That’s a Good Question!!
Making ‘difficult
conversations’ easier
Presentation by Elizabeth Causton MSW
Three characteristics that (almost) all
‘difficult conversations’ share and two
common responses by healthcare workers
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There is emotional content
The ‘news’ is unexpected
The ‘news’ is hard to hear (may even be
unacceptable)
Common responses are ‘avoidance’ and ‘passing
the buck’
However, when having difficult
conversations is accepted as a natural
and inevitable part of our work,then we
can begin to explore our role in making
them easier, both for ourselves and for
the patients and families we work with
The ‘foreign land’ that is
healthcare
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Inherent hierarchy
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compounded by hero /victim medical model
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Continuous process of separation
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Problem-focused / solution based orientation
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compounded by fear of failure
Technical jargon
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compounded by ‘secret’ handwriting (?)
A lack of consistency and clarity
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Creates anxiety and confusion, often
expressed as anger
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Can destroy trust in the entire team
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Often results in families being unfairly
labelled as ‘difficult’
Unrealistic expectations and
faulty beliefs, such as….
“In family meetings everyone hears
(or should hear) the same thing and you should
only have to say it once”
 “Success is achieved when you are delivering
bad news when no one cries and there are no
questions”
 “Giving bad news is like admitting failure and
should be avoided for as long as possible”
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More of those faulty beliefs and
expectations…
“Patients need to hear the whole truth
whether they are ready for it or not”
 “Patients need to be given information in
small doses because they can’t handle
knowing everything at once”
 “It is better to say something you’re not
sure of than to say, ‘I don’t know’”
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Lack of planning
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Usually caused by avoiding ‘difficult’
conversations / topics until there is no
escape
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‘Unexpected news’ is often NOT
unexpected to the healthcare team
How do these 4 factors prevent patients and
families from participating in ‘difficult
conversations’ in an effective way?
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they may feel fragmented, uncertain, fearful,
and stressed…
and therefore find it difficult to focus in order to
understand and integrate new information
they may be wary of who to trust and therefore
quick to question or challenge difficult
information…
or they may be silenced by a fear of being
judged for asking a ‘stupid’ or improper question
and so fail to clarify what they think they are
hearing
Plan ahead, plan ahead, plan
ahead
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Anticipate changes that are likely to happen
and/or that are common in the dying process
Talking about difficult topics before there’s a
crisis is the single most effective way to make
‘difficult’ conversations easier
Give ongoing, accurate information with
compassion
Be prepared to answer difficult questions…they
are inevitable!
What do I need to ask and
what do I need to understand?
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“How do you like to receive information?” (in
this context?)
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“What do you hope for?” “What do you fear?”
“What is most important to you right now?”
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“What changes have you seen in your loved
one’s condition in the last week or so?” “What
you think they mean?”
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“I know you’ve said that you don’t want to talk
about death and dying at this point in your
wife’s illness, but are there any circumstances
under which you would want to have a
conversation about that?”
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“Is there anything that you would be doing
differently right now if you knew that your wife’s
condition was changing faster than you had
perhaps hoped it would?”
Be prepared for emotional
content…it’s normal
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Choose a private place and give people time
and permission to express their emotions
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Use language that is clear without being blunt
and compassionate without being vague; then
ask, “what is your understanding of what I just
said?”
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Consider taking a colleague with you to get
support for yourself,so that you can be more
supportive to the patient / family
Be consistent as a team
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Before you talk to families, talk to each other!
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Chart and read what is charted about the
patient and family’s hopes, expectations, fears,
previous experience with the system,as well
what they have already been told
Consider developing a Question
Prompt Sheet (QPS)
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Read “What questions do family caregivers want to
discuss with healthcare providers in order to prepare for
the death of a loved one?” Hebert, R. Journal of
Palliative Medicine 11(3) 2008.
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Such a list gives patients and families permission to ask
questions about sensitive topics taking into account
their specific needs for information; their sense of
timing; and their preferred style of receiving information
while helping them anticipate upcoming changes
Know thyself
Without ongoing self-reflection, difficult
conversations too often become about us.
Then we communicate to protect ourselves from
pain. We share information the way that we
would want to receive it. We avoid or discount
emotions that we don’t accept in ourselves.
And we may further complicate the situation by
not sharing the burdens and responsibilities of
our work with colleagues because of our own
discomfort with receiving support.