The Art of Difficult Conversations in Primary Care

Why is it important to master the art of difficult conversations,

especially in the context of end of life care?
All health and social care professionals should demonstrate effective information giving, compassionate
communication and general psychological support NICE (2004).
Patients tell us that the emotional impact of dealing with a life threatening illness is as difficult and
distressing as the physical aspects.
Being open about end of life issues can allay anxieties, allow people to plan ahead and do the things they
want to do before they die. In other words, it can make life easier and better.
Poor communication can lead to psychological distress and morbidity, poor adherence to treatment,
reduced quality of life, dissatisfaction with care, complaints and litigation and, last but not least, potential
burnout in healthcare professionals.
How to do it general principles
Take opportunities as they arise, rather than waiting for perfection an end of life care conversation (and
documentation) can evolve over time. Remember, a strength of general practice is time.
Asking permission will engage the patient describe whatever it is you are asking permission for and then
ask are you okay with that?
Be frank but compassionate.
Avoid euphemisms and medical jargon.
Take time to listen and pay attention to verbal and non-verbal cues.
Information and advice is more likely to be heard AND absorbed if it:
Is delivered in manageable chunks.
Is tailored to the needs of the individual person.
Allows any resultant concerns and feelings to be acknowledged.
Allow for silence and tears, and avoid the urge to talk to overcome your own discomfort. Proceed at the
patient / relatives pace. (A good tip is to count to ten slowly in your head before talking again.)
Check the patients understanding and encourage
them to express his/her concerns, ask questions.

Make a plan of action, including as much positive

practical support, but not false reassurance.

Ensure a follow up appointment is available.

If you dont feel you have the time or skills to discuss in detail you can reschedule try sounds like we
should make time to talk about that properly or Ill find out who can help you with that.
Sometimes people are not ready to talk about their end of life care, but you wont know if you dont ask at
the very least, they will know you will be there to talk to when they are ready.
Give written information ready as appropriate.

Check your own state of mind before seeing the next

patient.

Useful phrases to consider when facilitating discussions around end of life decisions
Use phrases that you feel comfortable with in everyday consultations, such as:
How do you think things are going?
Whats important to you?

Whats the main thing on your mind?

Beginning statements with Can I speak honestly with you? can provide a warning shot that you have
difficult news.
Has anyone spoken to you about your condition?
Have you any thoughts about how you want to
manage (or do) things in the future?

Before we start talking about plans for the future,

can I just check how you are seeing the situation at
the moment?

Have you got any questions about your condition and specifically about what this might mean for the
future?

Have you and your family had any discussion

about your condition if so, were there any specific
questions or issues that came up that would be
helpful to discuss with me?

So thinking ahead, what would be your main

concerns now?

On this occasion, you have been treated with [x]

for your condition. Have you had any thoughts
about what you would want to do if a similar
situation arose in the future?

Supplementary questions to consider:

If it was not possible for us to get you any better
than you are now, have you thought about what you
would want us to do if your heart suddenly stopped
or you stopped breathing?

Unfortunately your [lung] condition is now very

serious. This might be the time for us to think about
your treatment and care if you become very unwell
again. Has anyone discussed this with you?

Could lead into a statement such as: The hospital

Have you had any thoughts about where you might
team feel that if you became very unwell again in the want to be looked after if you became more
future, that you would be very unlikely to recover if
unwell?
you needed to go on to a ventilator. For that reason,
they do not feel that it would be in your best interests
to be admitted to the ITU again.
Closing down the conversation - Empathise and acknowledge feelings
I know this seems a stupid question right now, but
how are you feeling?

I know this is a lot to take in, should we leave it at

that and talk again

I understand this is a lot to take in, do you have anyone you can talk to?
Some phrases to avoid
I know how you feel.
I know what youre going through.

I understand.
You could have 10 days, 10 weeks or 10 years.

Further resources
Macmillan Cancer Support, www.macmillan.org.uk, has lots of resources on its website and LearnZone,
(learnzone.org.uk) such as ACP guide,
http://www.macmillan.org.uk/Documents/AboutUs/Health_professionals/EndofLife/ACPBooklet.pdf
The National EOL website, www.endoflifecareforadults.nhs.uk, has many useful resources including information for
patients and health care professionals on ACP, DNAR and communication training DVD and pack called Finding the
Words
The Dying Matters Coalition, www.dyingmatters.org, also has both training resources and patient leaflets covering a
variety of relevant scenarios. Also, facilitated Communication skills training for GPs.
The National Council for Palliative Care www.ncpc.org.uk, Difficult Conversations with people with COPD.