In a new, cruel way, the coronavirus 2019 (COVID-19) pandemic has revealed limitations in medical capacity that amplify the challenges that clinicians already face in communicating with patients about serious illness. The most recent estimates of the effects of the pandemic describe a scenario that none of us have ever seen: Demand for hospital beds in the United States will exceed capacity by 64 175 acute care beds and 17 309 intensive care beds; over the next 4 months, clinicians are projected to witness 81 114 deaths (1). These statistics, though, are merely a 30 000-foot view of the territory that clinicians are seeing now, as they grapple with patients and families on the ground about how to prepare, what is happening, and what to expect.

For clinicians who have received training in evidence-based methods to communicate with patients with serious illness, many of these conversations will feel familiar. Delivering serious news and discussing goals of care still work as heuristics for COVID-19–related illness (2), although clinicians will face an extra measure of COVID-19–related apprehension, uncertainty, and fear. But clinicians are also being confronted with new communication tasks that none of us have faced before, including proactive COVID-19 planning for patients who are already frail with other serious illnesses, facilitating virtual goodbyes between family members and dying patients with restricted access, and explaining decisions on why a particular patient will not receive a scarce resource.

For clinicians who have not had such training, the COVID-19 pandemic is likely to be a demoralizing experience. The shortfall in system capacity will guarantee that they will run out of time repeatedly, and the usual phrases will be out of place in new situations. For clinicians equipped with a deep understanding of communication principles and a flexible repertoire, however, their expertise is already enabling them to innovate and adapt.

It is not too late for clinicians to learn these skills. We have used 5 years of experience with scaling up serious illness communication skills training—our nonprofit startup VitalTalk (www.vitaltalk.org) has reached at least 30 000 clinicians—to create a series of just-in-time tips, talking maps, and video demonstrations we have made freely available (3). Our approach, which has shown positive outcomes in clinician behavior (4), patient quality of life (5), and patient trust (6), is based on 3 core principles. First, dealing with emotion is more important than giving lots of information. Unless we acknowledge the fear, sadness, and anxiety that patients and families experience, they will not absorb the information they need. Second, information is best delivered in small packets that start with a headline. When we embed bad news in a long, technical medical narrative, our patients lose the thread and miss the news. The third principle states that patient values should be at the heart of medical treatment plans. When we elicit values from patients, they feel heard and understood even when the care plans bend toward what is medically possible.

The caveat introduced by COVID-19 is that our third principle yields to crisis standards of care. Under crisis standards, the ethical foundation shifts from individual values to population-based resource allocation that maximizes the most good for the largest number of people (7). Clinicians should become familiar with their state standards, which differ somewhat across the United States. When systems and clinicians are operating under crisis standards, patients will not have some choices. Triage committees will make decisions for patients that may hasten death. In these circumstances, clinicians will need to shift away from the third principle. Instead of eliciting values that drive care, clinicians will need to explain the care that is possible, refrain from offering treatments or interventions that aren't available for that patient, and instead share what crisis standards mean for them (Figure). This does not require that clinicians stop listening, stop talking about what's important, or stop empathizing—those skills will be more important than ever. But in a crisis, the third principle must yield.

For clinicians, we expect that the experience of working under crisis standards will be far-reaching, with repercussions that persist for a long time (8). For us, the COVID-19 pandemic has evoked feelings that we haven't visited since the first phase of AIDS: huge uncertainty, deep vulnerability, and gruesome anecdotes. Yet back then, we were also humbled and inspired by clinicians who stepped up heroically to care for those first HIV-positive patients (9), and that personal experience shaped much of the work in communication we do now. Our hope is that the attention we bring to the communication that lies at the heart of clinical care could enable us and our colleagues to emerge from this pandemic with more wisdom and kindness. For patients and families, we hope that care from a clinician who communicates their caring could mitigate a measure of the suspicion and mistrust that seems likely to be another legacy of COVID-19.

We are not suggesting that communication skills alone are going to be a silver bullet for clinician moral distress, exhaustion, and grief in the face of COVID-19. Communication is only one part—albeit an essential part—of what clinicians will need to survive well. What our experience in training thousands of clinicians to communicate better has shown us is that it is possible to get better at facing inequality, suffering, and dying, regardless of the circumstances. It takes a sense of purpose, systems that commit resources, and high-quality communication skills. We can rise to this challenge. Each of us who cares about communication can reach out to our colleagues to encourage, mentor, coach, and support each other; advocate within our systems; and keep ourselves healthy, while we do the work of our calling: communication, compassion, and healing.

冠状病毒2019（COVID-19）大流行以一种新的残酷方式揭示了医疗能力的局限性，加剧了临床医生在与患者就严重疾病进行沟通时已经面临的挑战。关于大流行病影响的最新估计描述了一种我们从未见过的情况：美国对医院病床的需求将超过64 175张急诊病床和17 309张重症监护病床的容量；在接下来的4个月中，预计临床医生将目睹81114例死亡（1）。但是，这些统计数据仅是临床医生现在所见领土的3万英尺视图，因为他们在实地与患者和家人就如何准备，正在发生的事情以及期望发生的事情进行了斗争。

对于已经接受过基于证据的方法培训的临床医生，以便与严重疾病的患者进行交流，这些对话中的许多对话会让您感到熟悉。尽管临床医生将面对与COVID-19相关的忧虑，不确定性和恐惧，但传递严重新闻和讨论护理目标仍然可以作为COVID-19相关疾病的启发法（2）。但是临床医生还面临着我们从未遇到过的新的沟通任务，包括为已经身患其他严重疾病的患者进行积极的COVID-19计划，促进家庭成员之间的虚拟告别以及病情有限的垂死患者关于为什么特定患者将不会获得稀缺资源的决定。

对于尚未接受过此类培训的临床医生而言，COVID-19大流行可能是令人沮丧的经历。系统容量的不足将确保它们将反复用尽时间，并且在新情况下常规短语将不合时宜。但是，对于具备对沟通原理的深刻理解和灵活用法的临床医生，他们的专业知识已使他们能够创新和适应。

临床医生学习这些技能还为时不晚。我们已经使用了5年的经验，用于扩大严重疾病的沟通技巧培训（我们的非营利性创业公司VitalTalk（www.vitaltalk.org）已达到至少3万名临床医生），以创建一系列即时提示，谈话地图，和我们免费提供的视频演示（3）。我们的方法基于3个核心原则，在临床医生的行为（4），患者的生活质量（5）和患者的信任（6）方面显示出积极的成果。首先，处理情感比提供大量信息更重要。除非我们承认患者和家人所经历的恐惧，悲伤和焦虑，否则他们将不会吸收他们所需的信息。其次，最好以小包（以标题开头）传递信息。当我们长期埋下坏消息时，技术上的医学叙事，我们的患者迷失了方向，错过了消息。第三个原则指出，患者价值应该是医疗计划的核心。当我们从患者身上获得价值时，即使护理计划朝着医学上可能的方向发展，他们也会感到被倾听和理解。

COVID-19提出的警告是，我们的第三项原则符合危机护理标准。在危机标准下，道德基础从个人价值转向以人口为基础的资源分配，从而最大程度地为最大数量的人带来最大利益（7）。临床医生应熟悉其州标准，该标准在美国各地有所不同。当系统和临床医生按照危机标准运行时，患者将没有其他选择。分诊委员会将为可能加速死亡的患者做出决定。在这种情况下，临床医生将需要摆脱第三项原则。临床医生除了要得出可以推动护理的价值观，还需要说明可能的护理，避免提供对该患者不可用的治疗或干预措施，而是分享危机标准对他们的意义（图）。这并不需要临床医生停止倾听，停止谈论重要的事情或停止同理心-这些技能比以往任何时候都更加重要。但是在危机中，第三项原则必须屈服。

对于临床医生来说，我们期望在危机标准下工作的经验将是深远的，其影响将持续很长时间（8）。对我们来说，COVID-19大流行引起了我们自艾滋病第一阶段以来就没有去过的感觉：巨大的不确定性，深远的脆弱性和可怕的轶事。然而，那时我们也受到了临床医生的谦卑和启发，他们英勇地加倍照顾那些最初的HIV阳性患者（9），而个人经验决定了我们现在在沟通方面的许多工作。我们希望，我们对临床护理核心沟通的关注能够使我们和我们的同事以更大的智慧和友善从这一大流行中脱颖而出。对于患者和家庭，

我们并不是在说面对19面对COVID-19时，仅凭沟通技巧就不会成为临床医生道德苦恼，精疲力尽和悲痛的灵丹妙药。交流只是临床医生要生存良好所需的一部分，尽管是必不可少的一部分。我们培训成千上万的临床医生以更好地交流的经验向我们表明，无论情况如何，面对不平等，痛苦和死亡的情况都有可能变得更好。它具有目的感，承诺资源的系统和高质量的沟通技巧。我们可以应对这一挑战。我们每个关心沟通的人都可以与我们的同事联系，以鼓励，指导，指导和互相支持；在我们的系统内倡导；并保持健康，同时我们要进行自己的使命：沟通，同情和康复。