‘Keeping It Human’ When Having Difficult Conversations With Patients Receiving Terminal Cancer Diagnoses

‘Keeping It Human’ When Having Difficult Conversations With Patients Receiving Terminal Cancer Diagnoses

Oncology nurses and advanced practice providers play a pivotal role in providing patients with cancer and their families with the emotional support needed to navigate a terminal diagnosis, an expert said.

Oncology Nursing News spoke with Kristina Espinosa, PsyD, oncology psychologist at Baptist Health, to learn more about the emotional intelligence and communication skills needed by oncology nurses and APPs to have difficult conversations with patients who received a terminal diagnosis of cancer and the complexities of cancer itself.

What is an oncology nurse’s role in having difficult conversations with patients who received a terminal diagnosis?

Being part of a multidisciplinary team, we know oncology nurses develop a unique relationship with patients over the course of the disease trajectory, and with the advancement of nursing practices, they play a pivotal role in targeting difficult conversations and leading them with patients and their families. It is going to be especially important that nurses learn to navigate not only how to communicate with patients, but also with physicians, because at times, they serve as the integral connection between the physician and the patient. Communication is what informs, educates, and supports our patients, and it is not so much what we say, but how we say it. That is going to be important for oncology nurses to navigate throughout the patient’s medical journey at multiple points such as initial diagnosis, treatment, during end of life, or in alterations of disease trajectory, recurrence, and so forth.

How can nurses provide support for these patients during recurrence, a difficult diagnosis, or another time during the cancer journey?

There is a wealth of information in how to best support our patients, including different mnemonics and checklists of what is right and what is wrong. I consider 3 simple but major points, which is to communicate in a way that is honest, empathic, and with positive regard.

There are a variety of techniques that psychologists use in their work to enhance rapport between clinician and patient. One of my favorites, that I incorporate to increase the quality of a working relationship is unconditional positive regard, developed by Stanley Standal and then popularized by Carol Rogers. Unconditional positive regard refers to being curious about how a patient is feeling without judgement and with full acceptance to support the patient. And this technique highlights a form of person-centered care.

When we communicate honestly, patients have a clearer picture of what is going on, and it can lead them to feeling more empowered. Oncology nurses aim to best support their patients and surely want to instill hope, but at the same time, they will need to deliver news in a way that provides patients with realistic expectations. The goal here is not to create more worry or diminish hope, but rather to prepare patients for those difficult moments in their lives. We are going to need to, yes, instill hope, but still be practical. And this is where honesty comes in.

To communicate empathically means to meet the patient where they are at emotionally with consideration. That is inevitably a challenge in and of itself, as we are humans navigating through our own emotions as well. But starting out with learning to pay close to attention to emotional cues is going to be essential for oncology nurses to use this skill effectively. For example, there are many subtleties within the behavior, such as if someone is a bit more silent, or a bit more reserved than usual, or they may seem as though they are lashing out a bit. All of these are signs in the way that a person is processing information and their emotions in their own way. We must take a step back and be more aware of these individual presentations of behavior to respond supportively and empathically.

There is a mnemonic—I think oncology nurses may be very familiar with—called NURSE responding to emotional cues. And it stands for naming the emotion, understanding the emotion, respecting the patient, supporting the patient, and exploring more. And that's a great way to tap into the emotional cues of a patient. The goal is not for nurses to become mental health experts but to become proficient in turning into these sensitive times.

Here is an example of the NURSE technique in action. Start with naming the emotion, “I can see you are saddened by the news.” Next understand, “I understand this must be a difficult time for you.” Respect, “I will respect your decision of how you would like to move forward with this information, such as if you want like some space to process this, if you want to talk to a family member, or another allied professional.” Support, “I would want to best support you during this time.” Last, explore, “Let me know me what you prefer, and what you are thinking now. I will work to make sure your request is met.”

Finally, using positive regard in communication. While I mentioned earlier the term “unconditional” this can be left in the scope of mental health professionals as we will navigate this tool uniquely. The term “positive regard” is simply having the utmost respect for the patient and where they are at in their journey, suspending judgement. Statements such as, “What can I do to best support you in this moment,” and allowing the patient to be the expert in their decision-making process. Other ways to use positive regard is to use a warm tone of voice, address the person by name, hold eye contact (appropriate for patient’s culture), allow moments of pause during conversation to allow the person to process, and respect their next steps in decision making.

Oncology nurses wear many hats, one of which is this role. What do they do when a patient is closed off, they're processing the news, and they may not want to talk to anyone? How should oncology nurses approach those patients?

With the utmost respect, oncology nurses and perhaps nurses in general, are trained to be rapid responders. They make decisions under pressure, assess, and provide immediate care to ensure the wellbeing of patients They are there to provide effective decision-making skills by asking the right questions and getting to the right solutions. But when we work with matters of mental health and emotional processing, rate of speed works a bit differently, because while we can elicit and invite a conversation, we cannot force it. There is power in holding space for another individual. Mental health providers use this phrase often such as, “Allow me to hold space for you right now.” This technique goes beyond medical care; it is also valuable in all kinds of interactions and relationships. This technique looks like taking some time to pause and listen, or maybe say, “If you would like to express to me how you feel, I am not going to judge. I do not need to respond if you do not want me to. I simply want to be present with you in this moment.” What you do as a listening ear is bear witness to what it is unfolding for the individual and intently be present. This is an impactful tool to strengthen a bond.

The next tool is silence, as a way to allow a moment for the patient to lead in their care, express emotion, and be met with empathy. We, as a society, often think we need to be action oriented all the time, but sometimes, slowing down and holding space is the action that is just right. It is OK for the pause.

How can nurses find the positive, especially during a terminal diagnosis?

When we think about positivity, we think about hope. We make connections between positive thinking and hopeful outcomes; however, a terminal diagnosis may be difficult to fit into that logic. Every moment that you have with that patient is a moment that the patient is experiencing, and positivity can be related to providing them with comforts, with reassurance they have the support, with respecting how they want to be honored in their final days. These mindful approaches embrace positivity in its meaning to have dignity in this universal human experience. We can feel positive that our life matters, and our voice does as well. Therefore, the positivity is the hope that those caring for us in the final moments of our life acknowledge and honor our requests to make our human experience meaningful.

Nurses are meant to be a source of support for patients. But how can nurses also take care of themselves while they're having these difficult conversations?

We have all heard the phrase, “We cannot pour from an empty cup.” It is well known that as medical staff, supporting the patient is paramount, but what is even more significant is supporting the self. This looks like checking in with your own emotional cues and what's happening for you before attending to another’s emotional state. Perhaps while you function in the nurse’s role, you are also functioning as a full-time caregiver role at home. Your life is requesting of you many roles that can affect you emotionally and physically.

There are a variety of techniques to self-preserve and define your roles. The best place to start is understanding the way in which you handle and express stress. Do a quick check-in with the self and determine how you show up in moments of feeling overwhelmed or overworked. For example, do you notice you become more quiet or irritated, less focused, and tired? Then write down a list of tools you could use to feel more centered, such as deep breathing, going for a brief 5-minute walk, jotting down what you’re feeling, or speaking with a trusted colleague in determining extra support. It is not uncommon for stress to gradually increase, and stress get the best of us. This can look like internalizing someone else’s stress as our own, getting more stressed by another’s emotions because we feel its “too much,” and not fully being present with our patients. If you notice stress starts to affect your ability to clearly define roles within your life, it may be beneficial to speak with a mental health professional for further support in this area. There are many techniques one can learn and apply, but where to start is getting to know the self and how we respond to stress.

What advice would you give oncology nurses about having these conversations with patients?

Keep it human. In the era of AI and social media, we are becoming familiar with rapid responses and a large amount of information to sift through. This works great for business, but in terms of human connection, it can be a disruption in connecting authentically. Keeping it human means actively listening, responding with empathy and the intent to understand, and acting in a way that supports one another. Speaking directly with oncology nurses, there's no right or wrong in the way you should show up as a nurse and as a human being also going through hardship, joys, and moments of uncertainty. If you lean in with empathy and with acknowledging the emotional experience, you're doing a great job. You’re doing it! The last is that as long as you realize how important your role is as an oncology nurse, that is going to transcend in the manner in which you speak to your patients and their families, and provide quality care. And that’s going to lead to better mental health and physical outcomes.

Anything else you would like to mention?

Oncology nurses need to be supported by leadership and institutions, as they are critical and valuable in the care of patients’ wellbeing. They're doing so much. And as much as we want them to check in with themselves emotionally, we must provide resources and an environment that provides a foundation to do just that. Mental health resources should be readily available, when needed.

This transcript has been edited for clarity and conciseness.