April 23, 2020

Delivering Bad News During a Pandemic

By Victoria Poillucci, MSN, MEd, ACNP-BC, Duke Cancer Institute

Being a nurse for nearly thirty years, I have been surrounded by sickness and death. I spent many years in the ICU talking to patients and their families at the end of life, talking about what the end will be like when the ventilator is shut off and helping patients to have a peaceful death while trying to say the right words to ease a family’s pain.

But I didn’t realize the skills it took to deliver bad news until I become a nurse practitioner working with cancer patients. It is here that I realized that the ability to conduct these conversations was even more difficult, as I had built a relationship with patients over time and slowly saw the disease and chemotherapy chip away at the hope that they once had about overcoming this diagnosis and living a long life with their family and loved ones.

Role of Communication at End of Life

Here we are now in the middle of one of the worse pandemics in history. During the past several weeks, we watched the news about the number of COVID-19–related deaths. It has become apparent that delivering bad news to patients with cancer is just as important. The compassionate way we deliver bad news will help alleviate fears and provide needed education about the unknown next steps that patient will take.

Honest and open communication between a patient and their health-care provider is vital, and it becomes even more important when an acute change has occurred or a chronic or terminal disease nears the end. It is at this juncture that a patient’s clear understanding from the thoughtful disclosure of information will allow the patient and provider to engage in shared decision-making and address all questions and concerns. It is important for this dialogue to be compassionate and supportive with an understanding that clear knowledge of the agreed-upon plan can improve the quality of care at the end of life (Kaldjian, Shinkunas, & Cannon, 2009).

Goals of Care Discussions

Goals of care discussions involve helping a patient make informed decisions regarding the use of life-sustaining measures, as well as identifying the patient’s desire for pain management and type of care they want to receive if they are unable to communicate this for themselves. Goals of care discussions may include treatment options, prognosis, quality of life, the dying process, patient values, and patient preferences if certain conditions present themselves (Starr, Ulrich, Corey, & Meghani, 2019). These conversations could also involve referral to palliative care or hospice and involve education about the role of these two entities. Discussions should also involve education surrounding advance directives with the patient and their families (Kaldjian et al., 2009).

Kaldjian and colleagues (2009) conducted a structured literature review of 116 articles to identify if there was a consensus of the top documented goals of care among those researched. The top six goals identified were: 1) be cured, 2) live longer, 3) improve or maintain function/quality of life/independence, 4) be comfortable, 5) achieve life goals (e.g., preparation of death, remain at home, strengthen relationships, accomplish a particular personal goal, spiritual needs), and 6) provide support for family/caregiver (Kaldjian et al., 2009).

Delivering Bad News During COVID-19

At our institution, our palliative care team has asked for volunteers who would be willing to be available to have these difficult conversations via telephone or video conference with COVID-19–positive patients and/or their families. These volunteers were given the opportunity to undergo an online educational conference to review methods of delivering bad news that promote understanding of next steps without diminishing hope.

I haven’t been asked yet to talk to one of these patients or families affected by COVID-19, but as a volunteer, I will be there if needed. Until then, I return to work every day to be with my cancer patients. I try to alleviate their fears of yet another threat to their lives. I practice as much social distancing as I can while still giving the standards of care that I am used to and hope that soon this horrible pandemic will leave us.

One thing I can say is that although I would never have wanted this to happen, it has brought us together more as a nation, as a world, and as a community of oncology health-care providers doing everything we can to alleviate our patients’ suffering.

References

Kaldjian, L., Shinkunas, L., & Cannon, K. (2009). Goals of care toward the end of life: A structured literature review. American Journal of Hospice and Palliative Care, 25(6), 501–511. https://doi.org/10.1177/1049909108328256

Starr, L. T., Ulrich, C. M., Corey, K. L., & Meghani, S. H. (2019). Associations among end-of-life discussions, health-care utilization, and costs in persons with advanced cancer: A systematic review. American Journal of Hospice & Palliative Medicine, 36(10), 913–926. https://doi.org/10.1177/1049909119848148

Read more from the APSHO Advance: Special COVID-19 Series