The delivery of palliative care comes with a number of sensitive issues for both patients and healthcare professionals (HCPs). To address these challenges, HCPs need to be able to communicate in a way that is not only effective, but also sensitive. Patients in the palliative care phase tend to come to us accompanied by family and friends, which also need to be included in any important discussions.
Arguably, it is more challenging to communicate with patients and their loved ones when they are often in a highly emotive state, perhaps manifesting in anger, guilt or psychological distress. For decades, certain emotions have been associated with varying behaviours (May, 1977), some of which include displays of aggression or euphoria, to name a few. May (1977) is clear that emotions take different forms that encompass physiological, as well as cognitive, expressions. In palliative care, it is evident that such emotions are often provoked when HCPs break news that alters or threatens patients' reality. As such, it is important to note that all emotions—anger, in particular—uses up a lot of our energy (May, 1977); therefore, these cannot be sustained for long periods of time without making the patient lethargic. This means that the initial approach of HCPs in dealing with their patients' emotions should be to find ways of reducing its intensity through trying to support that person.
Many commentators, including Fisher (2017) and Patell et al (2018), suggest the use of numerous facilitative communications skills to manage patients' emotions. Given the plethora of such skillsets and techniques, this column focuses on the use of empathy and the art of being silent (pausing) as the first steps towards supporting patients and their expression of emotion. It is not intended to offer a definition of empathy here, but, instead, to suggest how it can be used effectively to benefit the patient. The use of such basic but key communication skills can also help HCPs develop a robust and trusting relationship with patients and their loved ones.
The art of silence
The skill of maintaining silence with patients involves the use of purposeful silent periods to enable the patient to divulge more information about their emotional state. Although these periods of silence may be difficult to endure and seem very lengthy, HCPs should remind themselves that the patient's mind will be engaged in processing their situation and responding to any questions or information given (Fisher, 2017). The silence allows patients to reflect on their condition and its impact on both themselves and their loved ones. The temptation for HCPs is to interrupt and ‘fill the void’ to avoid discomfort, which would be counterproductive to the entire exercise. One technique to practise is to try and hold silence for up to 90 seconds; if the patient has not said anything in this time, the HCP may want to gently probe by asking them to explain what they are thinking at that moment. Fisher (2017) reminds us that thoughts and feelings can sometimes be difficult to verbalise, so it is important to also watch for non-verbal cues.
‘Walking beside’ your patient
The skill of empathy is often equated to the ability to imagine how the patient might be feeling without forgetting that it is impossible to exactly experience another person's emotions. Simply put, it is the realisation that we cannot ‘walk in their shoes’ but, instead, we can ‘walk besides them’. Empathising can greatly increase rapport with the patient (Fisher, 2017) and lead to more important disclosures by the patient. With greater disclosure comes a better understanding of their issues and needs, which forms a good basis to support the patient effectively. Indeed, with rapport established, patients often begin sharing their feelings, thoughts and aspirations with their attending HCP more freely. Therefore, it is important that we acknowledge the patient and their feelings in two significant ways:
- Reassuring them that we have genuinely listened to their issues;
- Giving them an opportunity to correct us if we have misunderstood them in any way.
It is important that our acknowledgement takes into account any verbal and non-verbal cues the patient might exhibit.
Food for thought
As community nurses, readers will be visiting numerous patients throughout the course of their working day. Therefore, it is important to think through how one can prepare for the next patient, who may be meeting you for the first time. That interaction is the only time they have to express and share their concerns, fears and successes with you, and is it important, therefore, that you try to prioritise them as best as possible, despite the fact that they may be your fifth patient of the day. It is crucial that HCPs use both empathy and listening skills to afford patients the opportunity to share their innermost fears and feelings in a safe and empowering place.