environment that prioritizes patient-centered care and values the insights gained through Humble Inquiry.
To facilitate the adoption of Humble Inquiry in delirium care, we must invest in training and education for healthcare professionals at all levels, emphasizing the value of open communication, empathy, and collaboration.9 Additionally, organizations should prioritize the development of policies and practices that support patient-centered care and create a culture that encourages learning and growth.
It is pertinent to underscore that the utility of Humble Inquiry is not confined to a specific healthcare environment. Its principles - cultivating empathy, embracing active listening, and centering care around the patient - are universal in their applicability, irrespective of the setting. Whether in the bustling corridors of a hospital, the dynamic environment of a nursing home, or the personalized interaction of a clinic, these elements retain their importance.
However, a nuanced understanding acknowledges that the application of Humble Inquiry may require adaptability in line with the specific needs, dynamics, and constraints of each setting. For instance, in a high-paced hospital environment, the method of questioning and time devoted to each interaction may differ from that in a nursing home, where a more conversational approach may be adopted. Nonetheless, the core tenets of Humble Inquiry - curiosity, respect, and empathy - remain consistent across all landscapes.
Hence, while Humble Inquiry can be seamlessly integrated across diverse healthcare landscapes, the mode of its application may require appropriate tailoring. This adaptability is, in fact, one of the strengths of Humble Inquiry, rendering it a potent tool to enhance patient care universally. By fostering a culture rooted in curiosity and collaboration, we should envisage the creation of a healthcare system that is not only more effective but also compassionate and patient-centered.
Moreover, Humble Inquiry, in its essence, prioritizes the human connection in healthcare. It acknowledges that every patient, family member, and healthcare professional brings a unique set of experiences, perspectives, and concerns to the table. This approach empowers patients and their families by validating their experiences and engaging them actively in their care.
In a hospital setting, for example, this might translate to bedside discussions where open-ended, patient-centered questions are utilized to understand the patient’s unique concerns and preferences. This can not only guide individualized treatment plans but also foster a sense of agency and partnership in patients.
In contrast, a nursing home environment, where the pace may be less frenetic, Humble Inquiry can be implemented in a more in-depth manner. Here, it can take the form of extended dialogues, involving not just the patient, but also the wider circle of caregivers. Through respectful inquiry and active listening, caregivers can gain invaluable insights into the life stories, values, and preferences of residents. This, in turn, could guide personalized care strategies that respect each resident’s autonomy and enhance their quality of life.
Meanwhile, in outpatient clinics or community health centers, Humble Inquiry can help bridge the gap between health professionals and patients who come from diverse cultural and socioeconomic backgrounds. By approaching each interaction with genuine curiosity and without preconceived notions, healthcare providers can foster trust, improve communication, and ultimately enhance the quality of care delivered.
In conclusion, the implementation of Humble Inquiry, though varied across healthcare settings, has the power to universally enhance the quality of care. Embracing this concept in delirium care can revolutionize communication and collaboration among patients, families, and healthcare teams. By fostering open dialogue and a culture of genuine curiosity and empathy, healthcare providers can better address the unique needs of both the patient and their family, improving care outcomes. The integration of Humble Inquiry into our daily practice is pivotal, not only for the care of older patients with delirium but also for advancing a compassionate healthcare system that values the perspectives of all its members. As we progress in geriatric medicine, the essence of humility and seeking insights remains indispensable.
Future research must delve into the efficacy of Humble Inquiry across healthcare environments and gauge its influence on patient outcomes, caregiver contentment, and team dynamics, ultimately establishing a strong foundation for best practices in delirium care and geriatric medicine at large.
Case scenario
Mrs. Smith, a 78-year-old woman with a history of hypertension and diabetes, was admitted to our hospital due to a urinary tract infection. On the third day of her hospital stay, the nursing staff noticed a change in her mental status, characterized by fluctuating attention, disorganized thinking, and an altered level of consciousness. Delirium was suspected.
The Doctors’ Approach
Mrs. Smith’s attending physician used the humble inquiry approach to encourage Mrs. Smith to talk about her experiences, starting with open-ended questions about her physical and emotional state, “Can you help me understand what you’re experiencing right now?”.
When Mrs. Smith mentioned difficulties sleeping and vivid dreams, the doctor probed further, “Have these dream-like feelings continued even after waking up?” Mrs. Smith affirmed, raising suspicion of hallucinations, a common feature in delirium.
The doctor then asked gently, “Sometimes people in the hospital might see things that aren’t really there or experience things that are puzzling. Has anything like this happened to you?” When Mrs. Smith hesitantly confirmed this, the doctor assured her that these experiences were a part of her condition and not something to be scared of.
Recognizing the potential for paranoid thoughts or delusions, the doctor continued, “What sorts of things have you been worrying about? Are you afraid anyone here is against you in any way? Do you feel safe here?” The open discussion helped Mrs. Smith express her fears, leading to a discussion about potential treatment strategies.
Nurses’ Interaction
The advanced nurse practitioner (APN also integrated the humble inquiry into their interactions with Mrs. Smith. She acknowledged the emotional challenges of her condition and provided an empathetic listening ear, reassuring her, “It’s normal to feel overwhelmed, but we are here to support you.”
When Mrs. Smith expressed distress over her cognition, the APN reassured her, “I’m going to ask you some questions to test your thinking and concentration. Some of them might be tricky, but it doesn’t matter if you get them right or wrong. No one is expected to get all of them correct, and your answers will help us understand more about your health.”
To assess Mrs. Smith’s cognitive function, the APN asked her to recite the months of the year in reverse order. Recognizing the complexity of the task, especially in her distressed state, the APN gave a clear instruction along with a demonstration, “You know the months of the year, January, February, and March, and so on till December. I would like you to recite them in reverse order, starting from December. For example, December, November, and so on”.4
Family Members’ Involvement
Mrs. Smith’s family were essential members of her care team, and they were encouraged to take an active role in her care, guided by the principles of humble inquiry. They started by asking questions about Mrs. Smith’s overall state and experiences, “Mom, can you tell us how you’ve been feeling? Has anything unusual happened that you’d like to share?”
In response to Mrs. Smith’s expressions of fear and confusion, her daughter demonstrated empathy, “I can’t imagine what you’re going through, but I want to be here for you, Mom.” Her son showed support, “We’re on this journey together, Mom. We’ll seek guidance from the healthcare team whenever we need it.”
When they noticed Mrs. Smith appeared distressed by the hospital environment, they inquired, “What makes you uncomfortable here, Mom? Are there things we could bring from home that might help you feel more at ease?”
Family members also sought to better understand her condition and care needs, “We want to learn more about your situation, Mom. Can you tell us more about what you’re going through?” They also proactively sought additional resources, “Let’s research together and attend support groups to expand our understanding of delirium and how best we can support you.”
The family’s active role didn’t stop at direct interactions with Mrs. Smith. They frequently communicated with the healthcare team, asking open-ended questions like, “How can we coordinate our efforts to support Mom better? What else could we do to help enhance her comfort and hasten her recovery?”
These actions not only reassured Mrs. Smith, reducing her feelings of fear and isolation, but also provided valuable information that significantly contributed to tailoring her care plan to her specific needs and preferences.
Conclusion
In the case of Mrs. Smith, incorporating humble inquiry into the interactions of doctors, nurses, and family members facilitated a more comprehensive, patient-centered approach to delirium care. Each perspective brought unique and valuable insights, and their coordinated efforts helped manage Mrs. Smith’s distress and improved her overall hospital experience. This multidimensional approach underscores the vital role of humble inquiry in promoting effective communication, understanding, and care in the complex setting of delirium management.