Communication skills

Not uncommonly, patients with worsening life-limiting conditions attend the ED with no recorded discussion of their wishes about treatment options in the event of an abrupt deterioration; only 4% of patients have any documented evidence of advance care planning prior to hospital admission¹⁷.

Honest communication is therefore an essential component of palliative care but is frequently avoided by healthcare staff due to a lack of confidence, a wish to avoid causing distress, or due to uncertainty over treatment response, such as in a frail patient with sepsis who may respond to treatment but has a significant chance of dying.

The goals of communication are to^10,17:

• Inform the patient and their loved ones what is likely to happen next
  • Be sure to convey the seriousness of situation.
  • Some patients may not want this conversation. We should respect that decision, while planting a seed to allow them to raise the issue later if desired.
• Convey uncertainty honestly
• Set realistic expectations in an open and honest way, without removing all hope
• Avoid specific predictions about possible length of time to death by using ranges (hours to days, days to weeks, etc.) and reminders about how uncertain the process is
• Explore a patient’s wishes and priorities rather than just break bad news

A conversation might go like this:

You’re very sick at the moment, sick enough that you might die.	Conveys seriousness of situation
Do you want all the details, or just the bare minimum about what might happen to you?	Finds out how whether individual is open to this conversation
We’re treating you with antibiotics, fluids and nebulisers and we hope you’ll improve with them.	Sustains a small degree of hope, grounded firmly in reality of situation
But your body is very weak and I’m worried that you won’t respond to the treatment.	Honestly conveys expectations
The next few hours to a day or so are critical, but we can’t be certain how things will go.	Gives loose possible timeframe range
If you don’t improve and get sicker, I need to know what’s most important to you….	Opens door to explore patient’s wishes or priorities

Various communication models to support conveying bad news in a structured way have been developed¹⁸.

If death does not appear imminent, but is likely during this admission, explore understanding about the patient’s illness trajectory with them or their loved ones:

• What do you understand about what is happening to you now?
• Have things changed in the last six months?
• Do you want to talk about what will happen to your health in the future?
• Are you afraid of anything in particular? Do you have any strong feelings about treatment that you would or wouldn’t want to receive?

This helps you get an idea of the patient’s awareness of their overall trajectory and can help the inpatient teams lead further discussion about goals of care later in the admission if appropriate.

When a patient has a learning disability, it is especially important to be aware of their cultural background, likes and dislikes, how they communicate and how they express pain. A family member or caregiver who knows them well is often essential to ensure adequate communication¹⁹.

Avoid using language that suggests palliative care involves doing nothing. Phrases like ‘withdrawing care’, ‘stopping treatment’ and ‘ceilings of care’ can give the impression that all care is stopping, instead of futile or inappropriate treatments being stopped and a focus shifting to comfort and helping patients use their remaining time most wisely¹⁷.

Learning Bite

The phrase a patient ‘is sick enough to die’ helps crystalise the seriousness of the situation for the patient and their loved ones.