Nurse Perspectives on Difficult Conversations: How Do I Tell My Kids That I Am Dying?

Anna Skwira-Brown, APRN, AOCNP

Oncology nurses may frequently find themselves in emotional conversations with their patients within a moment’s notice, which can be overwhelming at times. However, learning to take a pause before responding, showing a willingness to understand, and trying to make the patient feel supported are the best steps a nurse can take in any situation, according to Anna Skwira-Brown, APRN, AOCNP.

Brown, a nurse practitioner at Essentia Health Duluth Clinic in Minnesota, recently co-authored an article in the Clinical Journal of Oncology Nursing about best practices in palliative and end-of-life nursing conversations.¹ In a case-study format, Brown outlined an instance in which “Mary,” a 63-year-old bookkeeper who underwent surgery and chemotherapy for colon cancer, confides to her nurse that she does not know how to tell her kids that she is dying after a CT scan shows ascites and liver metastases.

Mary, who was in the midst for filing for disability when she developed pain, nausea, and weight loss, had 3 adult children. In a family discussion with the medical oncology team, all 3 children agreed that “Mary is a fighter,” because of her past cancer treatments and her life as a single mother. Yet, when the children leave the room, Mary confides in the RN, “Ella,” that she felt too tired and sick to “fight” anymore.

Brown explained that this case study was based on a real-life experience.

“This happened to me when a patient said, ‘How am I going to tell my kids I’m dying?,’” Brown told Oncology Nursing News®. “I had 2 young kids at home [at the time] and the first thing I thought of [was] that would be the most awful thing in the whole wide world, but that’s not what this patient needed to hear.”

Take A Pause

As Brown highlighted in the case study, and noted in the interview, an RN who finds themselves in this situation can always benefit from taking a short pause before responding—although it may seem awkward or uncomfortable, a brief silence can permit the RN to take a moment to gather their thoughts.

“One of the most powerful things the nurse in this case study does is pause,” Brown said. “As nurses, we are inclined to try and answer questions. We try and answer the content at the surface level. Pausing gives everybody a break. When a patient asks a question that can be really emotionally impactful, that’s just a moment [where] more than anything, we all have to take a breath.”

In terms of addressing the patient’s question, Brown noted that it can be intimidating, and that the RN may feel pressured to say the “right thing.” However, in this instance, a great place to begin the conversation is to try and name the emotion that the patient seems to be feeling. In this example, Ella, the RN, made the following statement in her desire to be empathetic: “That sounds like a really hard thing to be thinking about.” She then stated, “You seem sad.” Pause. “And maybe scared?”

Brown noted that Ella does not to be correct about the emotions of the patient. The important part is that she is open and inviting the patient to communicate with her.

“Attempting to understand what that must feel like is the important part. And then listen. We could say, ‘This helps me understand what you’re thinking,’ ” Brown explained. “If I said to the patient, ‘That sounds really hard,’ or, ‘That must be a really hard thing to be thinking about.’ She might say, ‘No, I’m angry,” Brown said, adding that follow-up response could address that gained understanding of their emotions. “Whatever the patient says, it’s [important] to make sure that they know that you’re listening, not reflecting on your own angst about what a hard question that might be,” she underscored.

In the case-study example, Mary cried and explained her fear and anger about her cancer recurrence. Ella asked Mary what her concerns are about talking to her children and Mary shared that she felt guilty that she would not be able to provide for the family, and she is heartbroken that she would not be able to see her grandchildren grow.

Respect and Support

At this point, the initial conversation had ended. Ella helped Mary feel both heard and supported. In future visits, when the nurse practitioner asked if Mary is OK with being asked some questions about the familial understanding of the illness, Mary admitted that she shielded them from bad news. The team encouraged her to consider ways to talk to them on an individual basis.

According to Brown, nurses may often be caught off guard by surprising or hard questions from patients and caregivers. However, this case study illustrates how the power of pausing and finding a way to make an empathic statement can be more important than an immediate attempt to find a right answer.

“We don’t have to know how to say the right thing at the right time,” Brown said. “I think a lot of us didn’t learn how to do this—some of our families might have helped us duck away or use some humor, or change the subject. But this is about seeing these situations as opportunities to really try and center ourselves on what the patient is saying.”

Integration Into Practice

When building communication skills, nurses should not be hard on themselves, Brown noted. She said to recognize that nurses are all always learning and to see new and difficult situations as an opportunity to improve. She also noted that there are many free resources available to help nurses prepare themselves to handle difficult converations.²

“Knowing where the resources are can be really important,” Brown said. “I’m seeing more and more clinical guides on websites, there are groups that are really working toward improving communication [for health care providers].”

She concluded by noting that communication skills are similar to technical skills, such as starting an IV or changing a dressing: both need to be practiced.

“Communication is 1 skill that all of us are always improving,” she said.

References

1. Spine K, Skwira-Brown A, Schlifke D, Carr E. Clinical oncology nurse best practices: palliative care and end-of-life conversations. Clin J Oncol Nurs. 2022;26(6):612-620. doi:10.1188/22.CJON.612-620
2. Responding to emotion: respecting. Vital talk. Accessed February 6, 2023. https://bit.ly/3wZYd3T