Over my years of working in and teaching palliative care, I have often used the terms ‘empathy’, ‘sympathy’ and ‘pity’—in some cases, even interchangeably. While we could discuss the definitional differences among these three words, in this column, I intend not only to define them, but also to show the impact they have on communication with patients in their palliative care phase. The definitions I have chosen here are the ones I use when teaching, which are scenario rather than dictionary-based, to help illustrate these concepts visually.
While walking back to the office, busy on my smart phone, I fall into a deep muddy hole that workmen have dug to repair waterpipes, and I badly hurt my left knee. I am lying there and calling for help. Person 1 comes along, with his hand covering his mouth: ‘How awfully terrible, this chap is in an impossible predicament’. To me, this comment is pitying me, has not helped me and is not even directed at me. He has not noticed my hurt knee and he walks away.
Person 2 comes along and says, ‘Oh, my life! You poor man’, and she quickly comes into the hole to help me; she feels the cold mud and wetness around us. She is now experiencing the discomfort with me and gets quite emotional, as she is now struggling with me. To me, this is sympathy, which is intended to share my situation by experiencing it as I am. However, although we may be in the cold mud together, the way we experience and appraise the situation might be very different. The fact that person 2 is now emotional suggests that she is overwhelmed by what she is experiencing for me.
Finally, person 3 comes along, sees us both in the hole and starts talking to us: ‘I can imagine how awkward you must feel, are you hurt?’. She decides to remain outside the hole but starts helping us, now that she knows I cannot move my knee. She starts handing us some boards and ropes, so that we can help ourselves out of the hole. Here, person 3 has demonstrated empathy towards us, by imagining what it must be for us without trying to experience the situation with us. These empathic sentiments help person 3 to focus on our situation rather than on hers. Once she has understood about my knee, she uses this and her observations to seek the right tools to help both me and person 2 out.
Impact of using pity, sympathy and empathy
When talking to patients, any pity response from the health professional (HCP) tends to convey a negative message, that the patient is not being listened to and, with that, they are not reassured about receiving the care and support they need. The focus is no longer on the patient but on what has happened and the HCP's perception of it.
When the HCP uses sympathy and acts like person 2 in the anecdote, they are perceived as suggesting that they know how the patient feels, since they are experiencing the patient's situation first hand. Three things tend to happen in this case:
In palliative care, it is not possible to actually experience the patient's situation; even if the HCP had the same diagnosis as the patient, they may not experience this the same way as the patient does. This is why the use of sympathy in palliative care is not useful or productive.
Through their empathic response, person 3 first tries to understand the situation and then finds ways to help that involve the patient, thereby encouraging the patient to divulge more about their situation as they have confidence that they are being listened to. Such empathic sentiments enable HCPs to develop an emotional connection with their patients (Gagan, 1983), a view that has been consistently held for decades now.
Gagan (1983) claimed that empathy creates a powerful position for trust, respect and patient empowerment even at the end of life, whereby they can actively participate in decision-making about their situation. The empathy shown by person 3 in the anecdote offers an imaginative account of how it must be for the patient and, therefore, keeps the focus on the patient, unlike the other two situations in which pity and sympathy were shown. Empathy affords the patient more control of their situation. Community nurses should remember that once they grasp the underpinning principle of empathy, they can also use non-verbal empathy (posture mirroring, listening and silence while patients process their thoughts) (Gagan, 1983), or even develop their own empathic techniques for each patient they support. Such an empathic approach is powerful, bringing them closer to the patient and enhancing the patient's experience, quality of life and dignity in death.