Promoting Effective Nurse-Patient Communication in Palliative Care Using the SAGE and THYME Model: Can it be Implemented Cross-Culturally?

Seng H. M. Ang1, *
1 School of Health and Social Science, Nanyang Polytechnic, Ang Mo Kio, Singapore

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Creative Commons License
© 2019 Seng Hock Martin Ang.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the School of Health and Social Science, Nanyang Polytechnic, Ang Mo Kio, Singapore; Tel: +6592213363;
E-mail shangmartin@gmail.com


Effective communication in palliative care is essential in making optimal health care decisions that align with the interests of the patients and empowering them to be involved in their care planning. However, many Asian nurses lacked the prerequisite communication skills required to assess and address the informational needs of advanced cancer patients. These nurses often adopt a routinized approach of giving information to patients to overcome their inadequacies in eliciting patients’ concerns. Thus, this opinion paper seeks to understand whether the SAGE and THYME model can be utilised widely by nurses across different cultural contexts to facilitate more effective communication and to develop therapeutic relationships with advanced cancer patients who are receiving palliative care.

Keywords: Information, Relationship, Cancer, Palliative, SAGE, THYME.


Effective communication in palliative care is a powerful therapeutic tool which, when used appropriately, can lead to inculcate a sense of empowerment in patients, encourage them to make good decisions and make them feel to be a part of care planning [1]. Studies have found that patients living with life-limiting illness often experience emotional distress and require informational support to improve their psychosocial adjustment, as well as to cope with their physical concerns [2-4].

As many as one in three adult late-stage cancer patients suffer from either anxiety or depression [5]. Effective communication can help provide much-needed safety and comfort through transmitting open, honest and accurate information and by eliciting the concerns of patients [3]. The communicative behaviors of nurses can assist these patients to resolve their problems and integrate the illness into their daily lives by offering additional information that addresses their concerns [6].

The SAGE and THYME model is a robust, structured and accessible form of communication model that has the function of facilitating the nurses in interacting effectively and developing therapeutic relationships with patients living with advanced cancer who are receiving palliative care. Thus, this opinion paper aims to identify whether the SAGE and THYME framework can be utilized widely by nurses across different cultural contexts given that studies on this communication model were conducted entirely in a Western context.

2.1. The SAGE and THYME Communication Model

The SAGE and THYME model helps to guide the nurses through the active cycle of empathetic listening to identify and address the key concerns of patients living with advanced cancer [7]. Table 1 shows the SAGE and THYME model.

Table 1. The SAGE and THYME Model.
If you notice concern - think first of the setting, create some privacy - sit down.
“Can I ask what you are concerned about?”
Gather all of the concerns - not just the first few - “Is there something else?”
Respond sensitively - “You have a lot on your mind.”
“Who do you have to talk to or help you?”
“How do they help?”
“What do YOU think would help?”
“Is there something you would like ME to do?”
Summarize and close - “Can we leave it there?”
Source: Griffiths et al., 2015

Within this model, ‘SAGE’ reminds the nurses to arrange the Setting to provide some privacy, Ask their patients about their major concerns, Gather all their concerns, and show Empathy by being sensitive to their feelings [8]. As for ‘THYME’, it prompts the nurses to ask the patients whether is there anyone they have Talk to regarding their concerns?, does it Help after talking to them?, is there any solutions that the patients (You) believe would help?, and is there anything that they would like the nurses (Me) to help? followed by summarizing their concerns to End the conversation [7].

2.2. Cross-Cultural Communication in Palliative Care

As compared to the nurses in the Western contexts, most Asian nurses often adopt a routinized approach of giving information to patients given that they are not sufficiently equipped with the required prerequisite communication skills and are not capable of interacting effectively with advanced cancer patients to identify and explore their information needs [2]. As a result, they have the tendency to quickly make an advice before their patients have had a chance to fully express their needs to overcome their inadequacies in eliciting their concerns [3, 8, 9].

Besides, cross-culturally, nurses in both Western and Asian contexts find it challenging to withstand the desire to resolve patients’ problem whenever a concern is raised, which is one of the most common blocking behaviors [10-12]. Studies found that these nurses offer advice prematurely to end-of-life cancer patients, which may significantly constrain them from disclosing more about their anxiety and distress, and that the information given may not actually focus on their key concerns [6, 9, 13, 14].

Together, these communicative behaviors can potentially cause advanced cancer patients to make incorrect assumptions about nurses for being unwilling to interact and connect with them, which subsequently can lead to dissatisfaction and impede the nurse-patient relationships [11]. Furthermore, failure to provide patients with appropriate information that addresses their psychosocial needs and physical concerns can significantly affect their quality of life and ability to make informed decisions about their own care, leading to unnecessary emotional distress [15].

2.3. Effectiveness of the SAGE and THYME Model

To enhance the Asian nurses’ communication skills and minimize their blocking behaviors, the SAGE and THYME model is an ideal framework that guides the nurses to utilize evidence-based communication skills such as active listening, empathy and empowerment to support them in withholding their advice before the patients have fully disclosed their needs and concerns [16]. Such communication behaviors are considered to be universal, which can be implemented cross-culturally, and are useful in minimizing the nurses’ use of blocking behaviors which can inhibit the patients from revealing more about their distress [11]. In this way, the nurses are able to gain a deeper understanding of the patients’ cancer-related concerns before giving them the appropriate advice to help them maximize their psychological adjustments and improve their quality of life [6].

The SAGE and THYME model is structured in a way that it facilitates the Asian nurses through patient-centered assessment and simple problem-solving to evaluate patients’ level of informational needs and to empower them to utilize their existing coping methods to resolve their concerns [13]. Giving too little or too much information may increase patients’ likelihood of experiencing anxiety and emotional distress, which may affect their overall well-being [7, 14, 17].

Although, much of the literature found that majority of the advanced cancer patients want to have information about their prognosis or disease progression to preserve hope by staying positive and to triumph over the forces of negative emotions and maintain a sense of control over their lives, the level of information needs differs between patients [6, 10]. Given that uncertainty allows patients to gain a sense of normalcy and independence in their daily lives instead of living with an overwhelming fear of impending death [9]. In this way, they are able to acquire greater control over their lives by adopting an active role rather than the sick role [14].

Besides, employing the SAGE and THYME model allows Asian nurses to develop meaningful and sustained relationships with advanced cancer patients, which is the key towards showing the patients their willingness to connect with them and to establish a healing environment that optimizes their health outcomes [6]. When a quality relationship is cultivated and developed, patients are more likely to reveal their distress and seek informational support from the nurses [13]. This also allows them to feel cared for as an individual and reassures them by giving them a sense of hope that the nurses have a continuing responsibility of their care in spite of their poor prognosis [6].

2.4. Limitation of the SAGE and THYME Model

The most substantial limitation of the SAGE and THYME model is that it is not suitable for delivering bad news to patients who are newly diagnosed with terminal cancer and dealing with patients who are in denial about their cancer conditions [3, 18]. Given that, this framework is more appropriate for recognizing and addressing the key needs and concerns of patients living with end-stage cancer and are receiving palliative care treatment [19].


This paper has highlighted the value of using the SAGE and THYME model to guide Asian nurses to communicate effectively with advanced cancer patients undergoing palliative care. This structured framework improves the nurses’ communication skills and discourages their blocking behaviors by enabling them to explore and respond to patients’ needs and concerns using evidence based patient centered communication skills. Moreover, this communication model is effective in assisting the nurses to provide the appropriate advice that focuses on their true concerns by establishing trust with their patients so that they may feel involved and respected and are more willing to disclose openly their distress and seek informational support from them.




The authors declare no conflict of interest, financial or otherwise.


Declared none.


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