Improving Communication Skills in End of Life Care

This essay reflects on the author's experience in end of life care and the need to improve communication skills when delivering news to patients and their families. It discusses the importance of effective communication in palliative care and critiques two research papers on the topic. The essay also explores the challenges faced by caregivers and the benefits of using the Carer Support Needs Assessment Tool (CSNAT) in discharge planning. Overall, it emphasizes the significance of compassionate communication in providing patient-centered care.

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Introduction
End of life care also known as palliative care is provided to patients who are terminally ill
and cannot recover from their condition. Practitioners caring for palliative care patients require
effective communication and compassionate skills due to the sensitive nature of conversations
with families, carers, patients and the emotional side of the matter (Shapiro, 2011). Lack of good
communication between healthcare professionals, patients’ carers and families is the
contributory factor in number of complaints across many National Health Trusts in the United
Kingdom (Parliamentary and Health Service Ombudsman, 2015).
Terminally ill patients receive holistic care which involves spiritual, social and emotional
support to the patient and includes fulfilling the patients’ wishes of patients which helps them to
die peacefully (Deo & Thejus, 2013). Delivering bad news to a patient or a family member at the
end of life care can be challenging for caregivers and requires skills (Arnold & Boggs, 2015). In
my professional practice, I have come across many patients on end of life care whilst on my
clinical placements and I struggled to effectively communicate with the patient or a family
member.
This paper will aim to reflect on one of my special learning needs - “improve my
communication skills and confidence when delivering news to patient at end of life care”.
The author of this essay will use “Gibb’s reflective cycle” to reflect on personal experiences in a
structured way. This model of reflection is preferred over others as it is easy and straightforward.
This essay will also provide a critique of two evidence based research papers in regards to the
importance of communication with the patient and the family at the end of palliative care.

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My Specific learning needs that needs to be developed
Description
In my academic career as a student nurse, all my clinical placements have been in
palliative care wards where I had the opportunity to provide care to patients who are terminally
ill. It came to my realization that I lacked confidence while communicating with palliative care
patients. It is nerve-wracking to disclose bad news to a patient, carer of family member due to
the emotional distress that follows. One such case is when I encountered an 85 year old patient
who was suffering from progressive dementia. I was given the responsibility to inform the
patient and his family, that the pharmacological treatment was not effective hence it was not
possible to cure his illness. Both the patient and his family were in extreme shock and disbelief
and accused me and the entire ward team for not taking care of the patient. The patient also
displayed extreme emotional distress due to the sudden revelation of this adverse news, that there
was no available treatment for his condition.
Feelings
I felt angry at myself for not seeking support of my peers, before I disclosed the news. I
felt pain for the patient and had a strong feeling that I lacked the skills required to disclose bad
news to the patients and hence forth I contacted with my peer nurses to get suggestions. I
challenged my own assumption that I was capable of communication bad news effectively and I
was determined to work on my communication skills. The accusation by the patient family that
we were not taking good care of the patient left me challenging my skills set and competencies
as a general student nurse. I felt that I did let the whole team down and I was worried that my
working relationship will damaged and I was worried that they might fail me. Looking back
now, I feel this episode helped me to understand my personal and professional strengths.

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Additionally, my mentor explained that many people learn by experience and this exposure gave
me some insight into the power of effective and compassionate communication.
Evaluation
The incident served to be quite demoralizing for me as it questioned my capability as a
student nurse and I have always tried to give my best, keeping the best interest of the patient, and
providing them with the best possible care. Looking back now, I have come to realisation that it
is normal for such reactions when sad news is delivered. I also acknowledged that I had the
opportunity to evaluate my skills and strengths after the episode and aim to refine my
interpersonal and communication skills in order to practice safely and effectively.
Analysis
I have always believed that effective communication is one of the fundamental
components of nursing while providing an end of life care. Some people might feel comfortable
talking about death but when taking care of the patient who is dying it is important to
communicate clearly and with compassion to open up conversations. Good communication skills
help the staffs to establish patients’ priorities and support them to make informed decisions (Deo
& Thejus, 2013). Effective communication helps the caregivers to explore any gaps in
understanding the situation that can assure the patient, families and alleviate their anxiety and
stresses.
I strongly believe that I have to work extensively to improve my communication skills
while delivering news to the patient in the end of life care. The action plan to improve this
specialization skill will be discussed in the later sections supported by literature. Although the

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challenges faced by the dying patient are potentially overwhelming, the end of life care several
challenges both clinical and ethical for the caregiver (Deo & Thejus, 2013)..
It has to be mentioned that patient suffering from terminal diseases experience pain often
drives the behaviour and also the fear of pain can lead to depression and suicidal behaviours
(Grande, Ewing & Sawatzky, 2012). Studies have revealed that more than 50% of the patients
suffering cancer have reported psychological disorders. One of the important challenges for
patients suffering from terminal illness is the difficulty in coping with the fact that death will be
imminent (Deo & Thejus, 2013). While some patients’ demonstrate practicality, optimism,
resourcefulness, flexibility and awareness, others may suffer from extreme emotional and
physical turmoil. A study consisting of 189 patients found that people suffering from cancer has
been linked with poor psychological adjustments (Mack et al., 2012).
Communicating with empathy and compassion is one of the important steps in the
provision of a patient-centred care. While communicating, it is necessary to document about the
type of care the patient wishes to or expects to receive(Grande, Ewing & Sawatzky, 2012).
Turner et al. (2011) stated that in the end of life care, small things matters, such as letting the
patient share private moments with their loved ones, conversing in a polite manner, exhibiting
kindness and empathy. There are likely to be sensitive conversations in the end of life care.
Critical analysis
A large number of authors have tried to find out the barriers and the facilitators of the end
of life practices. Gillett, O'Neill and Bloomfield, (2016) conducted a qualitative study in order to
explore the factors facilitating the development of the end of life communication skills by the
medical and the nursing students. The qualitative study consisted of five focus groups, consisting

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of second year undergraduate nursing students and fourth year undergraduate medical students
from a London University. As per the findings the facilitators and the barriers that influenced the
communication with the palliative care patients were identified to be a combination of intrinsic
as well as the extrinsic factors. The extrinsic barriers were found to be ‘gate keeping by the
qualified staff and lack of opportunities by the help of discussions.
Some of the intrinsic factors included not knowing what to say in case of extreme grief
and how to respond to the family’s grief. In most of the cases, the undergraduate inexperienced
nurses face real difficulties in dealing with their own emotions while facing distressing
situations, or death of a patient (Deo & Thejus, 2013). Some of the facilitating factors that have
been identified are previous experiences, good role models and classroom inputs. One of the
limitations of this study is the small sample size that cannot be generalised to the entire
population. Furthermore, the participants in this study were self-selecting, that is, they had
special interests in working in the palliative care sector, which might have influenced the results.
Informal caregivers usually face a huge burden while dealing with end of life care
information and it is the duty of the nurses to provide support to the family caregivers (Grande,
Ewing & Sawatzky, 2012)..
Another study by Grande et al. (2012) explored whether patients’ carers are supported
post patient discharge at the end of life care and whether they understand the benefits and
feasibility of using the Carer Support Needs Assessment Tool (CSNAT). The findings were that
the current barriers for supporting the carers at the time of hospital discharge were the focus of
the organisation based on the needs of the patient, the unrealistic expectation of the caregivers

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and lack of awareness of the patient (Mousing et al., 2016). However, the paper did not consider
the perception of the patients about the end of life care.
In relation to the paper by Ewing et al. (2018) and Van den Heuvel et al., (2016), the
findings informs us that patients are less likely to be ready for the end of life care than that of the
family care givers and hence it is necessary to communicate with the patients. The paper had
found that the family caregivers found to be more ready to talk about the end of life care with the
patient (Fried et al, 2010). The barriers that have been perceived for the unwillingness of the
patient to talk about the end of life care can be fear of death or they do not want to make plans
for the future. Family caregivers are more comfortable in making the future plans since it
prepares them for both the emotional and the physical support needed by their loved ones. This
can make them feel more confident in providing proper care to the dying patient (Barnes et al,
2012). It is evident from the paper by Mousing et al., (2016), that family care givers admitted
that they often do not get trusted physician to talk about end of life care for the patient. This can
be supported by the paper by (Van den Heuvel et al., (2016), where it is reported that patients
and the family caregivers prefer to have an end of life conversation with a known and a trusted
physician.
Furthermore, Ewing et al. (2018) study suggested the use of a new intervention tool
(CSNAT) for assessing the needs of the caregivers for a successful discharge planning in
palliative care. Slatore et al. (2013) have found that CSNAT is a useful tool for the carers within
the journey of the care giving. This tool can facilitate early resolution of the difficulties and it
potentially reduces the need for crisis management. According to Barnes et al. (2014) the
CSNAT directly asks carers about a set of 14 domains and directly assess the support needs of
the carers. Since the family caregivers play an important role in supporting the patients at home

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at the end of life, it is necessary to understand the domains of support associated with the
harmful effects from the care giving, where lack of support might bring about a great negative
effect. Grande, Ewing and Sawatzky, (2012) evaluated the importance of the 6 support domains
of CSNAT- strain, global health preparedness and distress. Lack of support has been made
through 14 domains. Again, Grande et al., (2017) tested the effect of the CSNAT tool on the
family carers, where a stepped wedged randomized control trial was conducted. Researchers
have found that low level of implementation and awareness about the needs of the carers about
the implementation of the CSNAT brought about better outcomes. It was found that the
intervention carers experienced lower level of grief, good physical and psychological status
(Grande et al., 2017).
However, the difference between the paper by Gillett et al., (2016) and Ewing et al.,
(2018) is that, the paper by Gillett et al., (2016), was more concerned with undergraduate nursing
students who face difficulties in communicating with the palliative care patients. Whereas the
paper by Ewing et al, (2018), solely concentrated on the use of a new intervention tool (CSNAT)
for assessing the needs of the caregivers for a successful discharge planning in palliative care. In
relation to this, Goelz et al., (2012), have stated that barriers like difference in culture, language,
culture and issues like confusion, deafness and other condition related issues can bring about
difficulties in the provision of care.
As discussed earlier, one of the main challenges faced by the caregivers is the way to
disclose bad news to the patients and the families. McLennon et al., (2013) stated that nurses
often face from ethical dilemma whether the truth should be revealed to the terminally ill patient
or to the family members only. Baer and Weinstein, (2013) argues that disclosure of sudden bad
news to the patients can be distressing and can even ruin the few left days of a patient’s life. And

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as per the ethical theory of nursing, non-maleficence –“patients should not be harmed in any way
and whatever that is sensed to be morally correct should be done”. Again nurses are always at
the forefront of the health care and should be committed to give truthful information to the
patients and support the patient and their families in line with standards set out by NMC
(Friedenberg et al., 2012).
However, special skills and steps should be maintained while disclosing information
about the end of life care to the patient or the families (Aslakson et al., 2016). Turner et al.,
(2011) have recommended a six step protocol for delivering news to the patients and the
families. The initial step is the setting up. The setting should call for privacy and comfort for
encouraging communication. The body language should include facing the patient, elimination
of the distractions and making eye contact and should be culturally appropriate for each of the
patients. Secondly, it is necessary to understand the perception of the patient (Hanratty et al.,
2013). It is necessary to listen to the way the patient describes the situation for identification of
the level of comprehension and the degree of denial (Arnold & Boggs, 2015).
Again, it is necessary to obtain the invitation from the patient. Unless the patient is ready
enough to receive the bad news one might not understand the complications and the serious
information (Grande, Ewing & Sawatzky, 2012). According to the Palliative care information
Act in the end of life care, information should only be disclosed to the patient only if the patient
is ready to receive it (Mack et al., 2012). It is necessary to observe the emotional responses of the
patients and then address them with the empathetic responses (Arnold & Boggs, 2015). Next it is
important to identify the responses of the patient and allow the time to show concern (Arnold &
Boggs, 2015). Baer & Weinstein, (2013) stated that majority of the health care professional opt
for the direct method of disclosure and only a minority of the caregivers prepare a scene for the

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news with a gradual build-up of the conversations. Sharing of the information in stages is likely
to make situations lighter for the patients. Baer and Weinstein, (2013) have argued that
sometimes there is lack of clarity and patients have complained that they never knew about their
conditions from the beginning. It is difficult for the nurses to assess which patients are mentally
stronger and resilient to bad news and a direct revelation of bad news might bring about greater
distress in some of the patients (Kumar, D'souza & Sisodia 2014).
Attempts to improve the practice
In order to develop my communication skills for communicating with the palliative care
patients, I will work on by inner beliefs and values that help me to uphold my noble job of
nursing. In compliance with the different codes of ethics, I possess much knowledge about the
various nursing standards yet I find that there is a gap left which is restricting me from providing
holistic palliative care.
Disclosure of end of life care can be done in both the direct and indirect way. At first I
should develop a clear knowledge about the appropriate steps for disclosing news to dying
patients, such as how to initiate a conversation with the patient and the family without hurting
them and without hiding any information (Turner et al., 2011). Being a nurse, it is necessary to
have self-awareness of own body language when communicating I need to develop skills on how
to ask open ended but relevant questions, listen for and pick up cues (Aslakson et al., 2016).
I believe that I need extensive learning using the evidence based researches. Going
through the different codes of ethics, I have realised the importance of human dignity and
integrity. In order to have an avid knowledge about the patients’ rights it is necessary to be
acquainted with the knowledge of medical legislation such that the laws are not breached. While

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disclosing the information about the end of life care patients, it is necessary to maintain
confidentiality and privacy. I believe that updating by knowledge about the new legislation and
the patients right will help me in my future professional practice. For dying patients, one of the
illness related concern is the preservation of the dignity (Slatore et al., 2012). Dying patients
should be communicated in a way such that it upholds honour, respect, self-esteem and the
dignity of the patient.
Furthermore, I also intend to consult with my seniors about the different methods of
communication that can be used for communicating with patients coming from diverse culture
and backgrounds. According to Aldridge et al., (2013) peer interaction and seeking consultations
helps a person to see things from different perspectives, hence seeking of the feedback is
necessary (Perrin & Kazanowski, 2015). Self-reflection is necessary for self-regulation. When
nurses reflect, they bend back their attention in an attempt for discovering the personal meaning
gained from their personal encounters and interaction with their peers. It helps the nurses to
understand what is right and wrong. Reflective practices assists health care professional to
understand the gaps left in their own practice. I intend to maintain a reflective practice logbook
where I will document my personal portfolio along with any researches which I will conduct
every day.
Conclusion
Being a good communicator is normally considered to be one of the essential skills of the
clinicians and nurses. Poor communication with the patient might have adverse effects for both
the patient and the clinician. For patients with cancer or progressive dementia it has been
associated with extremely negative outcomes, as most of the needs of the patients remain unmet

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due to lack of communication. Nurses without communication skills fail to understand the
grievances of the patient. However, this paper has identified some of the facilitators and the
barriers governing the communication of the caregivers with the patients. However, cultural
differences, language differences, un-realistic expectations of the patients have been found to be
the perceived barriers. This paper had further emphasised on the CSNAT tool for assessing the
needs of the home caregivers caring for the end of life care patients. Several literatures have also
been found in relation to this. Apart from this, the paper had also pointed out some
recommendations to improve the communication skills and confidence during the disclosure of
the information, including setting up of the environment, with gradual revelation of the
information. This paper had also recommended for lifelong evidence based researches in order to
gain more knowledge about communication skills. Emphasis has also been given on the
reflective practices and obtaining feedback from the peers and the seniors in order to improve
future professional practice.

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