Communicating with dying clients and their relatives

Dying clients and their relatives often have preconceived ideas and sometimes misconceptions about death and dying. Whilst some individuals seek answers and reassurance from religious sources regarding the where, when, why and how death might befall them, many clients and their loved ones look to health care professionals. Unfortunately we are not always able to give an unequivocal response and often fear that anything we do say will create even greater anxiety and distress. Often we feel too uncomfortable with the topic ourselves to believe we can be of any help to others. Rather than admit these facts, all too frequently we adopt the tactic of self-preservation whereby we use a variety of strategies, consciously and sometimes unconsciously, in the hope of avoiding these difficult questions. The commonest strategy in busy health care environments is to focus on clients’ physical needs and appear ‘too busy to chat’. The consequence of such actions is that clients and their families are frequently left with unmet needs. The following section is therefore designed to offer some pointers for novice health care professionals when communicating with dying clients and their significant others.

Always remember, dying clients are, in fact, still very much alive and may not necessarily wish to be surrounded by those they perceive to be doom and gloom ‘experts’, nor wish any encounter to be planned like a military operation. They very often welcome the approach of bright-eyed,effervescent, naive neophytes so never be afraid to stop and talk to a client who is known to be dying: it can make such a difference to their last days, hours or moments of life. The greatest skill is recognizing when they wish to be left alone.

Before the interaction:
• Be clear about your own attitudes, values and beliefs about death and dying.
• Learn about and endeavour to be accepting of others’ differing values and beliefs.
• Do not underestimate the importance of spirituality to some clients.
• Do not assume that because it is OK for you and your nearest and dearest that it will be OK for others.
• Be aware of the support mechanisms you can draw upon if you feel you are getting ‘out of your depth’, such as the Macmillan nurse, palliative care team, chaplaincy and specialist counselling services.
• Establish what has or has not been said by the doctors and other health care professionals.
• Establish whom the client wishes to be present during the interaction, taking care not to be drawn into any collusion or secrecy.
• For some clients tape-recording the interaction can be helpful to refer back to. They may then also share it with others if they so wish.
• If possible prepare the environment to ensure privacy and no disturbances.

At the commencement of the interaction:
• Try not to have any preconceived ideas: each client and relative is a unique individual and may respond very differently to similar sets of circumstances.
• Think before you open your mouth to speak.
• Establish the most important source of information to the client/family.
• Establish the client and family’s level of awareness of the situation.
• Establish trust and confidence.
• Try not to be judgemental.
• Do not be afraid to stop and listen.
• Be accessible; show that you have time and are willing to listen.
• Don’t be afraid to say ‘I don’t know’.
• Don’t agree to collude or keep secrets.
• Be prepared for the vast array of reactions that can occur, such as anger, guilt, fear, denial, acceptance or loss of control.
• Sometimes anger can be directed at you; try not to appear defensive unless truly warranted. Don’t take it personally. Try and stay calm and kind. Try to understand and to see the situation from their perspective. for guidance as to what to do should the situation become particularly aggressive or violent.
• Empathy in this situation is almost impossible, but sympathy and compassion can be equally important.
• Give time to grieve, talk, and reminisce, to express fears and anxieties, to express wishes and dreams.
• Offer to contact a priest or other religious leader if the client wishes.

At the end of the interaction:
• Ensure that the client and/or their relatives are clear about the key points of the interaction.
• If appropriate write down the key points for them to keep, refer back to and/or, if desired, share with others.
• If necessary arrange a day/time for a follow-up consultation.
• Make it clear that either you or a colleague are available at any time should the client require any further help or support.

Following the interaction:
• Document any key points that will facilitate continuity of care.
• If you have indicated that you will contact another person, health professional or agency, be sure to do so promptly before you become involved with other tasks that mean you might forget later.
• Endeavour to promote a positive atmosphere.
• Always convey the impression that you have time, and pay attention to the little things, as they often mean the most to clients and those they love.

Communicating with dying patients and their significant others is probably one of the hardest tasks facing health care professionals, but it can be one of the most rewarding. Do not be disheartened if you are left thinking you didn’t get it quite right. It takes time to develop the skills. Instead analyse the interaction and discuss your thoughts and feelings with your mentor or other members of the health care team.