Difficult Communication in
Oncology Nursing
Objectives
• Describe the purpose and process of
communication in oncology nursing.
• Describe strategies for responding to at least
three difficult communication scenarios in
oncology nursing.
Why Is Communication Important
in Cancer Care?
• 2001 Institute of Medicine (IOM) Crossing the
Quality Chasm report
• 2011 Patient-Centered Cancer Treatment
Planning: Improving the Quality of Oncology
Care: Workshop Summary
• 2013 IOM Delivering Affordable Cancer Care in
21st Century Report
Nurse Communication and Quality
• Nurse-patient communication strongly
influences patient satisfaction, outcomes and
costs of care.
(Press Ganey Associates, 2013)
Communication in Palliative Care
• National Consensus Project for Quality Palliative
Care (2013) emphasizes importance of
communication in all aspects of care:
o Structure and processes of care
o Aspects of care:
 Physical
 Psychological and psychiatric
 Social
 Spiritual, religious, and existential
 Cultural
o Care of patient at end of life
o Ethical and legal aspects of care
Communication in Nursing
• Multiple components
• Communication is the foundation of the nursepatient relationship.
o Knowing the patient as person
o Assessment of symptoms, understanding of illness,
goals, values, beliefs
o Patient and Family Education
o Offering psycho-social-spiritual support
o Assisting with decision making
• Advocating for patient.
• Collaborating with the interdisciplinary team.
(Wittenberg-Lyles, Goldsmith, Ferrell & Ragan, 2013; Dahlin, 2010)
Learning Activity
What is Communication?
• Communication: process of mutual influence that
is ongoing and dynamic.
• Purpose is to impart:
o Information
o Affect
• All communication occurs in relationship to other
person(s).
• Communication occurs verbally and non verbally.
(Wittenberg-Lyles, Goldsmith, Ferrell & Ragan, 2013; Grover, 2005)
Levels of Communication
• Task
o The content of the message.
o Often verbal (includes written).
o Examples: assessing, teaching, supporting
• Relational
o Interpretation of message.
o How the message and its delivery influenced
/impressed by the other.
o Often construed from nonverbal message.
(Wittenberg-Lyles, Goldsmith, Ferrell & Ragan, 2013)
Nonverbal Communication
• Consider role of culture and context.
• Body movement, gestures, eye contact,
position.
• Use of touch.
• Space and distance “personal space.”
• Appearance: grooming, clothing, accessories.
• Tone of voice, volume, pitch, rate of speech, use
of pauses and silence.
• Time perception.
• Attentiveness to verbal and non verbal
message.
Communication Axioms
• One cannot “not communicate.”
• Communication occurs on two levels.
• Nonverbal communication is most powerful.
• Congruence between verbal and non-verbal
message enhances credibility.
(Wittenberg-Lyles, Goldsmith, Ferrell, & Ragan, 2013; Grover, 2005)
Communication Needs: Patient
and Family
Patients
• Need for information
• Disclose feelings
• Maintain / create
o Sense of control
o Meaning / hope
o Purpose
Family / significant
other
• Information
• Permission to speak
• To be listened to
(Dahlin, 2010)
Influenced by context, culture, past experience, and trust
Communication Barriers: Nurse
• Failure to listen
• Failure to address
concern of the
other
• Incongruence
• Parroting
• Being judgmental
• False reassurance
• Offering advice
• Changing the
subject
• Defending
• Rote responses
• Patronizing
• Distancing
• Role / scope of
practice
• Lack of time
Communication Barriers: Family /
Caregivers
• Belief that nothing
will help
• Not wanting to
burden / distract
the nurse / doctor
• Not wanting to be /
appear weak
• Not a legitimate
concern
• Not wanting the
information
• Responding to
provider message to
not address topic
• Denial of
seriousness of
diagnosis
• Culture
Therapeutic Communication
Techniques
• Listening
• Silence
• Open ended
questions
• Acknowledgement
• Restating
• Reflecting
•
•
•
•
•
Clarifying
Validating
Focusing
Summarizing
Planning
Non-therapeutic Communication
Techniques
• Not listening
• Failure to probe
• Closed Ended
Questions
• Parroting
• Being judgmental
• Ignoring comments or
affect
•
•
•
•
•
•
Reassuring
Rejecting
Defending
Patronizing
Giving advice
Changing topics
New Communication Concepts in
Nursing Practice
• Emotional Intelligence
o The ability to correctly identify emotions in others and
self, use emotions in reasoning, and understand
emotions and manage them.
• Motivational Interviewing
o Helpful in settings of ambivalence and resistance.
o The focus on understanding the patient’s motivation of
a behavior/decision and supporting self efficacy.
(Codier, Muneno, & Freitas, 2011; Pollak, Childers, & Arnold, 2011)
Motivational Interviewing
• Basic tenets
o Resist the righting reflex
o Be curious about the patient’s motivations and
experiences.
o Listen.
o Empower the patient.
o Use open ended questions, affirmations, reflections
and summary.
o Allow patients to talk as much as the clinician.
o Use reflective statements.
o Provide advice or guidance only after asking
permission.
(Pollak, Childers, & Arnold, 2011)
COMFORT Initiative
• Nurse communication curriculum for early
palliative care integration in oncology
o Based in narrative nursing practice
o Patient and family centered
o Adaptive communication among health care team
including patient and family
(Wittenberg-Lyles, Goldsmith,
Ferrell, & Ragan, 2013)
Axioms of COMFORT
(ClinicalCC, 2013)
What Makes some Conversations
Difficult
• Disagreement about
“facts”
o Uncertainty
o Lack of clear
information
o Inconsistent
information
o Failure to have a plan
• Timing
• Our own emotions
o Feeling awkward and
vulnerable
o Lack of preparation
o Feelings of guilt or
failure
o Fear of consequences
(Sheldon, Barrett, & Ellington, 2006; Davis, Krisjanson, & Blight, 2003;
Stone, Patton, & Heen, 1999)
Nurses’ Role in Difficult
Conversations
• American Nursing Association (ANA)
Position Statements
o Nursing Care and Do Not Resuscitate and
Allow a Natural Death Decisions (2012)
o Registered Nurses’ Roles and
Responsibilities in Providing Expert Care and
Counseling at the End of Life (2010)
Common Difficult Nurse:Patient
Conversations in Oncology
• Information regarding cancer diagnosis and
cancer therapies.
• Supporting patients who received bad news.
• Advance Care Planning and clarifying goals of
care.
More Common Difficult Nurse:
Patient Conversations
• Answering difficult questions:
o “Will this treatment work?”
o “Will this cure me?”
o “Am I dying?”
• Coping with intense emotions
• Offering psychological and spiritual support
• Conflict
Patient and Family Expectations
• You will be honest and truthful.
• You will not abandon them.
• You will elicit and request their values/goals and
will help as much as is possible to achieve these.
• You will assist them to explore their realistic
options
• You will work with the entire interdisciplinary team
to assure consistency in plan of care
• You will LISTEN!
(Dahlin, 2010)
Listening and Presence
• Listening and being present are key elements to
effective communication.
• Both require focus and energy.
• Listening requires hearing, understanding,
analyzing, reflecting and summarizing to affirm
that you have heard correctly.
• Presence requires being available physically,
emotionally and intellectually.
Listening Exercise
General Approach to Difficult
Conversations
• Listen
• Establish trust
• Ask – Tell – Ask
• Plan for follow up discussion or action
(Baer & Weinstein, 2013; Back, Arnold, Baile, Tulsky, & Fyer-Edwards, 2005)
Information Sharing and
Breaking Bad News
Setting
• Nurse – patient communication may be a formal
interview but is more often is informal as other
care is provided.
• When possible, assure:
o Time to offer attention to patient and family
o Privacy
o Invite other members of IDT to participate
Assessment of Information Needs
• How much information is needed / wanted?
• Who or who else should have the information?
• Establish what is known or suspected.
Sharing Information
• Align with patient.
• Avoid jargon, abbreviations.
• Give information in small amounts with frequent
pauses to allow for questions/ clarifications.
• If delivering or reaffirming bad news, give a
warning.
• Allow time for patient and family to process the
news/ information.
• Elicit and answer additional questions.
Acknowledging the Feelings
• Information about disease, symptoms and
treatment may elicit both positive and negative
emotions.
o Watch body language, facial expressions
o Ask about feelings
• Acknowledge and validate feelings.
o Numbness, sadness, anxiety, anger, fear are common
reactions
o Name the obvious
Make a Plan
• Having a specific plan helps alleviate uncertainty.
• Provide any written information that may be
needed.
• Provide interim contact information.
Advanced Care Planning
(ACP)
Advanced Care Planning (ACP)
• ACP discussion benefits for patients with a
terminal illness and life expectancy of ≤ 1 year:
o Does not shorten survival rather improves
survival
o Lower rates of ICU admission
o Improved quality of life with earlier enrollment
and longer stay in Hospice
o Lower health care costs in last week of life
(IOM, 2011; Chung et al., 2009;
Wright et al., 2008; Ganti et al., 2007; Weeks et al., 1998)
Advanced Care Planning (ACP)
• Discussions with patients to elicit their values,
preferences, concerns that form decision
making for health care and end of life care.
o Process, not an event
o Decisions may change over time
o Ambiguity and inconsistency common
• Increases patient–family satisfaction; decreases
family distress; improves patient-family –provider
communication.
(Waldrop & Meeker, 2012; Dahlin, 2010)
What is Important about ACP
• Allows the patient to state their wishes.
• Empowers patients with some control in disease
management and end of life planning.
• Promotes trust.
• Normalizes the discussion of end of life planning
and allows ACP to be seen as ordinary like any
other treatment discussion.
• Relieves the surrogate decision maker of the
burden of making difficult decisions.
ACP Discussions in Oncology
• Only 30-40 % of oncology patients have had
ACP discussion with providers.
• Many patients admitted to hospital have never
had ACP discussions.
(Cohen & Nirenberg, 2011)
ACP Documentation
• Includes the following:
o Living wills
o Medical Orders for Life Sustaining Treatment
(MOLST)
o Orders for Do Not Resuscitate (DNR), Do Not Attempt
Resuscitation (DNAR) or No Code for both the
hospital and out of hospital settings
o Do Not Intubate (DNI)
o Health Care Power of Attorney / Surrogate health care
decision makers / Proxy
Why is ACP so hard?
• Sensitive topic
o Hard to ask the questions and raise issue
• Finding appropriate language
• Concern that patient will misinterpret intention of
the discussion
o New diagnosis
o Prognosis
• Fear of frightening patients
• Time
• Timing
(Smith et al,, 2010; Temel et al., 2010; Panagopoulou, 2008;
Wright et al., 2008; Connor, 2007; Matsuymam, Reddy, & Smith, 2006; )
Challenges for Providers
• Little education and training in End of Life Care
• Concerns that ACP could lead to futile treatments
or encourage use life sustaining therapies
whether appropriate or not
• Fear of litigation
• Lack of time to get to know patients and families
• No knowledge about previous discussions of
wishes, preferences, and goals of care
• Lack of documentation of important
conversations
• Expectation of outcomes of the conversation
Challenges for Patients
• Often patient wishes are unknown or not
honored.
• May feel pressured to receive therapies they
don’t want.
• Fear of abandonment.
• Don’t know they can decline treatment in any
setting.
• Don’t know about options such as home
services.
• Have poor insurance coverage for palliative /
end of life care.
(Cohen & Nirenberg, 2011)
Ethical Considerations for ACP
• Respect for persons
• Advocacy
• Veracity
• Decision Making
o Capacity
o Substituted judgment
o Best Interest
Nursing’s Ethical Obligations for
ACP
• Code of Ethics
• Professional Organizations
o American Nurses Association
o Hospice and Palliative Care Nursing
o Oncology Nursing Society
Values
• What does the person hold dear in life?
• What is their definition of quality of life?
• What gives them strength?
Beliefs
• What is person’s meaning of life?
• What is person’s religion?
• Is the person spiritual?
• What are the person’s thoughts
on the afterlife?
Preferences for Care
• What are goals of care?
• Will use of life-sustaining treatments assist in
achieving goals?
• Where does patient want care if dying?
When to Initiate Discussion
• Routinely
o
o
o
o
When you first meet patient
Discussion regarding diagnosis and treatment
When a poor prognosis is being presented
Non-urgent treatment decisions
• Urgent
o When there are difficult decisions to make
o When there is an unexpected change in clinical
condition
• When the patient asks for it
Starting the Conversation
• “Have you thought about:
o if things don’t go well?”
o the extent of treatment you would want?”
o who would make decisions for you in the case you
could not make them?”
o how you would guide them in the decisions?”
o what you would want if your disease became more
advanced?”
Hope for the Best; Plan for the
Worst
• Hope is a multifaceted construct; no universal
definition.
• Hope as a belief, desire, expectation, or wish for
positive future occurrence or outcome.
• Clarifying hopes for outcomes is part of ACP as is
reframing hope.
o “What are you hoping will happen?”
o “If that is not possible, what else would you hope for?”
(Cooper, 2006; Back, Arnold & Quill, 2003)
Eliciting Goals with Families
• “What do you imagine [the patient] would have
done or wanted in this situation?”
• “Given what’s gone on, what are your hopes for
[the patient] the future?”
• “Can you please help me to understand what I
need to know about [the patient’s] beliefs and
practices to take the best care of [the patient]?”
(End of Life Nursing Education Consortium, 2013)
Achieving Common Understanding
• Use summary statements. Consider decisions
for “therapeutic trial” or as needing only
family assent.
• Check for understanding of the decisions
made.
• Seek consensus on the decision or on the
need for more information.
(End of Life Nursing Education Consortium, 2013)
Responding to Difficult Questions
• Common difficult questions are:
o “Am I dying?”
o “Is the cancer worse?”
o “Will you help me die?”
• All raise emotional and ethical issues for the
nurse.
o Best response is often exploration of the question.
o Builds nurse-patient relationship through trust and
veracity.
Responding to Difficult Questions
• Acknowledge the question.
o “That is not a simple question. I will do my best to
answer.”
o “That is not a simple question. I am wondering what
brought it up now?”
• Explore the underlying concern.
o Understanding of disease status.
o Psychosocial – Spiritual concerns: anxiety,
depression, hopelessness, suicidal Ideation.
Continuing the Response
• Provide information and support.
o Do not be afraid to say, “I do not know but I will try to
find out.”
o Do not make promises that you cannot keep.
o Involve the interdisciplinary team.
Responding to Strong Emotions
• Name the emotion
• Explore the emotion
• Validate the emotional response
• Offer support
Conflict Negotiation
• Goal: Arrive at shared perspective or goal.
• In patient care, the wishes and best interests of
the patient take precedent.
• A “learning stance” may be helpful
o “Help me understand your position, concerns,
emotions, motivations.”
o Clarification often eases the conflict.
Steps in Conflict Negotiation
• Identify the conflict
• Weigh the benefit / burden in addressing it
o What is at stake?
• Address the conflict
• Identify goal of resolving the conflict
o Focus on facts not emotions
• Explore the conflict
o Learning stance with each party stating their
perspective and understanding
• Problem Solve
(Kendall & Arnold, 2009)
Summary
• Communication is fundamental to nursing
practice.
o Establishing and continuing the nurse-patient
relationship
o Patient and Family Education
o Assessment
o Collaboration
• Effective communication requires listening and
presence.
• Use techniques to assist in difficult conversations.
References
• Full list of references included with your
handouts
Special Thanks: Authors
Connie Dahlin APRN-BC, ACHPN,
FAAN, FPCN
Palliative Care Nurse Practitioner – North Shore Medical Center
Boston, MA
and
Maureen Lynch APN-BC, AOCN®,
ACHPN, FPCN
Nurse Practitioner – Dana Farber Cancer Center
Boston, MA
Special Thanks: Expert Reviewer
Debra Heidrich MSN, RN, ACHPN,
AOCN®
Nurse Consultant
West Chester, OH