How to initiate a palliative care conversation?

From the Guidelines

Having a palliative care conversation requires a compassionate, clear, and well-timed approach, and clinicians should use an organized framework to guide the bidirectional communication about end-of-life care with patients and families, as recommended by the American Society of Clinical Oncology consensus guideline 1. To initiate the conversation, find a quiet, private setting and ensure adequate time without interruptions. Start by asking what the person understands about their condition, using phrases like "What has your doctor told you about your illness?" Listen attentively to their response. Then, express concerns directly but gently, using clear language while avoiding medical jargon. For example, say "I'm worried that your illness is progressing" rather than using euphemisms. Some key strategies to consider include:

• Mental preparation: Prepare for discussions by anticipating patient and family member emotions as well as questions about topics such as prognosis 1.
• Develop rapport with the patient and family or caregivers.
• Information preferences: Ask patients and families about their preferences for information sharing.
• Assess understanding: Ask patients and families what they understand about their medical situation.
• Provide information in small amounts, using language appropriate to the patient’s level of education and health literacy, and check understanding frequently.
• Address emotions: Acknowledge and address emotions throughout the conversation.
• Define goals: Ask patients and families to define their goals in light of the medical situation. Discuss goals of care by asking what matters most to them at this stage, what they hope for, and what they fear. Explain that palliative care focuses on improving quality of life through symptom management, emotional support, and practical assistance, while emphasizing that it doesn't mean giving up hope or stopping all treatments. Address specific concerns about pain management, explaining that medications like morphine, hydromorphone, or fentanyl can be carefully titrated to control pain without excessive sedation. Discuss other symptom management options for common issues like nausea, breathlessness, or anxiety. Throughout the conversation, pause frequently, check understanding, validate emotions, and reassure the person that the healthcare team will continue to provide support regardless of what decisions are made. End by summarizing the discussion, outlining next steps, and scheduling a follow-up conversation, as these discussions often need to happen over multiple sessions as the person processes information. It is also essential to explore how a patient’s culture, religion, or spiritual belief system affects their end-of-life decision making or care preferences, and to recognize and respond empathically to grief and loss among patients, families, and themselves 1. Additionally, introducing and describing palliative care services, including simultaneous palliative and oncology care, palliative care alone, and hospice care, early in the course of terminal illness, can help patients and families make informed decisions about their care 1. Palliative care has been shown to reduce symptom burden, improve quality of life, and increase the odds of dying at home, and successful integration of palliative care early in the continuum of care reduces morbidity for patients with cancer and enhances patient and family/caregiver satisfaction 1.

From the Research

Effective Communication in Palliative Care

To have a palliative care conversation, it is essential to consider the following key elements:

• Open and honest information exchange 2
• Alignment with the patient's and relative's process of uptake and coping with information 2
• Empathy and understanding 2
• Clear and understandable language 2
• Leaving room for positive coping strategies 2
• Committed health-care professionals taking responsibility 2
• Recognition of relatives in their role as caregiver 2

Patient and Relative Preferences

Patients and relatives appreciate health-care professionals who:

• Pay attention to strictly medical issues as well as the patient's personal experiences and processes 2
• Use effective communication to facilitate shared decision-making and promote an empathic care relationship 2

Symptom Management and Medications

Commonly prescribed medications in hospice care include:

• Opioid and nonopioid analgesics
• Anxiolytics
• Anticholinergics
• Antipsychotics 3
• Benzodiazepines, such as lorazepam, for anxiety and agitation 4
• Morphine for pain management 5

Cognitive Behavioral Therapy (CBT)

CBT techniques can be used to help manage anxiety and depression in hospice patients, and can be applied by palliative care professionals with short CBT training 6