Essential communication skills
When a patient is dying, compassionate communication becomes a clinical skill as important as assessment, drug administration, and physical intervention. The fact is that nurses are in the best position to help dying patients communicate about their wishes, help families understand the course of the patient’s transition, ease conflicts and difficulties that are sure to arise (see Allowing acceptance), and facilitate interactions with physicians and other members of the palliative care team.
When communicating with a patient and family members, always take care to convert medical language into lay language, not only to increase the patient’s and family’s understanding but also to better invite them into the conversation. Also, keep in mind that many families have varying educational levels, reading abilities, and language preferences. To communicate effectively with patients and their families, make sure you’re communicating with cultural sensitivity, building rapport, using empathy, participating as needed in important end-of-life decisions, and continuously assessing yourself and your effectiveness.
Cultural sensitivity
The percentage of families ethnically and culturally different from the prevailing European model continues to climb. In the United States Census of 2000, respondents identified themselves this way:
65%white
13%black
13%Hispanic
Expert InsightsAllowing acceptance
A physician I work with routinely orders psychiatric consults for terminally ill patients who ask her to stop aggressive treatment. Do you think that’s warranted? — S.S., Ohio
No. I think it’s usually an indication that the physician is uncomfortable caring for a patient at the end of life. Some physicians also want to verify and document a patient’s competence for legal reasons.
Recently I got a referral to see a patient terminally ill with lung cancer and liver metastasis. His physician wanted me to talk with him about going to rehab so he could get strong enough to tolerate more chemotherapy.
I found my patient lying in bed staring up at the ceiling. I introduced myself as a clinical specialist who works exclusively with people who are seriously ill. I then asked if he wanted to talk about how things were going.
He simply said, “I’m fine.”
I went on to say that I was terribly sorry that the cancer had gotten away from us and that I wondered what he wanted now.
“I just want to go home.”
“Home to heaven or home to your house, Mr. North?”
“Both.”
I mentioned that his chart said he hadn’t eaten for many days, and I asked if he wanted to try an appetite stimulant.
“No. I’m fine.”
I asked if he had any questions or concerns he wanted to discuss, and he just shook his head no. But as I got to the door he said, “Joy, I’ve got no reason to lie to you. I’m done, and I’m fine.”
I reminded him that he could ask for me if he wanted to talk, and then I went to write my note in his chart.
The next day, Mr. North’s excellent nurse paged me. “You’ll never believe what Dr. Sutherland did!” she exclaimed. “He ordered a psych consult for Mr. North to find out why he won’t eat!”
“Mr. North doesn’t need a psych consult. He’s not eating because he’s lost his appetite and he’s ready to die,” I said emphatically.
The psychiatrist’s consultation was brief and to the point. Her note simply said that the patient wasn’t suicidal and that he was well-adjusted and accepted his terminal condition.
I believe that, at certain times, some terminally ill patients can benefit from psychiatry and antidepressant treatment. But it’s a mistake to routinely order consults for patients just because they recognize and accept their condition.
This approach is a glaring reminder of how poorly some health care providers deal with death and dying. Sorrow over leaving the planet isn’t an abnormal reaction that requires analysis. Most dying patients find great comfort in just being able to share their feelings with someone who’s caring and empathetic.
By the way, Mr. North went home the next day with a hospice referral.
— JOY UFEMA, RN, MS
4.5%Asian–Pacific islander
l.5%American Indian–Alaskan native
2.5%bi-ethnic.
All told, at least one-third of the patients and families you care for will be part of an ethnic or cultural minority. To establish good communication, it’s increasingly important to assess differences in values, priorities, customs, and goals among a culturally diverse population.
For instance, some cultures may view discussing serious illness or bad news harmful to the patient, as well as being disrespectful or impolite. Thus, family members may communicate from the perspective of protecting their loved one. Some cultures believe that open discussion of illness may provoke depression or anxiety. Others believe that discussing an illness may eliminate hope or that speaking out loud about the possibility of death could make it come true.
For example, a Navajo may believe that negative words and thoughts about health will become a reality. Because you spoke it, so it will be. The Navajo place a prominent value on positive thinking and speaking, a value that can make it difficult to openly discuss advance directives or end-of-life care. Chinese patients tend not to discuss advance directives either because of a similar belief that what one says will become a self-fulfilling prophecy. Chinese patients also hold their elderly in high esteem and don’t want them to be upset by bad news. In Asian cultures, it’s perceived as cruel to inform a patient of a cancer diagnosis.
Another communication problem may arise if the physician’s cultural background reduces the motivation to discuss end-of-life issues, which might give patients a sense of false hope. Differing views on end-of-life issues by both patients and health care professionals may translate into a lower likelihood of advance directives. One study found that 40%of older white patients had completed advance directives compared to only 16%of older black patients.
In summary, when communicating about end-of-life issues, many cultural variables come into play, including respect, causing harm, provoking anxiety or depression, and self-fulfilling prophecy. Use therapeutic listening to let the patient and family voice their concerns. And be attentive to issues of acceptance, tying up loose ends, voicing anger, and preparing for death.
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