Dr Catherine Millington Sanders, GP, RCGP and Marie Curie National Clinical End of Life Care Champion and co-developer of Difficult Conversations training programme, shares her experiences and top tips on having difficult conversations.

I recently had to tell a young woman that she was dying of metastatic breast cancer. She was a single mother with two beautiful children. Unfortunately, for so many of us, having these types of difficult conversations is a daily part of our job.

How strange, then, that it’s still mandatory for me to attend a yearly Basic Life Resuscitation course (when I have not encountered a collapsed patient in my 15 years in General Practice) but yet I have to have difficult conversations every day in my practice without any regular training…

This is never an easy job – no matter how long you’ve been in the profession.  However caring for terminally ill patients and their families along their journey is one of the most rewarding aspects of our work. It was on this basis that we developed Difficult Conversations courses.

If we want patients to have choice, then we must have effective and compassionate conversations about what options they have.

If we want patients to have choice, then we must have effective and compassionate conversations about what options they have. We must be open and honest about their prognosis or deterioration and we have to ask those tough questions about what is important to them.

Of course, some people may not want to talk about their wishes – but the significant majority of people will do at some stage. And the earlier we offer to start this journey in partnership with our patients and those important to them, the more time they have to plan, discuss and document their needs and concerns with key members of our multi-professional team.

We know for a fact that people nearing the end of life who document their decisions in a personalised plan will experience better care1.

For me, learning to have effective, compassionate conversations is a bit like learning to drive a car. I was terrified at the beginning but – with the help of a great instructor, a handbook for technical issues and some structure – I did get the hang of it. Nevertheless, I still have to focus every time I drive and I’m still learning new routes for new journeys.

Having now trained over 1200 multi-professionals through Difficult Conversations, it is clear that we all want the same thing for our terminally ill patients: the best outcome for them and those important to them.

Commonly highlighted themes about difficult conversations

Having taught palliative care and communication skills over the years, I recognise that these difficult conversations are different for everyone. However, there are common themes and the difficult conversations that many professionals say they fear or even avoid include:

  • Explaining DNACPR.  Also remembering that not ‘resuscitating’ still means that people can receive other active treatment and care.
  • Crisis consultation about deterioration and dying – ‘should the patient go to hospital?’
  • Assessing capacity and discussing the patient’s wishes when still unsure themselves.
  • Starting and finishing a difficult conversation safely – both for the patient and the professional.
  • Understanding how much time there is left to have these difficult conversations.
  • Deciding what to say to emotional and/or angry families and others close to the patient.

Top ten tips

For the above issues and other challenging conversations, I find the following helpful – even when a difficult conversation creeps up in the middle of a consultation

Preparation

A bit like an athlete – when you look at Usain Bolt preparing to do the 100 metre sprint, his focus and discipline is profound.

In our profession, conversation is a fundamental discipline. Our words matter and our patients remember them and take them on their journey. We’ve all heard patients come in and repeat whether good or bad, ‘the doctor at XYZ, told me that ABC was going to happen’.

So before you start a conversation, take a ‘difficult conversation moment’.

Check your internal barometer and know your limits

We’re all human. It’s important to gauge how you are feeling – this enables self-compassion and resilience.

For example, are you having a good day (8/10) or rubbish day (2/10)?

What do you feel like after the difficult conversation? (Rate again)

Be honest

Acknowledge that what you may find difficult to say, your patient may not find difficult to hear. Even if they do, they are often grateful for your honesty.

What’s the difficult part?

Try and pinpoint exactly what the challenge is for you – is it lack of knowledge, lack of confidence or that it reminds you of something personally?

Consider a Communication Framework

We use SCARS in our training which I find is a helpful structure. When used regularly, this becomes second nature.

Plan your conversation and ask the patient

‘Ask’ is a key part of SCARS. Ask what the patient’s understanding is and find out what is important to them. Ask if they would like someone to be present. Consider cultural, psychosexual and religious/spiritual needs and wishes.

It can be easy to make assumptions – listening is different to waiting to speak!

Awareness

Understand where patients and those important to them need support and guidance.

Have conversations in stages at the person’s individual pace. There’s a lot for people to process when they are hearing ‘bad news’ and this can take time.

Know the legal process: consent, capacity and legal documentation

For everyone’s safety: document, document, document!

Partner

If for whatever reason you’re not able to have the difficult conversation, ensure that you hand the responsibility over to a person who can.

Work in partnership with and signpost to your MDT and other services.

Timing

If a person is not ready to have a difficult conversation, acknowledge this and ask if it would be okay to come back to the conversation another time.

The compassionate organisation

Encourage compassionate conversations within your work place – working within a compassionate organisation with supportive networks really will help to build your own resilience.

As mentioned in the Talking about end of life care: communication film above, when a birth is expected there’s a lot of planning, discussing and preparing for what’s to come, but when it comes to dying the opposite is too often true and this leaves people feeling vulnerable and unprepared.

Effective communication is fundamental to understanding people’s needs and helping patients to make choices, decisions and plans at the end of their life. This should be looked upon as an essential treatment that you can offer to a patient, as well as helping support those close to them through bereavement.

Having the confidence, knowledge, skills and internal resilience to facilitate that treatment are important enablers that should not be overlooked. Please get in touch with Difficult Conversations  if you would like to find out more.

Footnotes

1. Mullick A. Martin K. Sallnow L. An introduction to advance care planning in practice BMJ 2013; 347:f6064

C Millington Sanders

 

Dr Catherine Millington Sanders, GP, RCGP and Marie Curie National Clinical End of Life Care Champion and co-developer of Difficult Conversations training programme

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