“Bad News” Communication in Palliative Care: A Challenge and Key to Success
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INTRODUCTION
An important skill of any healthcare provider is the ability to effectively communicate, an especially key element in the relationship between physician and patient. Successful and effective communication results in conveying and listening to information in a manner that is most appropriate to both the recipient and the provider of the information. Being “most appropriate” means that the goals of the interchange, including content, intent, and expectations, are met and understood by those involved. The approach in communicating information, predictions, and prognoses to patients and loved ones will have a crucial affect on their current and future behavior, as well as potentially on treatment and illness outcomes.1
CASE PRESENTATION
A 94-year-old female with metastatic breast cancer was residing in a nursing home. The staff felt that she would benefit from transfer to an attached palliative care unit because of difficulties the nursing home staff were having meeting her symptom needs, especially bone pain. The family, which included a son, a daughter-in-law, and a granddaughter, seemed interested in the proposed transfer to the palliative care unit. The nursing home physician, trying to be supportive in her explanations of the expected prognosis and palliative care needs, suggested to the family that it was difficult to anticipate the patient’s life expectancy, and that it could potentially be some weeks before she died.
The family, including the granddaughter, who seemed to be the family spokesperson, visited the palliative care unit and spoke to members of the care team. The team discussed the philosophy of palliative care and the focus on symptom management. They explained the likely course the grandmother would experience during her stay on the unit. From the staff point of view, it was deemed that the patient was pre-terminal with a potential life expectancy of no more than 2-3 weeks. The next day, a Friday, the patient was transferred to the unit because she appeared to be very uncomfortable, and the nursing home staff felt that they could not adequately provide effective pain management. When the unit’s attending physician evaluated the patient, he concluded that she was terminal with Cheyne-Stokes respiration and expressions of severe pain that interfered with nursing care, including the basic process of turning the patient.
The physician ordered morphine subcutaneously, with the dose based on previous morphine doses on a flexible dosing schedule that allowed for breakthrough pain. Supplemental haloperidol was ordered for agitation aggravated by the pain. Over the next 36 hours, the patient’s symptoms gradually came under control. The granddaughter expressed concern about the decline in the patient’s wakefulness. Medical advice was sought from the weekend on-call physician. With a decrease in medication, the patient began moaning again, and therefore the dose was increased to address the painful symptoms, much to the dismay of the granddaughter.
The patient died that weekend. According to the nursing staff and the on-call physician, her symptoms were apparently well-controlled. The physician explained to the granddaughter the rationale behind the medication orders, and tried to assure her that her grandmother was comfortable and that she was in the process of dying. He emphasized the importance of adequate pain management in her final period of life. She died with the staff believing that they had achieved the patient’s palliative care needs; the patient’s son, granddaughter, and daughter-in-law seemed satisfied with the care.
A week after the death, the unit’s social worker received a letter outlining a list of care concerns expressed by the granddaughter, on behalf of her family.
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