Children with cancer and their families face physical, psychosocial, and spiritual distress across the illness course. Honest, direct communication between patients, families, and clinicians is essential for provision of holistic, person-centered care during this stressful time (1–5). Use of silence is recognized as an integral aspect of empathic communication; silence serves as a mechanism for conveying support and respect, facilitating reflection, and bearing witness (6). In the context of suffering and difficult conversations, certain types of silence can create pivotal moments of shared understanding, connection, and presence (7). The use of empathic and clear communication punctuated by meaningful silence can build therapeutic alliance, reduce stress, and improve stakeholders’ perceptions of patient- and family-centered care (1).

Yet not all silence is equal. Silence defined as an absence of speech alone may entail awkward moments between clinicians and patients or be interpreted negatively by stakeholders (8). Within the field of communication science, researchers have examined differences between silences that engender connection, distance, or neutrality within patient-clinician encounters (7, 8). In general, connectional silences occur rarely, while silences that represent distance and neutrality are more common (7, 9). Silences that engender a sense of connection often feel profound and have been described within social sciences as “the stillness of listening to humanity”. (10)

Within medical research, the qualities and impact of profound silence as a communication tool remain understudied. In the field of pediatric cancer specifically, few studies have examined the characteristics of meaningful periods of silence within clinical encounters (7–9). The U-CHAT (Understanding Communication in Healthcare to Achieve Trust) trial was designed to better understand patterns in prognostic communication across advancing illness. In this paper, data from the UCHAT trial were analyzed to characterize the frequency and nature of silence in conversations about disease progression in advancing pediatric cancer.

This study was conceptualized and developed by an interdisciplinary team of pediatric oncology and palliative care clinicians and researchers in collaboration with an institutional Bereaved Parent Steering Council; it was approved by the Institutional Review Board at St. Jude Children’s Research Hospital [U-CHAT (Pro00006473); approval date: 7/12/2016]. We present study methods and findings following the COREQ (COnsolidated Criteria for REporting Qualitative Research) checklist ( Supplemental Table 1 ) (11).

Details about study recruitment, enrollment, and data collection processes were previously published (4, 12). Briefly, we enrolled a convenience sample of 33 children with high-risk cancer, their parents, and their primary pediatric oncologists at an academic pediatric cancer center.

Eligibility criteria and recruitment processes are summarized in Table 1 . We followed patient-parent dyads prospectively and audio-recorded serial disease reevaluation discussions occurring in the clinic or hospital setting across each patient’s illness course until death or 24 months from disease progression on study, whichever occurred first. Demographic and disease-related information were extracted from the electronic medical record.

To better understand the landscape of silence as a facet of communication during difficult conversations, we analyzed all conversations at timepoints of disease progression (i.e., “bad news” conversations). A research team representing medical and nursing disciplines across pediatric oncology and palliative medicine ( Supplemental Table 2 ) first reviewed the literature on silence as a communication approach within cancer care. Finding little consensus for fundamentals of connectional silence in pediatric cancer care, we used an inductive approach (13) to generate a typology for silences found within these conversations. Briefly, two researchers (S.R., E.K.) repetitively listened to audio-recordings, conducted memo-writing, and used raw data to inform development of codes, code definitions, and salient examples (14). Additional researchers (C.W., J.B.) reviewed recorded content and provided feedback in iterative cycles of codebook development. The codebook was pilot tested across several recordings representing various communication styles to identify areas of variance. We did not calculate interrater reliability, given theory suggesting that quantifying variances undervalues the interpretative mission of qualitative analysis (15). However, all analysts met regularly to review, discuss, and reconcile variances to achieve consensus, modifying the codebook when needed to improve dependability, confirmability, and credibility of independent codes (16).

The codebook was finalized following deep review of sufficient raw data to reach saturation, with no new concepts emerging from the recorded dialogue. Three levels of silence emerged from this process to comprise the codebook. First, intentional silence indicated an uninterrupted pause lasting at least 5 seconds; lapses in conversation in the context of transitions between topics or activities were excluded. This threshold was chosen following iterative memoing that revealed that pauses less than 5 seconds often were challenging to define conclusively as intentional. Second, profound silence emerged as a type of a silence in which the preceding or subsequent 60 seconds of dialogue included painful prognostic information, expressions of emotion, or shared sense of enlightenment. Third, stacked silence comprised a series of silence codes juxtaposed closely within dialogue, with fewer than 90 seconds between the end of one silence and the beginning of the following silence. Codes were not mutually exclusive, allowing for one or more codes to be applied to a given pause. The complete set of silence codes is presented in Table 2 , alongside boundary examples of silences that met one criterion but not others to bolster understanding of the proposed taxonomy.

All processes were conducted within MAXQDA, a mixed methods data analysis software system (Verbi GMBH, Berlin, Germany) (17). Following codebook finalization, independent double coding of each recorded encounter was performed by two analysts (S.R., C.W.), with weekly meetings to review coding variances and third-party (E.K., J.B.) adjudication to reach consensus. Consistency in code segmentation was reviewed to ensure a standardized approach (S.R., C.W., E.K.). Content analysis of dialogue surrounding coded silence was conducted, identifying themes co-occurring with profound silence (S.R., E.K.) Quotations surrounding profound silence and stacked silence were examined to identify patterns in language, content, and timing of silence to generate themes (S.R., E.K.).

For the 17 patient-parent dyads who experienced advancing disease during the study period, 141 disease reevaluation conversations were audio-recorded, comprising approximately 2400 minutes of recorded dialogue. Of these, 49 recorded discussions occurred at a timepoint of disease progression and were subsequently analyzed. Participating patients were mostly female (64.7%) and white (88.2%); further participant demographic variables are presented in Table 3 . A median of 7 medical discussions per patient were recorded (range 1-19). Most patients (14/17) died during the study period; 3 remained alive at 24 months. Data on patient-parent dyads who declined enrollment have been previously published; briefly 17% of approached dyads (n=7 dyads) did not enroll due to hesitation or refusal by either the patient (n=4) or parent (n=4). Although small numbers, refusal rates did not appear disproportionate by race or ethnicity (4, 12).

In 35 out of 49 conversations (71%), periods of intentional silence were identified 238 times. Nearly half of these silences (103/238) were dual coded as profound silence. Profound silence length ranged from 5-102 seconds. Below, we describe features of profound silence and themes identified within dialogue preceding (i.e., prompting) and following (i.e., emerging from) moments of profound silence.

High-quality communication between clinicians and patients and their families is essential to person-centered care, improving psychosocial outcomes while facilitating therapeutic alliance in pediatric oncology (5, 18–20). Although silence is considered a strategic aspect of communication, the landscape of silence during difficult pediatric cancer conversations remains understudied. In this paper, we identified periods of intentional silence occurring in more than two-thirds of difficult conversations about disease progression. Nearly half of intentional silences were recognized as meaningful, or profound, in their ability to create space for processing, allow questions to emerge, and acknowledge and affirm emotional expression. Interestingly, most profound silences also involved the stacking of multiple silences close together.

Patients and families place high value on their clinician’s recognition and affirmation of their emotions during difficult conversations (21–24). Prior data demonstrate that clinicians inconsistently respond to emotional cues and concerns expressed by patients and families (22, 25) and frequently verbally dominate conversations, affording less time for patients or families to speak or ask questions (26, 27). When clinicians speak less, however, more opportunities for emotional disclosure by patients and families manifest (22). Building upon these findings, this study suggests that skillful use of silence, particularly in synergy with empathic statements and stacking of silence, has the potential to foster meaning-making and connection between clinician, patient, and family.

Being purposeful about creating space for silence, however, does not necessarily encompass skillful use of silence. Intuitively, unintentional silences (e.g., shuffling papers, transitioning locations, etc.) do not offer opportunities for connection or meaning-making; one might think that intentional silences intrinsically create these opportunities. Yet inductive coding revealed distinct concepts showing intentional silence as a pattern distinct from other types of silence, suggesting that being purposeful (intentional) about silence does not necessarily make the silence meaningful.

In this study, profound and stacked silences appeared to facilitate a psychological space in which everyone in the room had an opportunity to sit together and process information. These data emphasize the importance of silence as a tool for encouraging processing of emotions as well as processing of cognitive information, both of which influence decision making processes (28). Intense emotional reactions, such as those elicited when hearing information about disease progression, can derail an individual’s capacity for processing and rational decision making (29). People experiencing intense emotions (sometimes described as “hot” states) make different choices compared to people in “cold” states (30), and the difference between a hot vs. cold state can impact person-centered decision making around treatment options and end of life care choices (28). Skillful use of silence by clinicians may give patients and families space for processing, allowing for further conversation and decision making to occur in a less “hot” state.

We advocate for silence to be taught as an integral aspect of communication training for clinicians. When faced with emotional expression by patients or families, clinicians most often respond with provision of information, which in turn decreases space for further emotional disclosure (22). Existing communication training programs emphasize provision of empathic statements and emotional support, but the specific importance of silence as a communication strategy is less often described in the literature (31, 32). When mentioned, silence generally is presented as a tool for creating space immediately after the provision of bad news (33), and additional opportunities exist to develop and explore experiential learning techniques to teach clinicians to integrate and stack silence with purpose across medical dialogue as a fundamental communication strategy.

Importantly, not all profound silences may be interpreted positively by patients or families; at times, silence during profound moments may be a default reaction when clinicians do not know what to say. Further research is needed to examine the impact of profound silence and stacked silence on therapeutic alliance and shared decision-making between clinicians, patients with serious illness, and their families.

This study has several limitations, including single site design, convenience sampling of participants, and limited racial and ethnic representation. All eligible oncologists participated, comprising a range of styles and years of clinical practice, however they are not necessarily representative of all oncologists’ practice styles and strategies. A few discussions were not recorded due to logistical issues or at the request of the participating patient or parent. Although missing data could influence synthesis and interpretation of silences, given saturation of themes across thousands of recorded minutes, several missing timepoints are less likely to impact synthesis of findings. Codes were inductively derived based on clinical experience and lacked input from patient and family perspectives, which is needed for further validation in future studies.

In summary, intentional integration of silence in conjunction with empathic statements may enhance processing of information and emotional expression, fostering a sense of connection and meaning-making during difficult conversations between oncologists and their patients/family. Stacking silence also may afford opportunities for engendering profound, connectional moments during challenging clinical encounters.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by St. Jude IRB. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.

SR conceptualized this study, carried out the analyses, drafted the initial manuscript, and revised the manuscript. CW collected data, carried out the analyses, and critically reviewed the manuscript for important intellectual content. ML assisted with analysis and reviewed and revised the manuscript. JB conceptualized and designed the study, supervised data collection, and critically reviewed the manuscript for important intellectual content. JM conceptualized and designed the study, assisted with analysis, and reviewed and revised the manuscript. KA conceptualized and designed the study, supervised analysis, and critically reviewed the manuscript for important intellectual content. EK conceptualized and designed the study, coordinated and supervised data collection, carried out the analysis, drafted the initial manuscript, and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

This work is supported by EK’s Career Development Award from the National Palliative Care Research Center and by ALSAC. Additionally, ML receives salary support from the National Institute of Neurological Disorders and Stroke (K23NS116453).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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