How health professionals need to discuss end of life situations – during coronavirus and beyond
The coronavirus pandemic has led to many difficult and urgent conversations taking place in hospitals. There will doubtless be many more. Over the last few days, I’ve been drawing together advice about discussing sensitive and distressing topics based on evidence from my own work and from work by other researchers who study real life examples of these kinds of exchanges.
I have shared this advice with UK palliative care experts who are producing COVID-19 specific guidance for the NHS. That guidance will combine clinical wisdom and research in order to help healthcare staff who will have to have many difficult conversations in the coming weeks and months.
Researchers like me analyse human interaction – how it is structured, and how it functions. This means that besides giving evidence-based advice on difficult conversations relating to coronavirus, we can also provide some general lessons about how phrases work (and fail).
Even with evidence-based advice on which phrases to use in difficult conversations, it is important to remember the importance of context and nuance. For example, one phrase currently recommended by many in the field of healthcare for when the medical judgement is that someone’s death is imminent is: “sick enough to die”.
But it’s one thing to read a “key phrase” in published guidance, and quite another to say or hear it in an actual conversation. However appropriate the phrase looks on the page or screen, it might fail utterly when spoken out loud.
This is because how a phrase is understood depends crucially on when it is said. A written down phrase can stand alone – a spoken phrase never does. We understand spoken words and phrases in context. Our words will inevitably be heard in the light of what has come beforehand within a conversation, and in the light of the broader circumstances.
So the phrase “sick enough to die” will be heard and understood very differently if uttered as part of a conversation between a doctor and an acutely unwell patient (or their family member), than if yelled down the phone when a first responder at an accident is trying to persuade the emergency services to dispatch an air ambulance.
Even within the conversation between doctor and patient, precisely when the doctor says “sick enough to die” will shape how it is heard and responded to.
For instance, issued at the start of a conversation without a lead-up, it may well be heard as shocking, blunt and cruel. Alternatively, the ground can be prepared – briefly if necessary – with the doctor first seeking the patient or family member’s understanding of the situation. Once they seem to have recognised the gravity of the situation, “sick enough to die” could then work to confirm and support, rather than shock.
A common way to prepare the ground is sometimes called “forecasting”. It involves moving step by step towards the conclusion, explaining signs and symptoms in a way that gently and gradually instils a recognition and understanding of the graveness of the situation.
Such forecasting may be particularly helpful in a situation where one suspects the news might come as a shock. So if planning to use a phrase, you should also work to guide the conversation towards the right place for it.
How we preface a phrase is also key to how it will be understood. A phrase like “sick enough to die” can be preceded by words like “I think …”, “Sadly …”, “Unfortunately …”, and so on. These words add nuance, meaning and sensitivity to what is being said. As such, they are really important in getting over what we want to get over when we deploy a key phrase.
What hides behind our words
What we say to one another does much more than transmitting and receiving information. It is important to be aware that we generally do several things at once when we say something. For instance, with a soft tone and a preface such as “I am so sorry but …”, the “sick enough to die” phrase can convey emotion, care and sensitivity as well.
Even more subtle actions go on, too. When a professional uses the phrase, they are likely to be understood as conveying not only information but also their medical expertise and experience. Depending on what comes before and after, the phrase itself will often form one part of a bigger communicative task, such as deciding whether or not ventilation should be started or stopped for someone.
So when we think about key phrases, it is important that our focus on getting the composition right does not blind us to these other important issues. We need to consider where we put that phrase within the overall conversation and within a particular sentence. If healthcare professionals think wisely and use key phrases carefully, they will hopefully achieve what they intend by saying them.
Ruth Parry receives funding from the National Institute for Health Research Academy Career Development Fellowship "Enhancing staff-patient communication in palliative and end of life care" Grant Reference Number CDF-2014-07-046. The views
expressed are those of the author and not necessarily those of the NIHR or the Department of Health and Social Care.