Preparing for Difficult Conversations

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Sharing bad news or difficult information with patients and their families is expected in healthcare practice. Time needs to be given to prepare for difficult conversations.  But doctors and nurses often find these conversations difficult to have. Consequently, it is not uncommon for them to say they:

  • feel apprehensive,  
  • feel unprepared,
  • question their competence or ability,
  • feel uncertain about what a patient may know or want to know, 
  • are too emotionally invested in a patient, 
  • find it emotionally draining,
  • are compromised by the environment to have private conversations, 
  • have a lack of time,

Here is a quote from a doctor who works in cancer services to demonstrate some of these points:

Breaking bad news, discussing treatment options, or diagnosing patients and families, especially for young patients, can be very difficult and emotionally draining. It is difficult in terms of personal emotions and how I am delivering the news, and how the subject is receiving the news. And what sort of impact is it going to have on that person and that family? Also, what sort of impact is it having on me in the long run?

 

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4205512/pdf/ijme-2-159.pdf

This story is a very personal and reflective account and raises several questions that are difficult to answer. In the same way, healthcare professionals express these sentiments daily in the media, particularly when looking after patients diagnosed with COVID-19. In this case, the situation is further complicated.

COVID-19

Due to COVID-19, patients are often alone in a hospital or care home, without family or friends by their sides. These patients are often seriously ill and fighting for their lives and making difficult conversations much more complicated. Additionally, sensitive information is shared with family members over the phone. Although we communicate on the phone a lot, it can be a barrier when we need to share difficult news because we can’t see non-verbal communications. Let’s not even start on personal protective clothing! Indeed, nurses and doctors are telling us of the emotional distress they are facing daily.

Preparing for difficult conversations

Some evidence-based strategies may help you prepare for difficult conversations. I like the SPIKES model to breaking bad news and have adopted this here. 

Setting

Plan ahead.  Consider where you intend to have this conversation.  Ideally, you want to limit interruptions, so choose a private room or location if possible. You also need to be in a space where you feel comfortable. If possible let others know what you are about to do and not to disturb you.

Prepare what you need to say. You may find it helpful to read the patient’s notes beforehand. This may sound obvious, but we don’t always do this well. It can be very distressing to a patient when we sit and read their noes in front of them. Consequently, it is essential to demonstrate that you know something about the person you are talking to. Patients have told me frequently how important it is to be seen and treated as an individual. Additionally, show you care by the tone of your voice and the words you use.

  1. Plan what you want to say
  2. Plan how you will say it
  3. Take note of how you are feeling, and when you get a moment, reflect on the conversation. What went well? What could you do differently? 
  4. Be present. Take a moment to put aside any emotions you may have from a previous conversation. Take a few deep breaths or speak to a colleague.
  5. Plan how you will end the conversation
  6. Consider any support you can direct them towards

Perception

Before you share any information, find out what the person already knows and understands. By doing this, you will be able to judge what you need to say. Start with an opening question. For example,

‘Can you tell me in your own words what you think is happening here?’

‘What do you think is going on?’

‘What have you been told so far?’

When the patient or relative is talking to you, listen to what they tell you. Try to use the same or similar words when you talk to show you are listening to them. You might also want to repeat what you have heard and check that you have got this right. You might say something like;

‘Just to check that I have understood you, you have been told that this is serious and you may not get better. Have I got this, right?’

You might then want to pause and use silence which is a powerful communication skill. Silence enables people to think and process what they have heard or how they might want to respond. 

Whilst you might think this will take a lot of time, it doesn’t. If you do this well, it may take less time. It may also make the person you are communicating with feel that you care.

Invitation

If possible, find out what the person wants to know or expect to hear before giving them any information.

If they don’t want to hear any bad news at this point, leave it (if you can) and make it clear you will come back to them.

Knowledge

Up to this point, you have been preparing for a difficult conversation. You have been asking questions to gather information about what the person knows and what they might want to know. You are now in a position to start sharing difficult news. Some simple guidelines will help you do this well.

SUMMARISE 

Summarise what has happened so far. You might want to compare how the patient’s condition has progressed or deteriorated.

Before you proceed to communicate the difficult information, give the person a WARNING SHOT. An example of this might be,

” I am so sorry but…..”

“The news isn’t good, I am afraid.”

Give information in small amounts and CHUNK AND CHECK. People on the receiving end of difficult information or bad news will only retain a small amount of information. Consequently, if you give too much information in one go, they won’t remember it all. They need time to process the information. Their emotions will be heightened, and their perception of their future will change.

Don’t use JARGON or EUPHEMISMS as this can confuse people. For example, when I did my PhD, 6 out of 16 patients were told they had a tumour rather than cancer. When they received their letter to come to the cancer unit, they were angry because they discovered their diagnosis in an appointment letter.

If you tell someone they are dying or telling a relative their loved one has died, use the words if possible. Try to limit any confusion.

Emotions and Empathy

When having difficult conversations where you convey bad news to someone, it will induce some emotional reaction. If they cry, let them cry. Slow down, use silence, pause and soften your voice. Acknowledge the emotion with an empathic response.

“I sense that this is very difficult for you to hear.’

‘I am so sorry that you are going through this.’

‘I can’t imagine what you are going through right now.’

” What I am hearing is that you are feeling so sad right now. Is that right?”

Empathy is more than words. You can show empathy in your posture and the way you interact with someone. Yet, we hear nurses and doctors describe how difficult it is to show empathy, particularly when wearing personal protective clothing. In this case, maybe the words you use will have more meaning. Sitting with someone (if you can) will also convey you have time for them at that moment. Listening and showing you are listening to someone will have meaning, as will noticing their distress. 

Empathy can show that you care and are compassionate and perceptive to the needs of the other person.

Summarise and draw the conversation to a close

As you draw the conversation to a close, check that you have covered all that needs to be covered. Do you need to explain anything again?

If appropriate, say something that will bring the other person some comfort. For example, if they are dying, try to reassure them that they won’t be alone. If you are telling someone about a person who has died, can you offer any comfort by saying they were not alone and held the nurse’s hand? Please be honest, though.

This next point will depend on the type of difficult conversation you have had.

  • Can you offer any information about what may happen next?
  • Signpost them to some supportive services?
  • Explain your approach to care moving forwards. e.g. symptom control

Evidence: preparing for difficult conversations

If you want to access further evidence to support you, please consider using the following links:

  1. National Institute of Clinical Excellence has produced a search of the terms breaking bad news or communicating bad news or difficult conversations: https://www.evidence.nhs.uk/search?q=%22breaking+bad+news%22+OR+%22communicating+bad+news%22+OR+%22difficult+conversations%22
  2. This is a paper by Robert Buckman and colleagues who developed the SPIKES 6 step protocol for breaking bad news. https://theoncologist.onlinelibrary.wiley.com/doi/epdf/10.1634/theoncologist.5-4-302

More information

If you need any further information, please contact us

Finally, if it would help reflect on a challenging conversation with an impartial person, please consider contacting us by using the link above. 

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