A major source of stress for oncology nurses revolves around discussions related to palliative and end-of-life needs and care planning.
We often focus on the timing of these discussions, being troubled about the appropriateness of these conversations and if patients and families are ready to hear them. But also knowing what to say and how to say it are equally compelling skills to consider. Having effective conversations can help mobilize hospice referrals earlier than the existing national norm (i.e., many referrals occur very late in the illness course with patients benefitting from hospice care for merely weeks).2
A wonderful resource in this regard is an article by Shin and Casarett1 who suggest useful language for hospice discussions within multiple domains. Below, you'll find examples from five of these important categories, which I have edited with relevance to oncology nurses' conversations.
Identify and invite critical members of the patient's support network and other decision makers:
- "Who do you usually rely on to help you make important decisions?"
- "When you discuss the results of your recent tests with the oncologist, who do you want to be present?"
Assess understanding of prognosis:
- "Tell me your understanding of where things stand with your cancer."
- "Can you share with me what you think will be happening to you in the near future/coming months?"
Identify goals of care:
- "What are your biggest concerns right now?"
- "What are you worried most about now? In the future?"
Identify needs for care:
- "What is a usual day for you now at home? How are you and your family managing?"
- "What has been hardest for you and your family?"
- "The hospice team specializes in caring for seriously ill patients at home."
- "Hospice can provide you and your family with more services and support."
Being sensitive to body language (i.e., making eye contact and being physically present) and tone of voice are critical elements of conversation. Touch is an important measure of support during these sensitive conversations, and the use of pause in one's dialogue is key. Listening to cues that impact the patient or family caregiver's interest and willingness to pursue discourse is paramount. While these skills are rarely taught to us in our basic and continuing educational offerings, they are instrumental in our competency to address the myriad concerns our patients and their families face at the end of life.
- Shin J &Casarett D (2011). Facilitating hospice discussions: A six-step roadmap. Journal of Supportive Oncology, 9(3): 97-102.
- National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America.www.nhpco.org/files/public/statistics, accessed 2/18/2013.