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How to Have Difficult Conversations With Patients, Families
An Expert Interview With Cyndi Cramer, BA, RN, PCRN
May 9, 2012 (New Orleans, Louisiana) — Editor's note:
Difficult conversations with patients are necessary and, when done well,
can actually empower patients and help them plan for the future.
Cyndi Cramer, BA, RN, OCN, PCRN, clinical
administrative supervisor and educator in oncology, palliative care,
critical care, and pediatrics at the Tampa General Hospital in Florida,
spoke about this issue here at the Oncology Nursing Society (ONS) 37th
Annual Congress.
Cramer talked about why good communication
skills are so important and discussed strategies for helping patients
and families cope with bad news. In an email interview with Medscape Medical News, she identified things nurses should and should not do when having difficult conversations.
1.What would you say to nurses who are nervous about having difficult conversations with patients?
Cramer: Nobody likes them. Conversations
with patients about bad news — grave diagnoses, difficult emotions,
tough decisions. We don't like these conversations because we don't like
hurting our patients.
This is an anxiety-producing scenario for most nurses.
First, they need to remember they are not alone. If they have any
kind of palliative care team, these folks are experts on communication
and can help them or even step in for them.
Next, they need to not be afraid. The most important thing they need to do is listen.
If they are doing most of the talking, they are talking too much! Most
of these conversations are about encouraging the patient to explore what
is going on and what they want.
They also need to be gently honest. No euphemisms, no jargon, just
simple explanations of what is going on. Patients want us to show we are
empathetic to their plight, but most of them want us to be honest.
Finally, they just need to be "present." Presence is all about being
there "in the moment." Eye contact and touch are important, unless the
patient gives cues that they are uncomfortable (this is unwanted or even
inappropriate with some people and some cultures). Giving the patient
your full attention is critical, as is encouraging them to continue
talking by repeating or rephrasing their statements or acknowledging
their fear.
2.Why is good communication important?
Cramer: Good communication is key to
everything we do. If we do not communicate well, misunderstandings,
false hope, and distrust can be the result. This can lead to patients
and families who are confused and angry. Communication is what helps us
bond with our patients.
Nurses are the "constant," as Betty Ferrel says. They are with
patients for extended periods of time, whereas other healthcare
providers come and go. They are the holistic practitioner who is looking
at every dimension of the patient. They are the interpreters of what is
going on and what others are saying, and they are the patient advocates
who are required to speak up for their patient's needs and goals. If
they don't do it, who will?
3.What are some examples of poor and good communication?
Cramer: Poor communication is hurried,
where the healthcare provider is doing all of the talking, using medical
jargon the patient doesn't understand, being distant, not engaged.
Good communication is the opposite — not rushed, simple words, mostly
listening, giving small bits at a time, following cues given, being
empathetic, and being "present."
4.Can you elaborate on the guidelines that nurses can use to develop good communication techniques?
Cramer: Some wonderful palliative care
experts have been writing about communication for years. There are
several great guidelines out there. Dr. Robert Buckman is one of my
favorites; he has written a great book — Difficult Conversations in Medicine. I really recommend it as a guideline for these conversations.
He gives guidelines and examples of several mnemonics for these conversations. One that he has talked about for years is the SPIKES protocol:
Setting/starting
Perception
Invitation
Knowledge
Emotions
Strategy/summary
Perception
Invitation
Knowledge
Emotions
Strategy/summary
5.Can you give some examples of words and phrases that should and should not be used?
Cramer: Don't say:
"We are going to withdraw care." (You mean you are not going to care for my mom anymore? Are you just going to ignore her now?)
"What do you want to do?" (referring to end of life issues: You want
me to decide? Aren't you the experts? Shouldn't you be telling me what
to do?)
"Do you want to make your mom a DNR?" (You want me to just give up?
To just let her die? I love my mom and I don't want her to die.)
Do say:
"I wish I had better news for you. (Pause, this is a "warning shot"
before giving bad news.) We've exhausted everything that will do
anything that will make your mom better. She is going to die from this
(many pauses). Did your mom ever talk about what she wanted?"
"This breathing machine is not helping her and patients tell us it's
not a comfortable experience. Do you think your mom would rather we let
her die naturally? We will stay right here with her and do everything we
know how to make her comfortable. There are many things we can do for
her."
"We can't fix this. I wish we could. Miracles are extremely rare and
happen even without our help when they do occur.... In my experience,
she only has hours to days left. You said your mom said she didn't want
to die like this. Do you agree that we should allow her to die naturally
and not do CPR (push on her chest) or put her on a breathing machine?"
6.Why is nonverbal communication
important, and how can nurses use nonverbal language therapeutically
with their patients?
Cramer: Only 7% of communication is
verbal; 38% comes from your tone of voice and 55% from your body
language. We really need to pay attention to what perceptions our
patients are getting from our nonverbal communication.
It goes back to "presence": Being with the patient in the moment; eye
contact and touch when appropriate; sitting at the bedside instead of
standing above the patient or talking over your shoulder while doing
other things; listening more than talking.
It does not take as much time as many nurses might think — remember
quality, not quantity. It all comes full circle to developing a trusting
relationship in a short period of time. Time spent in initial contacts
to develop that trust can yield huge benefits later when these difficult
conversations are suddenly something we have to face. It is all about
putting the "care" into nursing care.
Cramer has disclosed no relevant financial relationships.
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