Ask-Tell-Ask
The Ask-Tell-Ask model comes from medical communication training, particularly in palliative care, oncology, and critical care, and has been widely taught as part of serious illness communication frameworks.
It was popularized in the U.S. by groups like:
VitalTalk (an organization for clinician communication training),
Serious Illness Care Program from Ariadne Labs (Atul Gawande’s group),
and in textbooks like Mastering Communication with Seriously Ill Patients by Anthony Back et al.
Where it comes from:
- It is based on adult learning theory and patient-centered care, recognizing that people process information in small chunks and that their understanding and emotions shape how they hear news.
- “Ask” engages the family and assesses their baseline understanding.
- “Tell” gives information tailored to what they know and can absorb.
- “Ask” again checks their comprehension, invites questions, and explores concerns.
It is not a proprietary model—it’s a simple, widely adopted heuristic used in many medical schools and ICU communication courses worldwide because it’s easy to remember.
Ask-Tell-Ask is the basis of an implicit loop of multiple iterations, adjusting to how much the family understands and how ready they are for more information.
For example:
- Ask 1: “What’s your sense of how she’s doing?”
- Tell 1: “She’s very sick, and her condition has worsened.”
- Ask 2: “What questions do you have about that?”
- Tell 2: “Her lungs have failed, and there are no treatments left that can reverse this.”
- Ask 3: “Is there any more information I can give you now?”
Patients and families are processing complex, emotional information. Breaking it into chunks with pauses allows them to keep up. Each Ask checks understanding and emotional readiness, while each Tell delivers information in small, digestible pieces. The process repeats until understanding and the next steps are clear.
Headline-Pause-Detail
The Headline → Pause → Detail structure isn’t a formal “named” framework like Ask-Tell-Ask, but it emerged from medical communication training for serious illness, especially as a way to deliver information clearly and compassionately under stress.
“Headline first” is borrowed from journalism
- Borrowed into medicine as a way to give a clear, concise summary first (like a news headline) before explaining in detail.
- Adapted for clinicians in situations where families are overwhelmed and can’t process too much at once.
Palliative care communication training
- VitalTalk (Anthony Back, Robert Arnold, James Tulsky) teach a “Warning shot → Headline → Pause” sequence.
- Example:
“I’m afraid I have difficult news. (pause). Your father’s lungs are failing.”
- This is taught in Mastering Communication with Seriously Ill Patients (2009) as part of “chunk and check” methods.
ICU and oncology family meetings
- Ariadne Labs (Atul Gawande’s group) and the Serious Illness Care Program incorporated the same idea in their scripts.
- They emphasize:
“Start with the headline, pause for reaction, then add details only as needed.”
Aviation/Engineering influence
- Similar “headline first” structures come from Crisis Resource Management (CRM) in aviation/ER settings.
Why it’s used
- Families under stress can’t process long explanations
- A clear headline gives them orientation (“Things are worse than we hoped”)
- A pause gives space for emotions
- Details can be added or withheld based on how much they can take in
Examples
ASK 1
(Start by exploring family’s current understanding and feelings)
- “Can you tell me what you understand about your loved one’s condition right now?”
- “What have you been told so far about what’s happening?”
- “How are you holding up with everything going on?”
- “What worries you most about your loved one’s health?”
- “Is there anything specific you want me to explain today?”
TELL 1
(Deliver key info clearly, using Headline → Pause → Detail)
- “Your dad is very sick with severe pneumonia and needs a ventilator. (Pause) We’re giving strong medicines to support his blood pressure and lungs. (Pause) It’s too early to tell how he’ll respond.”
- “Your mom’s condition is worsening despite our efforts. (Pause) Her heart and kidneys are struggling to work properly. (Pause) We want to be honest about the risks ahead.”
- “Your brother is critically ill and has had multiple organ failures. (Pause) We’re doing everything possible, but this is very serious.”
- “The infection has been tough to control. (Pause) We’re focused on keeping him comfortable while monitoring closely.”
ASK 2
(Invite questions, feelings, and explore values/goals)
- “What questions do you have for me right now?”
- “How are you feeling hearing this?”
- “What is most important to your family as we move forward?”
- “What do you think your loved one would want in this situation?”
- “Are there specific things you want us to focus on now?”
TELL 2
(Respond with tailored info based on family’s response)
- If family asks about chances:
“Given how severe the illness is, recovery is uncertain. (Pause) We’ll continue all treatments but want to prepare you for all possibilities.”
- If family asks about treatment options:
“We can continue life support, but it may not improve the outcome. (Pause) Another option is focusing on comfort care, which means managing pain and distress.”
- If family expresses hope for recovery:
“I understand hope is important. (Pause) We will keep doing everything we can while being honest about what we see.”
- If family asks about next steps:
“We want to align care with your loved one’s wishes. (Pause) Can you share what they would want us to focus on?”
ASK 3
(Check understanding, invite decision-making and ongoing dialogue)
- “Does this make sense so far?”
- “What questions or concerns do you have now?”
- “Based on this, what do you think your loved one would want us to do?”
- “How can we best support you and your family at this time?”
- “Would you like more information on any part of this?”
Responding to “Doctor, what’s happening?”
EARLY ILLNESS (Still hope)
ASK 1:
“What have you understood so far about what’s been happening?”
TELL 1:
- Headline: “Your father is very sick with severe pneumonia.”
- Pause:
- Detail: “He’s on a ventilator and strong medicines. The next 24–48 hours are critical.”
ASK 2:
“What questions or concerns do you have now?”
TELL 2 (if asked about recovery):
- Headline: “We’re worried because he is very ill.”
- Pause:
- Detail: “It’s too soon to say if he’ll recover, but we’re doing everything possible.”
ASK 3:
“Does that make sense? What’s most important to you and your family right now?”
WORSENING CONDITION (High risk of death)
ASK 1:
“What’s your sense of how she’s been doing these past few days?”
TELL 1:
- Headline: “Her condition has worsened despite our best efforts.”
- Pause:
- Detail: “Her organs are failing. We’re very worried she may not survive.”
ASK 2:
“What worries you most about what’s happening now?”
TELL 2 (if asked about options):
- Headline: “We’re running out of treatments that can help her recover.”
- Pause:
- Detail: “We could continue machines, but they may not change the outcome and could cause more suffering.”
ASK 3:
“Would you like to talk about what she would have wanted?”
END-OF-LIFE (Dying or has died)
ASK 1:
“Can you tell me what you know about his condition now?”
TELL 1:
- Headline: “I’m so sorry, but his heart stopped, and we couldn’t restart it.”
- Pause:
- Detail: “He has died.”
ASK 2:
“What questions do you have right now?”
TELL 2 (if asked about next steps):
- Headline: “We’ll help you through what comes next.”
- Pause:
- Detail: “You can spend as much time with him as you need, and we’ll guide you through arrangements.”
ASK 3:
“Is there anything we can do for you or your family right now?”
