Use This Guide to Navigate Difficult Conversations
By Megha Shah, BSN, RN, OCN®
“I don’t want to die.” “What is my prognosis?” “Is this a death sentence?”
As oncology nurses, heart-wrenching questions like these are part of our day-to-day work. So how do we address patient concerns in a compassionate yet professional way? How do we respond to a patient with stage IV cancer who exclaims they only have two more cycles of treatment until they’re cured? How do we explain to patients with cancer that their journey is not short term?
During my decade as an oncology nurse, other healthcare providers have taught me what helps to initiate those difficult conversations. I’ve gained insight into maintaining conversations and learned when it’s best to pause and when it’s best to restart.
I’ve found that the most effective approach to initiating a difficult conversation is to ask patients about their understanding of their disease. Another ice breaker that almost always works for me is asking patients what their oncologist has told them about their disease. Many times, patients don’t have a solid understanding of their disease or prognosis. Starting the conversation in this way gives us the crucial opportunity to calmly explain what a diagnosis means and the curative nature of their disease.
Remember, patients are people, and people respond to news in all sorts of ways. Throughout my career, I’ve encountered patients who simply don’t want to continue these conversations. However, they still need to identify and understand their goals for treatment. Ultimately, this allows us to better assist with planning for end of life.
I usually ask patients to “tell me more.” Asking the patient what they expect from treatment usually results in one of two responses: prolonged life no matter the quality, or quality life no matter the length.
Yes, the ideal is a prolonged, healthy life, but that is seldom the option or outcome during conversations in the final stages of a disease. Patients also need to know how to get their necessary documents in order, such as a medical power of attorney (https://www.webmd.com/palliative-care/advance-directives-medical-power-attorney#1) or a Physician Orders for Life-Sustaining Treatment form (https://polst.org/).
I’ve learned that patients find comfort in knowing I have both of my own forms in a safe place and my power of attorney knows where those forms are. It reminds patients they aren’t alone in this journey.
This is usually a good point in the conversation to pause and give patients some to absorb the information. These are important decisions, and patients have a right to work through them at their own pace.
Remember to always revisit the topic and ask patients if they have any questions or concerns about the conversations . If patients need clarification, connect them to the appropriate agency or discipline.
If a patient initiates a conversation when I am in the middle of providing care to other patients, I always make sure to circle back and address the topic before they leave. I also make sure to involve the patient’s caregivers.
Some tips for theses intimate moments are to sit at a patient’s eye level, have a box of tissues ready, have pens and paper handy so patients and caregivers can jot down information, and have a drink ready for them.
I would love to hear how other oncology nurses approach these and other difficult conversations with patients. Feel free to send your strategies to me at TheOncologyNurse@gmail.com (mailto:TheOncologyNurse@gmail.com).