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The Ask-Tell-Ask Approach In Four Steps

The Ask-Tell-Ask Approach in Four Steps

Sometimes, we are put into a difficult position of communicating information that involves bad news such as, a poor prognosis or clarifying treatment goals to a family member with an advanced illness. A difficult conversation can be defined as one that takes place between the clinician and the patient during various transition points of the disease.

The Importance of Prognostic Conversations

In response to research revealing the importance of prognostic conversations and low patient recall of prognostic conversations, Margaret Isaac, MD and Randall Curtis, MD outlined a systematic approach for this patient communication.1 Their Ask-Tell-Ask technique serves as a method for discovering patient preferences regarding prognostic disclosure, communicating prognostic information, and assessing comprehension. Doctors Isaac and Curtis presented this approach as a remedy for challenges in patient care being revealed by current research:

  • The majority of patients in advanced disease states want to know their life expectancy, but only a minority of patients recall having such conversations with their doctors.2-4  In a recent study of advanced cancer patients, 71% of participants expressed a desire to know their prognosis, but only 18% recalled having such a conversation with a clinician.2
  • Patient recall of prognostic conversations can be poor. Among patients whose charts document a prognostic disclosure, nearly half of patients report not having a prognosis conversation.5
  • Patient recall of end-of-life discussions correlates with higher quality of life for patients and improved bereavement outcomes for caregivers.6

The Ask-Tell-Ask approach in four steps:

Ask: Ask the patient to describe his/her understanding of the disease and prognosis (“Can you tell me what you already know about your disease and what your other doctors have already told you?”). This step not only helps physicians determine what patients have learned elsewhere, it may also help physicians determine the retention of information they themselves have already presented.

Ask: Determine each patient’s preference for receiving prognostic information. This may be more than a “yes” or “no” question. Fried and colleagues found that patients who individually believed they had a prognosis of one year or less were more likely to want prognostic information.7 It may be advantageous for patients to explore certain conditions under which they may want to know their prognostic information (e.g. “If there were a chance of death within 1 year, 2 years, or 3 years, would you want to know?”).

Tell: Provide the prognostic information patients want or need to make informed decisions about medical planning. John Paling states that patients understand risk better when doctors provide percentages expressed in terms of x out of 100 versus a straight percentage figure and versus descriptive terms such as “low risk.”8 Paling also states that patients will retain the information better if the same risk is expressed as both a positive and a negative. For instance: “Among patients with conditions similar to yours, 25 out of 100 will die within one year and 75 out of 100 will be alive at one year.”

Kutner and colleagues found that 100% of patients wanted their clinicians to be honest with them while 91% of the same patients wanted their clinicians to be optimistic.9 When doctors need to state a negative such as the absence of a known cure, they can follow it with a positive such as the options for symptom control, improving longevity, and maximizing quality of life.

Ask: Assess the patient’s understanding.  “I want to make sure that I explained things clearly.  Can you tell me in your own words what I just told you about your disease?”

When patients have potentially life-limiting illnesses, the Ask-Tell-Ask technique holds promise for satisfying both patients who do and don’t want prognostic information and for overcoming the issue of patients not recalling information provided. 

The Optimism of Hospice Care

Hospice care can give patients hope. Palliative care focusing on comfort, dignity, and emotional support has been shown to correlate with greater longevity, improved pain control, greater quality of life, improved bereavement status among family, and greater satisfaction with care. Avoiding difficult conversations may limit the patient’s ability to pursue beneficial treatments and services. Conservations can help patients and families to hope for the best but be prepared for the worst.


  1. Isaac M, Curtis J. Improving quality of life for patients with terminal respiratory disease. Expert Review of Respiratory Medicine. 2009; 3 (6): 597-605.
  2. Enzinger A, Zhang B, Schrag D, Prigerson H. Outcomes of prognostic disclosure: associations with prognostic understanding, distress, and relationship with physician among patients with advanced cancer. J Clin Oncol. 2015; doi. 10.1200/JCO.2015.61.9239.
  3. Fried T, Bradley E, O’Leary J. Prognosis communication in serious illness: Perceptions of older patients, caregivers, and clinicians. Journal of the American Geriatric Society. 2003; 51 (10): 1398-1403.
  4. Daugherty C, Hubocky F. What are terminally ill cancer patients told about their expected deaths? A study of cancer physicians’ self-reports of prognosis disclosure. J Clin Oncol. 2008; 26: 5988-5993.
  5. Fried T, Badley E, O’Leary J. Prognosis communication in serious illness: perceptions of older patients, caregivers, and clinicians. Journal of the American Geriatric Society. 2003; 51 (10): 1398-1403.
  6. Wright A, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008; 300 (14): 1665-73.
  7. Fried T, Bradley E, O’Leary J. Prognosis communication in serious illness: Perceptions of older patients, caregivers, and clinicians. Journal of the American Geriatric Society. 2003; 51 (10): 1398-1403.
  8. Paling J. Strategies to help patients understand risks. Br Med J. 2003; 327: 745-748.
  9. Kutner J, Steiner J, Corbett K, et al. Information needs in terminal illness. Soc Sci Med. 1999: 48: 1341-1352.