How Do I Do It?
Practical Tips on Having a Difficult Discussion
This blog is complementary to the previous blog about becoming more comfortable with uncomfortable conversations. After many difficult discussions with families during my critical care fellowship, I finally became comfortable with uncomfortable conversations. It's impossible to develop a script to use for every conversation, but here are some of the techniques I've adopted over the years.
Sit down in a private room, have tissues if appropriate. Make sure your phone/ pager won't interrupt the conversation.
Have someone else with you. It’s always good to bring the patient's nurse, and there is often spiritual support staff (ie chaplains) who can accompany you and provide support for the family.
Introduce yourself, and ask who everyone in the room is, specifically how they're related to the patient. "Nice to meet you, I'm really sorry it's under these circumstances."
If it's your first conversation with the family, it's important to establish a foundation to build on (or establish the absence of a foundation). You can ask "what do you know so far" or "what's your current understanding of the situation"? This also allows them to express their current questions/ concerns.
Judge their level of comprehension and adjust as needed. This does NOT mean being patronizing or imposing stereotypes. Pay attention to facial expressions and listen to their questions/ responses. It's easy to fall back into speaking medical jargon- you need to deliberately focus on using easily understandable words. Words that we use every day are meaningless to most people who aren't in the medical field.
Keep the conversation brief and take frequent pauses. They don't hear everything you say, and they'll hear even less if you talk non-stop.
Allow them time to process what you’ve shared, and allow them to ask any questions they have.
Acknowledge that it’s common to be overwhelmed by the discussion. You can validate them by offering "I know I just told you a lot of information" or "I know this can all be overwhelming". It’s also helpful to say, “I’m sure you will think of other questions, please write them down so we can discuss them later”
Encourage them to discuss things amongst themselves and provide them a quiet private place to regroup after the meeting. It’s also helpful to say, “I’m sure you will think of other questions, please write them down so we can discuss them later.” This validates their feeling and reassures them that they don't have to worry about remembering every detail.
Specific difficult topics
- Death and dying. Acknowledge that what they are feeling is normal- regardless of what they feel, it's normal. Denial, angry, scared, guilty, confused, conflicted, exhausted, numb.
- When they are wrestling with the decision about transitioning to comfort care (colloquially known as "withdrawal of care", or crassly, "pulling the plug") and they've verbalized that they know it's what their family member would want, acknowledge how difficult that decision can be but also reaffirm that they are doing the kindest thing by honoring their family members wishes.
For other helpful tips, check out "Sunburn".
"For patients who are alive, concentrate on the ‘big picture’ and avoid the inclination to catalog every injury during this initial encounter. The primary concern in these settings often consists of survival, brain damage, paralyzation and other major morbidities. Again, an overabundance of information can be overwhelming."