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Breaking bad news…

By Terre Mirsch

One of the many benefits of hospice care is the ability to call for assistance at any time of the day or night, for any problem or concern. The other night we received a call from a family seeking guidance regarding how to talk with their mother about her need for hospice care. They already understood the benefits of hospice but were uncertain regarding how to approach the subject with Mom.

Perhaps you find yourself in the position of reviewing information about a diagnosis or treatment plan that the physician has already provided, or you may be the first person having this conversation with your loved one if the physician has not. Even after hospice care begins, family members may need to have difficult conversations or break bad news to their loved one. Perhaps you need to talk with Dad about the improbability that he will be well enough to attend his grandson’s graduation ceremony next month, or that Mom is no longer safe to live at home alone.

As discussed previously by Patty (Shhhh… don’t tell mom she’s on hospice), truth telling provides important opportunities for goodbyes and life closure. Having these conversations in a sensitive and respectful manner is essential and knowing when and how to have them may not come naturally for many of us. Anxiety and fear of ‘doing it wrong’, ‘saying the wrong thing’, or ‘taking away hope’ may result in delays or failure to have these difficult dialogues. After all, it is hard to deliver difficult news – it is even harder when the news impacts our own lives and the lives of those we love so dearly.

Medical students and other healthcare professionals undergo “breaking bad news” training early in their careers. Based on the work of Dr. Robert Buckman, skills are developed and refined using a 6-point protocol commonly referred to by the acronym SPIKE. Dr. David Casarett and others have explored factors that influence decision making and enrollment in hospice care, also suggesting specific professional communication interventions that ensure people get the information they need in order to gain access to quality end of life care. These ‘breaking bad news principles’ can also be applied when we, as caregivers, find ourselves needing to discuss uncomfortable or undesirable information with our loved ones.

Following these guidelines may help you to feel more confident when faced with the need to have difficult conversations:

Prepare. Think and plan ahead of time for what you want to say. Writing it down—or practicing it—may help. Anticipate possible reactions and questions and how you may respond to them. Choose an appropriate setting, free from distractions and interruptions.

Speak from your heart. Be genuine and empathetic. Don’t be afraid to show your emotions.

Ask for permission and obtain an invitation to proceed. Ensure that your loved one is free from pain or other symptoms that may be distracting.

Understand your loved one’s perception of the situation or problem. Inconsistent or conflicting information from others may have confused them. Poor memory, recall, or denial may also contribute to lack of understanding. You may need to correct information that was misunderstood.

Watch for verbal and nonverbal cues. Observe and listen for signals that indicate if your loved one wants more information, or if they have enough. The purpose is to provide enough information for informed decision making and planning, while not overwhelming them with unwanted details.

Allow your loved one opportunity to respond and express emotion, and don’t take their reaction personally. It is OK to be sad or angry when we hear difficult information. Acknowledge and validate these feelings.

Summarize and strategize. Offer appropriate guidance and solutions while also considering other ways to solve the problem.

Bad news is any information that is something other than the information desired by the recipient. Communicating bad news can be overwhelming for both the deliverer and the receiver of the information. Effective and respectful communication involves understanding, where all involved feel listened to and cared for, and can change the outcome of these difficult conversations, opening doors for new possibilities during challenging times.

What experiences have you had with breaking bad news or having difficult conversations? What strategies worked for you and your loved one? Please share your stories with us and other caregivers who may benefit in the comment box below.

2 Comments Post a comment
  1. Sometimes talking about hospice can also be a great relief to a loved one. My wife, who died of cancer, was extremely happy when we discussed getting hospice care (this was for home care). She had confidence in the hospice services and even more so after meeting them. This allowed her to relax, let go and move through her dying process with little to no concern. Without hospice she knew I would be overwhelmed and at times clueless, even inadvertently dangerous, as the primary caregiver.

    April 30, 2012
    • As you described, I often see that having difficult conversations, whether about hospice or any other topic, provides a much needed sense of relief for all involved. Fear of the unknown is often our highest source of anxiety. Acknowledging these fears and worries provides opportunity for sensitive conversations that lead to problem solving and solutions. It sounds like you and your wife were able to have this open dialogue and communication, and that hospice was of great support to both of you. You provided her with a wonderful gift by caring for her at home, where she wanted to be.
      Thank you for sharing your story and for following Caring with Confidence.

      May 1, 2012

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