Communication in End of Life Care

Introduction

The identification and understanding of the factors that indicate an individual is in their last hours or days of life are subtle and complex. However, the nurses are obligated to identify them and provide care to such patients in such a way so that it promotes comfort, relief pain and other symptoms as well as they are to support members of the family close to the patient to accept the condition. In this process, the nurse-patient communication is vital as through interaction the nurses can understand the needs of the patients in their last days and tries to fulfil the needs (Coyle et al. 2015). In addition, communication is considered as fundamental part of nursing care in any condition. According to NICE guidelines, the NHS informs that the nurses to care for dying adults in the last days of life are to consider the current mental and physical capacity of the individual to communicate and ensure their active participation for their life care (NICE, 2015).

The focus of the assignment will be on the nurse-patient and nurse-others communication in caring for dying adults in the last days of life. The topic has been chosen because effective establishment of communication by nurses with the dying patients in their last days assists to increase the concordance of reported care goals of the patients with the documented care goals within medical records, in turn, improving the care satisfaction of the patients (Hartog et al. 2015). Moreover, interaction in last days of life care is an important topic to be discussed because it influences the way subsequent decision regarding treatment of the patients is to be taken so that they can be ensured less painful time till death.

Evidence for importance of communication in palliative care

The last hours or days of the dying patient's life are a continuously changing landscape which needs to be regularly reviewed to assure proper care. Thus, the establishment of communication is beneficial in nursing practice for care of dying adults in the last days of life because through interaction with the person in their last days of life their changing needs can be appropriately identified within the time for creating an alteration in care to ensure satisfactory care (Caswell et al. 2015). As mentioned by Hendersen et al. (2018), in last days of life the care to the dying patients is provided through multi-disciplinary and multi-agency team. This condition makes communication in the care process important for nursing practice as establishment of interaction between teams helps the nurses to communicate between each other the best treatment to be provided to the patient for ensuring them relief from sensitive condition to some extent. As argued by Ramos et al. (2016), lack of communication for care of dying adults in the last days of life leads nurses to remain unaware of the changes in the health needs of the patients. This is because the without interaction the nurses are unable to know the specific areas of pain and in which respect of care and treatment the patients are facing hindrance in their last hours of life that is leading them to face painful death.

In caring of dying adults in the last days of life condition, the patients are often moved from one care setting to another to be provided specific treatment to ensure them better health. This condition makes communication in the process an essential aspect in nursing practice because it ensures continuous flow of health information regarding the patients among all nurses in any settings. It makes the nurses able to get disclosed of previous care provided to the patient, in turn, avoiding duplication of care and assure improved care (Sinuff et al. 2015). As asserted by Epstein et al. (2017), communication in care of dying adults in the last days of life condition is significant for nursing practice as it helps the nurses to make the patients confess their fears and concerns regarding health. This leads the nurses to understand the psychological condition of the patients making them aware of the nature of emotional support to be provided to the patients so that mental health condition can be stabilised. As argued by Erickson et al. (2015), fear or concerns regarding death among dying person has a negative effect on the health of the patient as it leads them to develop depression and avoid acceptance of care as they develop worries regarding what will happen after death. This, in turn, leads to hinder the care process for the patients as nurses often found the treatment provided is avoided to be accepted by the patients out of depression. Thus, in this condition communication is essential as the nurses through interaction and discussion can support and encourage the patients to overcome their fears and accept care to have improved quality of life till death.

The communication in caring of dying adults in the last days of life leads the nurses to ask the patients about their personal values and beliefs along with what is essential for them to be considered in executing their health decision (Heyland et al. 2017). This leads it to be essential aspect of nursing practice because the nurses can frame the care in such a way so that value and dignity of the person in the last days of their life are properly maintained and respected. Moreover, it leads the nurses to abide by the NMC Code of Practice where under "Prioritise People" it is informed that nurses are to include the patients to participate for directing their own care decisions (NMC, 2015). As commented by Rhodes et al. (2015), communication during caring of dying adults in the last days of life leads the nurses to inform patients about the outcome, benefits and risks of the life-sustaining treatment being provided to them. This makes communication aspect essential in nursing practice as the clarification often seen to make patients who are in their last days of life show less resentment to accept certain treatment which due to their lack of knowledge and confusion regarding its outcome are previously avoided to be accepted by them. It also helps the nurses ensure effective care delivery to the patients.

The cultural beliefs, as well as practices, are salient features within the family members and patients who are in their last days of life. However, they are often seen to be poorly known and understood by nurses and physicians mainly when their background differs from those of the patients they are entrusted to provide care (Mazanec and Panke, 2015). As stated by Paternotte et al. (2015), lack of enough knowledge about the way specific cultural beliefs and practices of the patients that define the meaning of days of death and the disease-causing it can contribute to create disparity in the care provided by the nurses in the last days of patients. This is because lack of the information leads nurses to deliver care that is not supportive of the cultural beliefs of the patients making service users avoid to receive support as they cultural sentiments are hurt and wishes are not fulfilled. As argued by Banerjee et al. (2016), communication between the nurses and patients in caring of dying adults in the last days of life condition lead the nurses have strength to know the cultural perspective and wishes of patients belonging from different cultural groups. It helps the nurses understand regarding the way to interact with such patients so that their cultural sentiments and wishes are not hurt while offering care, in turn, making the patients show less hindrance in accepting care. This condition makes communication a significant and critical aspect of nursing practice as it leads nurses to respect the cultural beliefs of the patient in their dying days, in turn, making the person feel valued and respected. According to the NMC Code of Practice, the nurses are to consider the cultural sensitivities and beliefs of the patient while providing care to them (NMC, 2015). Thus, communication also helps nurses in the process to abide by the laws of nursing practice as directed by the NMC (Nursing and Midwifery Council).

Barriers in communication-related to care of dying adults in the last days of life

There are different barriers faced by the nurses in making successful communication while caring for patients who are in their last days of life to be delivered proper care and support one of which is not getting enough time to interact with the patients. As commented by Horlait et al. (2016), lack of adequate time to interact with the patient who is in their last days of life leads the nurses unable to know in detail about the continuously changing preferences and needs of the patients as per their current condition. This is because the nurses are to execute the conversation quickly and in an improper manner making the service users who are in their last days of life feels lack of value to show proper participation to inform their needs creating barriers to establish successful communication. As argued by Hendricks-Ferguson et al. (2015), lack of time to interact with the patients in caring of dying adults in the last days of life is faced by the nurses due to work pressure to serve different patients at a time. Thus, they have limited time to spend for each patient in making proper communication to know in detail about their needs.

The lack of privacy and noisy environment acts as barrier in creating communication while caring of dying adults in the last days of life for the nurses as the meeting with the patients is fixed in shared rooms (Vermylen et al. 2015). This is because without privacy the patients in their dying condition feel vulnerable that their health condition and personal information may be revealed to others which may lead them to get harm from others making patients avoid sharing their detailed needs and demands of care in a proper manner with the nurses. The noisy environment makes nurses unable to pay proper attention to the informed needs of the patients. This makes nurses to either overhear the needs of patients or ask the patients to continuously repeat the same information which makes patients feel neglected and share further preferences regarding care in their last days of life (Esmaili et al. 2018). As asserted by Selman et al. (2017), not providing time to the patients to process the information being shared by the nurses during their last days of life condition creates barrier in communication. This is because it makes the patients feel being ignored making them avoid interaction with the nurses creating hindrance and disruption in successful communication.

The lack of time offered to the patients for expressing their concerns and fears during interaction while caring for dying adults in the last days of life condition act as barrier of communication for the nurses (Travers and Taylor, 2016). This is because such behaviour leads the patients unable to disclose what is causing them stress making them feel neglected by the nurses as well as remain anxious about death which leads them to disapprove of not continuing the interaction any further. As stated by Walczak et al. (2016), discomfort of the patients to discuss regarding their dying situation in last days of life with the nurses and physician creates barrier in communication. This is because without comfort the patient is unable concentrate to inform their specific needs and demands as asked by the nurses making the service providers unable to execute effective interaction.

The avoidance by the nurses to follow the leads provided by the patients who are in their last days of life and showcasing their own agenda during interaction creates barrier in communication (Bernacki et al. 2015). This is because it leads the patients feel disrespected as their opinions are not valued in turn making them avoid to further communicate with the nurses. As asserted by Scheerens et al. (2018), presenting information regarding treatment in biased manner to the dying patients who are in their last days of life creates barrier in communication. This is because biased information makes the patients unable to get properly informed about the detailed outcome, risks and benefits of treatment required by them in turn making them avoid to continue further interaction. As argued by Fisher et al. (2017), providing the patient a definitive prognosis of death on a defined period of time creates barrier in communication with the nurses. This is because the patients develop fear that they are going to die making them depressed and unable to concentrate in continuing the interaction with the nurses to inform about their needs in supporting the development of care plan.

The lack of documentation of the medical record regarding the discussion with the patients creates barrier in communication in nursing practice (Lilley et al. 2017). This is because the nurses are unable to share in detail with the multi-disciplinary team regarding the health condition and needs of the dying patients in their last days creating barrier in flow of information. As asserted by Carmont et al. (2018), the inability of the nurses and physicians to determine the extent of information patient who is in their last days of life have regarding their health condition creates barrier in creating successful communication. This is because the nurses may be discussing with the patients about treatment plans for the disease regarding which the patient has no idea making them show lack of concentration and avoid effective interaction to establish successful communication. As stated by Ahluwalia et al. (2015), barrier in communication during interaction with the patient in their last days of life is faced when the nurses are unable to understand the way the conversation is to be initiated. This is because the nurses in this condition often show confused behaviour and unable to make the patients comfortable to talk as well as share health information in turn avoiding talking with the patient to reveal their needs.

Recommendations

The NICE guidelines inform that while making communication in care of dying adults in the last days of life the nurses require to understand the cultural, religious and spiritual needs to ensure the effective establishment of interaction in the end days of life (NICE, 2015). This guidance is recommended to be followed by the nurses while establishing communication with the patients. It is required so that the nurses can show respect to the cultural sentiments and preferences of the patients making them feel valued in turn influencing to show interest in establishing effective interaction with the nurses to discuss their care goals avoiding cultural barriers. The NICE guidelines inform that accurate prognosis of the dying person is to be discussed with them in detail and inform them the way uncertainty and risk to be managed accordingly in care to avoid false optimism (NICE, 2015). It is recommended by the nurses to follow this guideline so that biased-manner of information delivery that leads patients to avoid concentrate in executing interaction (barrier in the communication) can be avoided.

The nurses are recommended to arrange adequate time to interact with the patients who are nearing their death without any interruption so that they can collect proper information through the establishment of successful communication. This is because as previously mentioned less time led to hurried conversation where patients feel lack of scope to properly interact with nurses as well as nurses are unable to inform prognosis of care to the patients creating barriers in effective communication. The nurses are also suggested to ensure the environment for communication are closed room and not public places so that the privacy can be maintained and less interruption in communicating with the dying patients regarding their care can be discussed. The nurses are recommended to have patience, minutely listen as well as interact empathetically with the patients nearing death as it makes them feel ease to share information resulting to create successful communication. The nurses are recommended to have proper training regarding the way to interact with patients nearing death so that they can understand the way emotions and personal agendas are to be avoided to create successful communication.

Conclusion

The above discussion informs that successful communication with the dying patient in last days of life is important in nursing practice to influence the patients to participate in their care decision, have detailed knowledge regarding prognosis, resolve fear and confusion, the establishment of effective care by multidisciplinary teams and others. The barrier experiences in executing communication with person who is nearing death by nurses include noisy environment, lack of privacy and time, presentation of personal agenda, offer less scope for the patient to talk and others. The recommendations provided to nurses are that they are to follow NICE guidelines for care to person who is dying and is reported to avoid the influence of personal agendas while interacting, provide time and privacy to patients and others.

References

Coyle, N., Manna, R., Shen, M.J., Banerjee, S.C., Penn, S., Pehrson, C., Krueger, C.A., Maloney, E.K., Zaider, T. and Bylund, C.L., 2015. Discussing death, dying, and end-of-life goals of care: a communication skills training module for oncology nurses. Clinical journal of oncology nursing, 19(6), p.697.

Hartog, C.S., Schwarzkopf, D., Riedemann, N.C., Pfeifer, R., Guenther, A., Egerland, K., Sprung, C.L., Hoyer, H., Gensichen, J. and Reinhart, K., 2015. End-of-life care in the intensive care unit: a patient-based questionnaire of intensive care unit staff perception and relatives' psychological response. Palliative medicine, 29(4), pp.336-345.

Caswell, G., Pollock, K., Harwood, R. and Porock, D., 2015. Communication between family carers and health professionals about end-of-life care for older people in the acute hospital setting: a qualitative study. BMC palliative care, 14(1), p.35.

Hendersen, A., Ryan, R., Hendersen, S., Young, J., Bradford, N.K., Bothroyd, J. and Herbert, A., 2018. Interventions for interpersonal communication about end of life care between health practitioners and affected people. Cochrane Database of Systematic Reviews, 2018(9), pp.23-45.

Ramos, K.J., Downey, L., Nielsen, E.L., Treece, P.D., Shannon, S.E., Curtis, J.R. and Engelberg, R.A., 2016. Using nurse ratings of physician communication in the ICU to identify potential targets for interventions to improve end-of-life care. Journal of palliative medicine, 19(3), pp.292-299.

Sinuff, T., Dodek, P., You, J.J., Barwich, D., Tayler, C., Downar, J., Hartwick, M., Frank, C., Stelfox, H.T. and Heyland, D.K., 2015. Improving end-of-life communication and decision making: the development of a conceptual framework and quality indicators. Journal of pain and symptom management, 49(6), pp.1070-1080.

Epstein, R.M., Duberstein, P.R., Fenton, J.J., Fiscella, K., Hoerger, M., Tancredi, D.J., Xing, G., Gramling, R., Mohile, S., Franks, P. and Kaesberg, P., 2017. Effect of a patient-centered communication intervention on oncologist-patient communication, quality of life, and health care utilization in advanced cancer: the VOICE randomized clinical trial. JAMA oncology, 3(1), pp.92-100.

Erickson, J.M., Blackhall, L., Brashers, V. and Varhegyi, N., 2015. An interprofessional workshop for students to improve communication and collaboration skills in end-of-life care. American Journal of Hospice and Palliative Medicine®, 32(8), pp.876-880.

Heyland, D.K., Dodek, P., You, J.J., Sinuff, T., Hiebert, T., Tayler, C., Jiang, X., Simon, J. and Downar, J., 2017. Validation of quality indicators for end-of-life communication: results of a multicentre survey. Cmaj, 189(30), pp.E980-E989.

Rhodes, R.L., Tindall, K., Xuan, L., Paulk, M.E. and Halm, E.A., 2015. Communication about advance directives and end-of-life care options among internal medicine residents. American Journal of Hospice and Palliative Medicine®, 32(3), pp.262-268.

Mazanec, P. and Panke, J.T., 2015. Cultural considerations in palliative care. Spiritual, Religious, and Cultural Aspects of Care, p.4.

Paternotte, E., van Dulmen, S., van der Lee, N., Scherpbier, A.J. and Scheele, F., 2015. Factors influencing intercultural doctor–patient communication: A realist review. Patient education and counseling, 98(4), pp.420-445.

Banerjee, S.C., Manna, R., Coyle, N., Shen, M.J., Pehrson, C., Zaider, T., Hammonds, S., Krueger, C.A., Parker, P.A. and Bylund, C.L., 2016. Oncology nurses' communication challenges with patients and families: a qualitative study. Nurse education in practice, 16(1), pp.193-201.

Horlait, M., Chambaere, K., Pardon, K., Deliens, L. and Van Belle, S., 2016. What are the barriers faced by medical oncologists in initiating discussion of palliative care? A qualitative study in Flanders, Belgium. Supportive Care in Cancer, 24(9), pp.3873-3881.

Hendricks-Ferguson, V.L., Sawin, K.J., Montgomery, K., Dupree, C., Phillips-Salimi, C.R., Carr, B. and Haase, J.E., 2015. Novice nurses' experiences with palliative and end-of-life communication. Journal of Pediatric Oncology Nursing, 32(4), pp.240-252.

Vermylen, J.H., Szmuilowicz, E. and Kalhan, R., 2015. Palliative care in COPD: an unmet area for quality improvement. International journal of chronic obstructive pulmonary disease, 10, p.1543.

Esmaili, B.E., Stewart, K.A., Masalu, N.A. and Schroeder, K.M., 2018. Qualitative analysis of palliative care for pediatric patients with cancer at Bugando Medical Center: An evaluation of barriers to providing end-of-life care in a resource-limited setting. Journal of global oncology, 4, pp.1-10.

Schrank, B., Rumpold, T., Amering, M., Masel, E.K., Watzke, H. and Schur, S., 2017. Pushing boundaries—culture‐sensitive care in oncology and palliative care: a qualitative study. Psycho‐oncology, 26(6), pp.763-769.

Travers, A. and Taylor, V., 2016. What are the barriers to initiating end-of-life conversations with patients in the last year of life?. International journal of palliative nursing, 22(9), pp.454-462.

Walczak, A., Butow, P.N., Bu, S. and Clayton, J.M., 2016. A systematic review of evidence for end-of-life communication interventions: who do they target, how are they structured and do they work?. Patient education and counseling, 99(1), pp.3-16.

Bernacki, R., Hutchings, M., Vick, J., Smith, G., Paladino, J., Lipsitz, S., Gawande, A.A. and Block, S.D., 2015. Development of the Serious Illness Care Program: a randomised controlled trial of a palliative care communication intervention. BMJ open, 5(10), p.e009032.

Scheerens, C., Deliens, L., Van Belle, S., Joos, G., Pype, P. and Chambaere, K., 2018. "A palliative end-stage COPD patient does not exist": a qualitative study of barriers to and facilitators for early integration of palliative home care for end-stage COPD. NPJ primary care respiratory medicine, 28(1), p.23.

Fisher, J., Nicol, J. and Nyatanga, B., 2017. Communication in palliative and end of life care. Palliative and End of Life Care in Nursing, 5, p.24.

Lilley, E.J., Cooper, Z., Schwarze, M.L. and Mosenthal, A.C., 2017. Palliative care in surgery: defining the research priorities. Journal of palliative medicine, 20(7), pp.702-709.

Carmont, S.A., Mitchell, G., Senior, H. and Foster, M., 2018. Systematic review of the effectiveness, barriers and facilitators to general practitioner engagement with specialist secondary services in integrated palliative care. BMJ supportive & palliative care, 8(4), pp.385-399.

Ahluwalia, S.C., Bekelman, D.B., Huynh, A.K., Prendergast, T.J., Shreve, S. and Lorenz, K.A., 2015. Barriers and strategies to an iterative model of advance care planning communication. American Journal of Hospice and Palliative Medicine®, 32(8), pp.817-823.

Selman, L.E., Brighton, L.J., Hawkins, A., McDonald, C., O'Brien, S., Robinson, V., Khan, S.A., George, R., Ramsenthaler, C., Higginson, I.J. and Koffman, J., 2017. The effect of communication skills training for generalist palliative care providers on patient-reported outcomes and clinician behaviors: A systematic review and meta-analysis. Journal of pain and symptom management, 54(3), pp.404-416.

Dig deeper into Communication and counselling with our selection of articles.