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Challenges and opportunities: communication near the end of life.

Article Excerpt
John Gunther's 1949 memoir Death Be Not Proud describes his and his wife's efforts to keep hope alive for their son who was diagnosed with a malignant brain tumor. Not talking about the seriousness of their son's illness was thought to be a good thing. Upon reflection, however, Frances Gunther stated:



It was only after his death, from his brief simple diaries ... that we learned he had known all along how grave was his illness, and that even as we had gaily pretended with him that all was well and he was completely recovering, he was pretending with us, and bearing our burden with the spirit of a singing soldier or a laughing saint (p.189).

Today, more than 50 years after Gunther's moving words, the practice of avoiding discussion of terminal illness and impending death still occurs. As the patient and family members struggle to cope with terminal illness, most of them will attempt to maintain a sense of cheerfulness and normalcy throughout the treatment phase. However, it is important to acknowledge that having a terminal illness is not easy and it does not create cheerfulness. Because cultural and ethnic differences can complicate the communication process further, nurses should recognize that communication with each patient and family is a unique experience. Evidence suggests that the terminally ill and dying patient desires open, honest communication with others (Barclay, Blackhall, & Tulsky, 2007). Several basic attitudes and behaviors can assist a nurse when communicating with the patient who is terminally ill and the patient's family. Openness, honesty, and understanding are foundations to this communication; thoughtful communication is based on awareness that life does not last forever and the end is drawing near.

Care on the Medical-Surgical Unit

One of the most important elements of end-of-life care from the perspectives of the patient and family members is honest communication (Heyland et al., 2006). Traditionally, nurses have viewed communication with dying patients and families as the purview of physicians. Additionally, speaking about dying to those who are near death is challenging for even the most talented and experienced nurse.

Many challenges on a busy medical-surgical unit create barriers for adequate or effective communication with a patient diagnosed with a life-threatening illness. Diagnostic studies typically are conducted daily in the setting. Findings indicating a terminal illness or poor prognosis are communicated to a patient by the physician, not the nurse. Barriers to patient-nurse communication begin when the nurse is unaware of what has been communicated to the patient and/or family by the physician. Misunderstandings and miscommunication between and among clinicians can complicate sensitive situations and frustrate patients and family members (Schirm & Sheehan, 2005). A common myth is that discussing dying and death will diminish the patient's hope (Knauft, Nielsen, Engelberg, Patrick, & Curtis, 2005). (see Table 1).

Because needs of the dying patient often involve emotional issues that the medical-surgical nurse cannot "fix," avoidance can become the nurse's mode of operation and communication. Research indicates that nurses generally have a high level of apprehension in caring for dying patients (Weigel, Parker, Fanning, Reyna, & Gasbarra, 2007). This apprehension, together with potential lack of experience in practical communication approaches and techniques, can lead the nurse to feel at a loss for words. In addition to not knowing what to say, the nurse may experience the added burden of balancing what the doctor has told the patient with the reality that death appears imminent.

On a busy medical-surgical unit, the nurse may find it difficult to round with each physician visiting each patient. However, to stay abreast of information being shared between physicians and patients, nurses should consider the act of rounding with physicians as an invaluable tool for communication and patient advocacy. When this is not possible, other strategies can be used....

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