Strategies for Having Difficult Conversations

Patients with advanced and incurable cancers grapple with the emotional impact of a life-limiting illness, difficult treatment decisions, and the challenge of sustaining hope while maintaining realistic treatment goals.1

Oncology nurses develop strong, trusted clinical relationships with their patients, caregivers, and families. Throughout their disease, patients and their loved ones look to the oncology nurse for guidance and support. As a result, oncology nurses often have many difficult conversations with patients, particularly when the cancer relapses or worsens.1

A difficult conversation can be defined as one that takes place between the oncology nurse and the patient at transition points on the disease trajectory.1

A well-conducted difficult conversation can help establish multifaceted goals of care, encompassing physical, emotional, and psychosocial domains. A well-led conversation also provides a forum for setting realistic expectations and sustaining hope.1 The following general tips can help facilitate a constructive conversation.2

Communication Tips2

Do Don't
Give a direct, honest prognosis Avoid responding to a patient request for information about prognosis
Provide prognostic information as a range; acknowledge uncertainty, eg, "we think you have weeks to a small number of months, but it could be shorter or longer" Provide vague, eg, "incurable" or overly specific information, eg, "you have 6 months"
Allow silence Talk more than half the time
Acknowledge and explore emotions Provide factual information in response to strong emotions
Focus on the patient's quality of life, goals, fears, and concerns Focus on medical procedures

Effective communication with cancer patients creates an environment that promotes better emotional response to diagnosis, enhanced cooperation with the healthcare team, and increased compliance to treatment.3 Ask-tell-ask, SPIKES, and NURSE are 3 structured models of communication strategies crossing many disciplines in medicine and psychology. These models can be drawn from when initiating a difficult discussion.1,4

Ask-Tell-Ask

The "Ask-Tell-Ask" strategy for difficult conversations allows an oncology nurse to learn about the patient's expectations, deliver information, and then assess for understanding.1

The Ask-Tell-Ask Strategy: Sample Phrases and Rationales1

Strategy Example for AP Rationale
Ask "I am hearing that you have a lot of questions that seem to be about your prognosis. I am happy to answer your questions. What worries you the most?" This is a patient-centered method that draws upon principles of negotiation. This question allows the AP to know what kind of prognostic information to disclose at this particular time.
Tell The AP discloses the prognostic information that the patient wishes to know at this particular time. Disclosure of specific prognostic information that the patient wishes to know fosters trust in the therapeutic relationship.
Ask "Did my response help answer your question?" This question helps to clarify the patient's understanding and need for information.
Note: AP = advanced practitioner. Information from Back & Arnold (2006) and Campbell et al. (2010).

SPIKES

The process of disclosing bad news can be extremely unsettling, even for seasoned professionals, but research shows that certain goals can help keep emotionally charged conversations on track. These goals include5:

  • Gathering information from the patient—gain an understanding about the patient's knowledge, expectations, and readiness to hear the bad news
  • Providing information that aligns with the patient's needs and desires
  • Supporting the patient by employing skills to reduce the emotional impact and isolation experienced by being the recipient of bad news
  • Developing a treatment plan with the input and cooperation of the patient

One strategy for accomplishing these goals is via the SPIKES tool. The SPIKES tool is a respected, six-step protocol for giving bad news that involves setting the stage, delivering bad news, and constructing a plan to move forward.1 Not every episode of breaking bad news requires all of the steps of SPIKES, but when used they are meant to be carried out sequentially.5

SPIKES Used in Conjunction With Ask-Tell-Ask1

SPIKES step Explanation Corresponding ask-tell-ask step
Setup Ensure that surroundings are conducive to a serious discussion of life-changing matters.
Perception Ask open-minded questions to ascertain how the patient perceives his or her medical situation. Ask: Establish what patient knows
Invitation Find out how much information the patient is comfortable receiving and discussing at this time.
Knowledge Disclose information to the patient and repeatedly check for understanding. Tell: Deliver news
Empathy Respond to the patient in a way that acknowledges his or her strong emotions and reassures him or her that these feelings are normal and expected.
Summary and Strategy Determine whether the patient is ready to discuss the next steps. When he or she is ready, check for understanding and questions and discuss treatment goals and strategies. Ask: Check for understanding and query about concerns and fears
Note: Information from Baile et al. (2000).

NURSE

The NURSE tool allows an oncology nurse to address and respond to the emotional response of the patient, which is absolutely vital when holding an emotion-laden conversation.1

The NURSE Tool Guides the Practitioner in Verbal Expressions of Empathy1

Skill Theme Example of phrase
Naming State your observation of the patient's emotion. "I can see you and your husband are concerned about your current condition."
Understanding Legitimize the patient's emotion. "I can imagine this news may be shocking."
Respecting Praise or acknowledge the patient's work. "I am so impressed with your courage."
Supporting Let the patient know he or she is not alone. "I want you to know that I will be with you throughout this process."
Exploring Ask the patient to elaborate on his or her feelings. "Tell me more about what is on your mind."
Note: Information from the Campbell et al. (2010).

References: 1. Svarovsky T. Having difficult conversations: the advanced practitioner’s role. J Adv Pract Oncol. 2013;4(1):47-52. 2. Bernacki R, Block SD. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994-2003. 3. Morgan B, Tarbi E. The role of the advanced practice nurse in geriatric oncology care. Semin Oncol Nurs. 2016;32(1):33-43. 4. Marcus JD, Mott FE. Difficult conversations: from diagnosis to death. Ochsner J. 2014;14(4):712-717. 5. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-311.