Dr Catherine Millington Sanders, GP and National Clinical Lead for Difficult Conversations, shares her experience.
I recently had to explain to a woman that she was dying of metastatic breast cancer. She was a single mother with two beautiful children. Unfortunately, for so many of us, these types of difficult conversations are a daily part of our job. It’s never easy, no matter how long you’ve been in the profession, but I find the following tips very helpful: even when a difficult conversation creeps up in the middle of a consultation.
1. Preparation prevents poor performance
In our profession, our words matter and our patients remember them and take them with them on their journeys. We’ve all heard patients come in and repeat, whether good or bad, ‘Doctor X, told me that ABC was going to happen’. So before you start a conversation, take a ‘difficult conversation moment’ and focus on the task ahead.
2. Identify the difficult part
Try to pinpoint exactly what the challenge of the difficult conversation is for you: perhaps your lack of knowledge, a lack of confidence or because it has a personal resonance for you.
3. Consider a communication framework
We use a proven framework in our training, which I find is a help to structure your conversations. When used regularly, this becomes second nature.
4. Ask, don’t assume
It is so easy to make assumptions – listening is different to waiting to speak. Before you start, ask your patient if they would like someone else to be present. Ask them what their understanding is and find out what is important to them. Remember to consider their language ability, cultural, psychosexual and religious/spiritual needs and wishes.
5. Pace the conversation
Understand where your patients and those important to them need support and guidance. Have conversations in stages at the person’s individual pace. There is often a lot for people to process when they are hearing bad news and this can take time. Provide time for questions.
6. Is the time right?
If a person is not ready to have a difficult conversation, acknowledge this and ask if it would be okay to come back to the conversation another time.
7. Honesty is the best policy
Acknowledge that what you may find difficult to say, your patient may not find difficult to hear. Even if they do, they are often grateful for your honesty.
8 Document, document, document
Know the legal process: consent, capacity and legal documentation and for everyone’s safety: document all aspects of the interaction.
9. Sharing is caring
If, for whatever reason, you are unable to have that difficult conversation, ensure you hand the responsibility over to a person who can. Work in partnership with and signpost to your multidisciplinary colleagues and other services.
10. Know your limits: check your internal barometer
We’re all human. It’s important to gauge how you are feeling to enable self-compassion and resilience. For example, are you having a good day (8/10) or a terrible one (2/10)? How do you feel after a difficult conversation? (Rate again).
11. Compassionate organisations build personal resilience
Encourage compassionate conversations within your workplace – working within a empathetic organisation with supportive networks really will help to build your own resilience.
Difficult Conversations GMC-endorsed End of Life Care Planning and Communication Skills Masterclass provides training for professionals aiming to master compassionate and effective care planning and communication at the end of life.