Explain why silence is sometimes an important part of communication in end of life care

Not many people feel comfortable talking about death, but when you’re taking care of a patient who is dying it becomes necessary and beneficial to communicate clearly

Death isn’t something that people like bringing up. It’s upsetting, it can feel uncomfortable and it might not feel like your place. However, it can make a big difference to a patient’s and relative’s quality of care, so it’s important to get it right.

Adrienne Betteley, palliative and end of life care programme manager at MacMillan Cancer Support believes good communication skills for a nurse are especially vital when it comes to palliative care. “Good communication can reassure and alleviate or reduce anxiety and distress,” she says. “You only get one chance to get it right when somebody is dying and memories live on with the loved ones after the person has died, so it is important these are not the worst memories they can be, such as someone saying the wrong thing.”

When a patient is dying you may be asked to talk with them about their wishes for their death so that a care plan can be prepared. Or you may wish to connect with how they’re feeling and offer support. You might need to record what they feel about the type of care they wish to receive, any advance decisions they would like to make now and appointing an individual to make treatment decisions if they’re unable to do it themselves.

Starting up the conversation

“The essence of good communication skills is to be led by the patient, ” says Helen Forrow, ward manager at Marie Curie Hospice in Newcastle. “A student nurse needs to ensure the patient has time to talk and that they listen and react appropriately.”

• Think about privacy. Is it appropriate to talk to your patient or relative in an open ward?
• Is it the right time? Find a time when your patient is feeling calm and relaxed
• Look for prompts. It might be a good thing to bring up tagged onto the end of a related conversation.
• Don’t use euphemisms. Using the words ‘dying’ or ‘die’ is honest and accurate
• Watch and learn. Watch how more experienced nurses do it, and have a chat with them about it afterwards too, you might be able to pick up some pointers that you hadn’t considered before
• Use open questions, like ‘What …’ or ‘How …’. These help to encourage someone to give more than single word answers. “When you ask open questions, don’t just ask one, allow time for responses and even when you think they have said everything, always allow for further responses,” says Ms Betteley. “A useful tip is to say ‘Is there something else?’, which encourages a response as opposed to ‘Is there anything else?’, which tends to close the conversation.
• Summarise.  Feeding back to your patient a summary of what has been said can be useful says Ms Betteley: “By recapping what has been said shows that as a professional you have been actively listening and are genuinely interested and concerns.”
• Don’t be afraid of silence. Using pauses will sometimes encourage the person you are speaking with to open up more. “Active listening skills are vital. If you ask a question and don’t get an immediate response, allow the person thinking time and by pausing and waiting will allow them time to reflect and gather their thoughts and you are much more likely to get a response,” says Ms Betteley
• Read up. Is there any documentation about the patient’s preferences? Anything you need to know that will affect the situation?
• Write it down.“If someone has a number of issues they wish to discuss it can be helpful to ask if it is ok to write down their issues or concerns so that you fully understand and can help them prioritise later,” says Ms Betteley.

 Talking about spirituality

Conversations about spirituality won’t necessarily be about religion. Topics can range from religious ideas, plans for the funeral, concerns about those who are going to be left behind, to the after-life and what death will feel like.

“Spirituality is a very personal subject and usually not related to religion,” says Ms Forrow from Marie Curie. “To many patients this is a very difficult subject to discuss and needs to be handled with sensitivity and care. Often patients will have these conversations with the staff that they know and trust.  By getting to know a patient and family in depth and gaining their confidence a student nurse will often be able to obtain an understanding of what is important to the patient from a spiritual point of view.”

Using your body language

“Showing empathy is key both verbally and non verbally. Non-verbal communication is vital as the way we interact impacts on the relationships with our patients, as we constantly give out signals through our body language in the way we sit and the gestures we make,” says Ms Betteley. “If these are positive they will contribute to a good therapeutic and trusting relationship.”

• Maintain an open posture with your arms uncrossed
• Keep eye contact
• Avoid barriers between you and the person you’re talking with
• Sit at an appropriate distance so that the person you’re speaking with doesn’t feel overwhelmed
• Leaning forward may help to indicate that you are listening intently

Taking the plunge

Don’t be too hard on yourself, these kind of conversations won’t always be easy. Ms Forrow says: “Student nurses are likely to find end-of-life care discussions very difficult in the first few occasions as often they don’t know what to say and how to say it.  It is very hard when we can’t always make things better.”

But Helen de Renzie-Brett, head of education at Dorothy House Hospice Care, adds that it’s important to remember that you’re not alone: “Students may be frightened of dying patients and having to deal with someone who is at the end of their life. The best thing is to feel supported, so it’s a two-way thing. Qualified staff need to recognise that students may not have experienced death before and need to be alert to providing support. Similarly students should voice their concerns looking after someone who is dying and seek out support if they need it.”