Caring and supporting patients at the end of their lives comes with numerous challenges for healthcare professionals. One of the main challenges is how to communicate effectively with patients and those important to them. It is even more challenging when communicating with patients and families expressing emotions such as anger, aggression, guilt or psychological pain. Emotions have for decades been associated with different manifestations of behaviours (May, 1977:75), some of which result in people expressing anger, euphoria or aggression. May is clear that emotions take different forms wide enough to include physiological as well as cognitive expressions. Here, I shall focus only on communication with people expressing cognition-related aspects such as loss of logical thinking, disrespecting social norms or etiquette (e.g. being rude and then apologising, often after the emotions subside), fear, anxiety, hostility and anger. In palliative care, such emotions are provoked when we break bad news. It is important to note that all emotions, but particularly anger, use up a lot of energy. Therefore, they cannot continue for prolonged periods of time without making the patient tired and lethargic. This means that our approach to dealing with or handling most emotions is to find ways of reducing their intensity by trying to support the person.
Many commentators including Fisher (2017) and Patell et al (2018) suggest the use of numerous facilitative communications skills to manage patients' emotions. There is a plethora of these skills, but this column focuses on the PEAS technique, which makes it easy to remember key skills during intense conversations with patients and still be effective. The use of these key skills can also help us develop a professional relationship with the patient and their close family members.
The PEAS technique described below represents a basis of the fundamental communication skills at our finger tips:
Pausing involves the use of silent periods to let the patient divulge more information during consultation. Although it may seem silent for us, the patient's mind is busy processing the question or what has been told to them, and they are reflecting on their situation and its impact on them and their family. The temptation is to interrupt them and fill the ‘void’ as silence can sometimes be difficult, but this would be counterproductive. We should try and hold our silence for up to 90 seconds, and if the patient has not said anything, we may want to gently probe by asking them to tell us what they are thinking of at the moment. Fisher (2017) urges that at times, thoughts and feelings can be difficult to put into words, so non-verbal cues should be looked out for as well.
Empathising greatly increases our rapport with the patient and can lead to more disclosure. With this comes better understanding, which forms a good basis to support the patient effectively.
Acknowledging what the patient is telling us verbally or through cues confirms we are actively listening, whereby Fisher (2017) claims the patient is more likely to share their fears and concerns with us.
Summarising the key points from the conversation every now and again confirms our understanding of the patient's emotions or situation, while offering them an opportunity to correct us and/or add information we may have missed. Summarising can also help us to refocus ourselves in the dialogue with the patient by rehearsing what has been discussed so far.
When the PEAS technique is used effectively, it can foster trust in patients and therefore enable them to discuss their fears and concerns more openly (Fisher, 2017). There is not always an expectation to have an answer, but to listen. Most district nurses see more than one patient in a day, and it is important to think through how they prepare themselves for the next patient, maybe as they travel to the consultation. That next patient may be meeting the nurse for the first time that day, even though they could be the fifth patient the nurse has seen. The point is that this interaction is the only one they will have with the nurse to express their concerns, fears and other emotions, so we need to afford them the opportunity to share their innermost fears and concerns safely through use of the PEAS technique.