Communicating With Oncology Patients About Palliative Care

April 2, 2007

Palliative care differs from other oncology care settings because it involves end-of-life discussions. This article is intended to help oncology nurses who deliver news that involves palliative care by describing components of breaking bad news, providing an example for how to break bad news, and suggesting methods for evaluating a nurse-patient interaction. One possible scenario for achieving a positive outcome after delivering unwelcome information will also be described. Applying the methods described in this article can help to promote a positive outcome when a nurse delivers bad news to a patient.

Palliative care differs from other oncology care settings because it involves end-of-life discussions. This article is intended to help oncology nurses who deliver news that involves palliative care by describing components of breaking bad news, providing an example for how to break bad news, and suggesting methods for evaluating a nurse-patient interaction. One possible scenario for achieving a positive outcome after delivering unwelcome information will also be described. Applying the methods described in this article can help to promote a positive outcome when a nurse delivers bad news to a patient.

Communication Skills

There are four basic skills of communication: imparting information, listening, gathering information, and maintaining presence and sensitivity.[1] When learning these skills, a nurse acquires important phrases and open-ended questions, storing them in a mental toolbox for use when talking with a patient. An important rule of thumb is that nurses should present information to patients and families in lay language instead of medical terminology, so that they can fully understand the information being delivered.

Asking questions to clarify what the patient or family wants instead of assuming is an important aspect of communication. High patient and family stress levels may require setting time limits on the initial conversation. If a patient is under a high level of stress, he or she is not likely to take in all of the information the nurse presents so the amount and level of detail should be geared to how much can be absorbed. Because listening is an active process requiring a patient's full presence and attention, this may require the nurse to wait until the patient is under less stress or schedule another time before presenting additional and more detailed information.

It is vital for the nurse to be aware of the patient's verbal and nonverbal communication. When a nurse is unsure of what a patient is trying to communicate, he or she can say, "Tell me more." Allowing some silence during the session is of paramount importance, as it gives the patient time to reflect on the moment and the situation.

Asking patients open-ended questions is the best information-gathering tool. Such questions draw out a patient's story and oftentimes reveals their concerns and needs. Some useful open-ended questions are as follows:

• What concerns you about your illness?

• How is treatment going for you?

• What are your worries?

• Who is important to you?

• What provides you with the strength to live each day?

• Who provides support to you?

When communicating with patients, it is important for nurses to have presence and sensitivity, which are probably the hardest communication skills to master. Presence, which refers to being in the moment with the patient and family, requires a high level of emotional maturity and depth of understanding. Sensitivity entails maintaining a nonjudgmental and unbiased role when caring for a patient and family.[2]

Part of communicating with patients involves helping them identify who they want to receive information about their condition and who should make health-care and treatment decisions. When a patient does not speak or fully understand English, it is important for nurses to always use an official translator.[2]

Models for Breaking Bad News

There are many authors that have contributed to the development of models for breaking bad news. One model that is easy to use is the SPIKE method of breaking bad news.[3] The acronym SPIKE stands for Setting, Perception, Invitation, Knowledge, and Empathy.[3] The sidebar on page 46 presents an example of a conversation between a nurse and a patient that demonstrates these skills and strategies.

In the example, the nurse begins the conversation with the patient by sitting down; this shows the patient she has time to listen. The nurse then asks the patient open-ended questions to gather information. She clarifies the patient's concerns by repeating what she thinks is concerning him. During the conversation, the nurse gathers information in small increments. It is important for nurses to wait for patients to be ready to express their concerns.

Another easy-to-remember strategy was also used in the conversation shown in the sidebar; it is represented by the acronym NURSE: Name, Understanding, Respect; Support, Explore.[3] The nurse in the example demonstrates an understanding of the problem and differentiates what is fixable from what is not.

Some nurses ask, "What if the patient starts crying while I'm talking?" A good strategy is to acknowledge the crying and offer the patient a break. Do not assume you know why a patient is crying. Crying is a very natural response and can reflect various emotions. Be supportive, but don't offer tissues too soon, as this may give the impression that the patient should not cry.

Summary

Achieving expertise in communication requires a long-term commitment. There are many strategies available for nurses seeking to accomplish this task. Many online resources (for example, http://www.conversationsincare.com/web-bookchapter05.html and http://www.breakingbadnews.co.uk/) and helpful pocket cards intended to assist in improving communication skills are available.

References:

1. Quill TE: Initiating end-of-life discussions with seriously ill patients: Addressing the "Elephant in the Room." JAMA 284(19):2502-2507, 2000.

2. Lapine A, Wang-Cheng R, Goldstein M, et al: When cultures clash: Physicians, patient, and family wishes in truth disclosure for dying patients. J Palliat Med 4(4):475-480, 2001.

3. Buckman R: Communication skills in palliative care. Neurologic Clinics 19(4)989-1004, 2001.