Dialogue – how to approach the subject of death in a sensitive way

Introduction to the topic

When you are part of an end-of-life patient’s care team, helping the patient to talk about death and dying is an important part of your role. You will want to present it in a positive manner; but this can be challenging when the likelihood is that the patient will not get better. There are several strategies that can help.

There is a growing literature base made up of blogs, video diaries, and books created in recent years which demonstrates the strong interest among people who are suffering from a chronic or terminal illness for open and honest conversations about death and dying. It is vital that the teams who are involved in end-of-life care need to be proactive in shaping these conversations.

One of the most important requirements of end-of-life care is holding conversations. This applies to all stakeholders involved in the process: relatives, carers, or professionals. It is important that these conversations are open and honest and focused on helping patients to express their desires, feelings, fears, and wishes. This means avoiding a natural inclination to obfuscate the reality of dying and death to the patient but at the same time approaching this with sensitivity.

In one of the earlier guides published on end-of-life care, Dr. Derek Doyle, a founding member of the International Association for Hospice and Palliative Care, writes that “each person, patient or carer, should have information given at the time and in the detail when it seems right for them. He adds: “It is certainly wrong to withhold vital information. It can be equally wrong and damaging to try to give too much at the wrong time or in the wrong way.”

Everybody in their last months or years of life should have the opportunity for honest, sensitive, and well-informed conversations about end-of-life care. The person at the end of life, and those close to them, should be at the center of all decisions.

Key points

Personalized end-of-life care requires conversations that focus on what matters to the individual patient and should include those close to them. Healthcare professionals need to look for opportunities to initiate conversations and conduct them in a way that best supports people to make difficult decisions. A key part of this is to explore options and not make direct recommendations which ensures that patients, their carers, and relatives have informed agency on end-of-life care decisions.

Even for an experienced palliative care doctor, recognizing and weighing up factors that may indicate someone is in their last days or hours of life is challenging and complex. As soon as it is recognized that a person may be entering the last days of life, the most appropriate team member should discuss this with the person and those important to them, unless they do not wish to be told.

Care should be taken with communication when a person is entering the last days of life. There are many examples of poor communication approaches where euphemisms are used such as ‘making them comfortable’. Not communicating correctly at the end can lead to misunderstandings and unnecessary distress in people who are dying and those important to them.

Summary

Having a dialogue about the subject of death in a sensitive way requires careful consideration of both verbal and non-verbal communication cues. Here is how healthcare professionals can approach this difficult situation.

Before initiating a conversation about death, assess the patients’ and relatives’ readiness to discuss the topic. Respect their pace and readiness to engage in the dialogue.
Use clear and compassionate language when discussing death. Avoid euphemisms or medical jargon that may confuse or distance the patient and their family from the conversation.
Be honest about the patients’ prognosis and what to expect in terms of end-of-life care. Provide information in a straightforward manner while remaining sensitive to the emotional impact of the conversation.
Encourage the patient and their family to ask questions and express their concerns. Create an open dialogue where they feel heard and supported in their journey.
Explore the patient's values, beliefs, and preferences regarding end-of-life care. Discuss their goals, wishes, and priorities to ensure that their care aligns with their values and preferences.
Provide emotional support and offer resources such as palliative care services, hospice care, counseling, and spiritual guidance. Help the patient and their family access the support they need to cope with the emotional and practical aspects of end-of-life care.
Respect the patient's cultural and spiritual beliefs regarding death and dying. Tailor the conversation to accommodate their cultural practices and beliefs and provide information on the offer of spiritual support as needed.
Validate the patient's and their family's emotions and responses to the conversation. Normalize the range of emotions they may experience, including sadness, fear, anger, and grief.

Discover More

Links

Some health and care professionals are uncomfortable discussing how long someone has left to live. One needs the skills and confidence to give difficult news or talk about the dying process. You can find relevant training on how to communicate sensitively and effectively here.

Healthcare professionals caring for end-of-life patients need to take into consideration the person’s current mental health capacity to communicate and actively participate in their end-of-life care. For more information see NICE's information on making decisions about your care.

There is growing recognition that a diverse range of healthcare professionals need competence in palliative approaches to care. Effective communication is a core component of such practice. This article informs evidence-based communication about illness progression and end of life through a rapid review of studies that directly observe how experienced clinicians manage such discussions. Communicating with patients and families about illness progression and end of life: a review of studies using direct observation of clinical practice | BMC Palliative Care | Full Text.

Videos

What is good communication in end-of-life care? The video shows doctors, patients, family members and carers to share their views and experiences.