Holidays Make End-of-Life Discussions Even More Challenging

By Mary Hanley, LMSW, CancerCare

Talking about end of life during what should be the happiest time of year can be difficult, but studies have shown that adults, including those with cancer, have a greater chance of dying during the holidays.¹ No one really knows why death spikes at that time, but a leading theory is that people in need of medical attention will put off seeking medical care in favor of spending time with their loved ones.¹

Nurses caring for patients in hospice care should communicate any holiday-related changes in schedule to the patient and any caregivers as early as possible. Patients tend to be more comfortable disclosing medical information to providers they trust.² Nurses caring for patients with cancer who are not receiving services at home should advise those patients to seek necessary medical care at any time, even during holiday activities.

Consoling a Patient

The end of life is a very challenging time for the person who is ill and also for their loved ones. The patient may experience feelings of regret, sadness, and anger and question spiritual beliefs. Starting conversations can be uncomfortable for both the patient and loved ones. Nurses are well positioned to help open this discussion and model how it can play out. It is not uncommon for patients to use tester questions or statements to see if loved ones are open to engaging in a conversation. A nurse who is asked to weigh in on an end-of-life concern should respond compassionately, which will facilitate a more in-depth and honest conversation.

Discussing religion happens more often around the holidays, because 95% of Americans celebrate at least 1 holiday in December.³ Although these celebrations often appear to place less emphasis on religion than those in the past,⁴ the end-of-life process tends to lead the dying person to examine these beliefs more carefully in search of meaning.

In these moments, the most important thing a member of the health care team can do is be respectful, honest, and engaged.⁵ Show genuine interest in what is being said. Patients may be concerned about burdening others, a feeling that may be heightened during a usually celebratory time and lead to additional remorse. Thoughtful intervention at this moment, however long or short, can foster difficult discussions with family without having a negative impact on the hopefulness of the season. Giving a patient the space to be heard in a way that will not invoke these myriad feelings can be significant for the patient and has the potential for healing across the family system.

Consoling the Family and Loved Ones

Coping with the death of a loved one is often hardest this time of year and can be underdiscussed. Research shows that a family systems perspective can work well for those experiencing anticipatory grief—a phenomenon that is common for both the patient and loved ones. This model aims to “optimize cohesion, communication (of thoughts and feelings), and the handling of conflict while promoting the sharing of grief and mutual support.”⁶ Because of a nurse’s unique relationship with patients, operating between the science of medicine and the holistic nature of suffering, these findings can help inform the approach taken with end-of-life family units. This conversation can stem from a medical perspective: what to expect the process of dying to feel like for the patient.

Ideally, a nurse will introduce these conversations early, before the family becomes busy with holiday preparations. It is also helpful if concerns related to a patient’s affairs (eg, location of important documents, whom to contact about the will, or the patient’s dying wishes) are discussed beforehand. Talking about concrete matters such as these in a safe space can make the family more comfortable.

Encouraging and normalizing these conversations can help patients and loved ones be more honest when discussing expectations for the holidays. In turn, this conversation can create an environment in which each family member can celebrate the season and also give voice to the sadness, allowing a mix of feelings and thereby some closure, and softening future reflections.

Advice for the Bereavement Phase

Losing a loved one is a universally difficult experience. If loved ones are willing to engage in a discussion about end of life and bereavement, nurses can assist by offering bereavement resources ahead of time. Individual and group counseling can greatly help individuals process grief in the months after becoming bereaved.

CancerCare offers free educational resources and face-to-face counseling for the bereaved in New York and New Jersey, as well as online bereavement support groups nationally. Oncology social workers provide these services. A hospice social worker or oncology social worker from the patient’s treatment center can also refer patients to local bereavement resources.

Mary Hanley is an Oncology Social Worker at CancerCare focusing on increasing awareness and emotional support of caregivers to cancer patients. Mary received her MSW degree from Adelphi University.

References

• Christensen J. Why do more people die at Christmas, New Year’s? CNN website. cnn.com/2013/12/23/health/christmas-death-rate/index.html. Updated December 23, 2013. Accessed November 13, 2018.
• Rowe R, Calnan M. Trust relations in health care--the new agenda. Eur J Public Health. 2006;16(1):4-6. doi: 10.1093/eurpub/ckl004.
• Flynn T. Five percent of Americans celebrate no December holiday. Center for Inquiry website. centerforinquiry.org/blog/five_percent_of_americans_celebrate_no_december_holiday/. Published December 23, 2013. Accessed November 13, 2018.
• Lipka M, Masci D. 5 facts about Christmas in America. Pew Research Center website. pewresearch.org/fact-tank/2017/12/18/5-facts-about-christmas-in-america/. Published December 18, 2017. Accessed November 13, 2018.
• Talking about death and dying. Dying Matters website. dyingmatters.org/page/TalkingAboutDeathDying. Accessed November 13, 2018.
• Watson M, Kissane D. Handbook of Psychotherapy in Cancer Care. West Sussex, UK: John Wiley & Sons, LTD; 2011.