Effective communication

Communication is a fundamental component of nursing in the provision of end of life care. Some people feel uncomfortable talking about death, but when you’re taking care of a patient who is dying it becomes necessary and beneficial to communicate clearly, and therefore it is essential to open up these conversations.

Good communication enables staff to establish the person’s priorities and wishes, supporting them to make informed decisions. It also provides an opportunity to explore any anxieties or gaps in understanding of the situation, can reassure patients and their families, and alleviate or reduce anxiety and distress.

As a patient approaches the end of their life, talking with the person and those close to them in advance will help to prepare them for the lessening need for food, and particularly fluids. Therefore communicating with those closest to the patient in a way that helps them understand the loss of ability to eat and drink as part of the dying process, is an essential component of compassionate care. Good communication will help them understand that not wanting food and drink at end of life is a natural part of the process.

Those close to the person at the end of their life can play an important role in keeping their loved one comfortable with mouthcare and offering sips of fluid.

Document the person’s wishes about the type of care they wish to receive, and check whether they have appointed an individual to make decisions if they’re unable to do it themselves.

Ongoing communication with the dying in a respectful and dignified manner should continue even when the person is unconscious as their sense of hearing may be maintained until death.

Remember in holistic end of life care it is “the little big things that matter”. This may be offering to sit with someone for a period to talk about or with the dying person, or raising the height of the bed for a relative to be in a more comfortable position to attend or be close to the dying person. Please also consider a risk assessment regarding the use of bed rails, as these may be a barrier at this very intimate time.

The following clip demonstrates the value of team working and involvement with families by using anticipatory care approach.

Sensitive conversations

In delivering end of life care there will likely be a number of sensitive conversations with individuals approaching the end of their life and those close to them. It is important to be able to initiate, facilitate and respond in these sensitive situations.

End of life care discussions about nutrition and hydration, particularly towards the end of the life, with patients and their families won’t always be easy. Sensitive explanation may be required to enable the family to understand that needing less and less food and fluid is a natural part of the dying process and, indeed, attempting to give these when they are no longer needed might cause distress or exacerbate symptoms.

The last days and hours of someone’s life is an ever changing landscape and regular review of the persons’ needs is required. Constant communication is vital to ensure everyone understands what is happening and why decisions have been made. Decisions to use or discontinue nutrition or hydration should be based on the individual’s condition.

When people are able to eat or drink a little by mouth they should be helped to do so and their wishes respected when they choose not to. Food choices should be offered to the patient, such as ice lollies.

In some situations a persons’ requirements for food and fluids may have been managed by clinically assisted means that might have been in place for some time. The dying person and those close to them should be involved in discussions and decisions to taper or stop these forms of support when there is evidence that continuing may no longer be of benefit to the person.

Less experienced nursing staff are likely to find these conversations difficult on their first few occasions, and may struggle with what to say or how to say it.

The following clip demonstrates the importance of leadership on the ward.

Communication with loved ones

The care of family members becomes ever more central to the holistic care of the dying person. Their prime need is to be reassured of the patient’s comfort.

Provide regular opportunities for the family member to understand or be updated on the condition, treatment and or care given to the patient. Consider at what pace family members may like to know what changes to expect and how they will be managed. Make the family feel welcome at all times and consider what arrangements can be made to offer them space to rest and eat and drink close by. Some family members may wish to stay with the patient continuously or others may wish to be called back if death is close by. Some may wish to be involved in direct care giving. Provide advice and support as needed.

The benefit  to families pre-bereavement of the nurse in helping both the dying person and those close to them understand the situation as it evolves and caring for them with intelligence, insight and understanding will contribute greatly to the experience of relatives and how they will grieve after death for the loss of their loved one. This is the legacy of nurses to those we care for.

This clip demonstrates of providing information as the person is actively dying.

Phone conversations

There will be times where you need to have a sensitive conversation over the phone. It can help to be aware of scenarios like the one outlined below, and how to approach them.

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A 48 year old lady with advanced MS has been admitted for end of life care in the ward. She was being cared for at home by family but her mother took ill and became unable to provide the care required, causing a strain within the family. Maude has advanced MS and has been bed-bound for 4 years- lives alone - her personal care is performed by her 2 sisters and her mum. She is now not expected to survive more than a few days. She has a 26 year old daughter who lives 250 miles away - and has phoned to ask about her mum - she is concerned she hasn't been able to eat...

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Pick up cue of different name - that may mean a different family dynamic

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When phoning relatives, especially a mobile - check out their environment and that it is safe to continue the conversation

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Families are more likely to be distressed by reduced ability to eat than the patient - relatives would welcome the opportunity to talk about nutrition/ hydration ( Bazian report)

When about to share difficult information re a persons condition - check what their understanding is and when they last saw the person

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Notes - Pick up on the cues - she was told re "kept comfortable" -

Daughter being reflective and thoughtful as she gains deeper understanding of seriousness of situation

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Reflecting back to check understanding - probing for further clarity

Providing gentle clarity

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Use of warning shot - "I'm afraid "

Gentle approach to explaining re the reduced need for fluids

Ensure you have:

  • Checked each person’s understanding of the situation
  • Ensure you have everyone up to date on the current situation
  • Addressed any sensitive issues you think might exist
  • Considered any gaps in communication which might exist – either between the individual who is dying and those close to them, between teams or organisations
  • Identified any specific communication needs of individuals, eg. deaf or partially deaf

For further information on communication, please see the communication section in First Steps: http://rcnhca.org.uk/top-page-001/