Communication at the end of life

Communicating information that may be difficult to receive for patients and their families and friends requires thought and empathy on the part of the healthcare professional. 

Many people want to know if they are dying and will continue a conversation about dying once it has been initiated by a healthcare professional. The National Institute for Health and Care Excellence (NICE, 2021) identified how such conversations need to be both accessible and sensitive to the individual needs of the patient and their loved ones.

Effective communication with people who are approaching the end of their lives enables them to be involved in advance care planning as well as to spend important time with family and friends.

Before having a conversation about end of life with a patient, the nurse must be certain they have the capacity and the capability to understand the topics that are going to be discussed. Where the individual lacks capacity, it is important to consider the role of their lasting power of attorney or court appointed deputy if they have one.

Even when an individual has capacity, given the nature of the news, it may be important for them to have a family member or friend present when the information is being communicated.  Some individuals will benefit from being given literature or resources that are specific to their disease and end-of-life care. However, given the personal nature of this issue, the nurse will have to gauge the correct responses during any conversation.

If the clinician having the end-of-life conversation does not know the patient well,

The clinical having this conversation will need the time and space to talk. Such conversations require a private space, and often a second colleague can be present in the conversation to provide support and additional insights.

When having an end-of-life conversation with a patient or relative, there is a general structure should be followed to enable the nurse to provide the best experience possible under the circumstances. However, it is important to move at a pace dictated by the patient. 

Breaking bad news is a process which will require the provision of ongoing support and opportunities for the person to ask questions and seek clarification as they process the information being communicated (Warnock, 2014).

Preparation

The nurse must ensure that they know the facts and figures about the person’s illness and have some idea about what they have already been told and asked about; this might be gained from the patient's notes or by talking to staff who who have been interacting with them. In preparation for this conversation, the nurse must:

• Ensure privacy - this may mean taking someone out of the ward to a

Some people may react very strongly to being told they are approaching the end of their life, and may require specialised support in coming to terms with their own mortality. Some people cope by denying what is happening. Nurses should not feel that they have failed if they cannot engage an individual with end-of-life conversations or if they choose to deny their own mortality; accepting the patient's viewpoint is a reflection of person-centred care.

Staff who have found end-of-life conversations challenging, or need to have these conversations regularly, should consider their own wellbeing and engage with supervision and other forms of support to enable them to continue to practice in an empathetic manner (Mills et al, 2017). Failing to engage with supervision and support can result in burnout.

The best way to improve at having difficult conversations is to accompany and learn from staff who have the experience and skills necessary to have such conversations. The nurse can attend training, which should include role play, and engage with other resource materials also helps develop this skill. 

Nurses should reflect on their practice and use this to guide future conversations; this can take place during supervision sessions. While end-of-life conversations are never easy, they can become easier if the nurse engages with training and reflects meaningfully on their experiences.

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 2: Procedures for the planning, provision and management of person-centred nursing care

3. Use evidence-based, best practice approaches for meeting needs for care and support with rest, sleep, comfort and the maintenance of dignity, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions

10. Use evidence-based, best practice approaches for meeting needs for care and support at the end of life, accurately assessing the person’s capacity for independence and selfcare and initiating appropriate interventions

10.6 provide care for the deceased person and the bereaved respecting cultural requirements and protocols

Egan G. The skilled helper: a systematic approach to effective helping. California: Thomson Brooks/Cole; 1975

Hanratty B, Lowson E, Holmes L et al. Breaking bad news sensitively: what is important to patients in their last year of life? BMJ Support & Pall Care. 2012; 2:24-28. https://doi.org/10.1136/bmjspcare-2011-000084

Isaacson MJ, Minton ME. End-of-life communication. Adv Nurs Sci. 2018; 41(1): 2-17. https://doi.org/10.1097/ANS.0000000000000186

Mills J, Wand T, Fraser JA. Self-care in palliative care nursing and medical professionals: a cross-sectional survey. J Pall Med. 2017; 20(6):625-630. https://doi.org/10.1089/jpm.2016.0470

National Institute for Health and Care Excellence (NICE). End of life care for adults. 2021. https://www.nice.org.uk/guidance/qs13 (accessed 25 October 2023)

National Institute for Health and Care Excellence (NICE). End of life care for adults: service delivery. 2019. https://www.nice.org.uk/guidance/NG142 (accessed 25 October 2023)

Warnock, C. Breaking bad news: issues relating to nursing practice. Nursing Standard. 2014; 28(45): 51-58. https://doi.org/10.7748/ns.28.45.51.e8935