Nocebo, Safe Words, Ethics & Informed Consent
Words can hurt. Words can help. Practical nocebo-aware communication for clinicians.
Communication is integral to patient care. Words can provide information, reassurance and connection, but they can also influence attention, expectation and perception. A clinician intending to prepare a patient for what might happen may inadvertently use negative suggestions that increase anxiety, pain or other harmful experiences.
What is a nocebo effect?
A nocebo effect occurs when negative expectations contribute to an adverse experience or outcome. The experience is real. Expectation, context, attention and previous experience can influence how symptoms are perceived and experienced, and healthcare communication is one source of those expectations.
Communication is not neutral
Familiar expressions such as “This is going to hurt”, “You'll feel a sharp scratch”, “This will sting”, “There is nothing to worry about”, “Be brave”, or “You'll probably feel sick afterwards” are usually well intentioned. Yet the same words that aim to provide information may also inadvertently create an expectation that helps or harms patients depending on how they are used.
Helpful and safe words
Therapeutic communication does not necessarily mean replacing every negative word with something positive. The therapeutic goal is to communicate effectively what patients need to know in a way that mitigates or avoids nocebo effects.
| Routine wording | A possible safer approach |
|---|---|
| “Sharp scratch coming.” | “Is it OK to finish up?” |
| “This is going to hurt.” | Avoid predicting the sensation. If appropriate: “Tell me if anything bothers you.” |
| “Don't worry.” | Acknowledge first: “You've had some difficult experiences before.” |
| “Be brave.” | Offer control or choice: “Let me know when you are ready for the arm to stay still.” |
There is no universally safe dictionary. Rapport, context, previous experience and the meaning the patient gives the words all matter.
Listen before choosing the words
Listening helps identify patient expectations and potential solutions in the patient's current reality. The patient's own words may help direct communication strategies that enhance a therapeutic outcome.
Information versus suggestion
Clinical information and therapeutic suggestion are not mutually exclusive. A clinician can communicate risk accurately without presenting every possible outcome as a prediction.
Nocebo, ethics and informed consent
Patients have the right to information necessary for informed decision-making, and clinicians have duties of honesty, disclosure and respect for autonomy. At the same time, clinicians should avoid causing harm. The solution is not to withhold material risk, but to consider how truthful information can be communicated in a way that mitigates or avoids nocebo effects.
Risk information: timing matters
Material risks required for informed decision-making should not be concealed. However, discussing material risk is different from repeatedly predicting transient minor adverse symptoms during the procedure itself. Where appropriate, negative risk information can be discussed in advance, when the patient is better able to consider it.
A practical check
- Am I communicating a negative expectation of an outcome?
- Is my language meaningful from the patient's perspective?
- What does this patient want to know?
- Can I also communicate prevention, treatment, how the patient's experience can be improved, or how risks can be mitigated?
Podcast — hypnocommunication and the nocebo effect
Interview with Allan Cyna on the Royal College of Anaesthetists’ Anaesthesia on Air, discussing hypnocommunication, suggestion and the nocebo effect in clinical practice.
Listen to the podcast →