May 14, 2020

Delivering Difficult News Using Telehealth During COVID-19: Lead the Way

By Deborah Rust RN, MSN, CRNP, AOCN^®

The coronavirus will change how we deliver cancer care forever. Already, it has changed our routines, norms, and the way that we communicate. Previously, sending a patient into a hospital for urgent evaluation was okay; now, it is not. Reducing the number of outpatient appointments to minimize crowding is now a priority. For the patients who have to be treated for chemotherapy or immunotherapy, they may need to be seen face-to-face. Appointments are necessary for new patients, who need to be examined regardless of CT scans. Many patients are on long-term follow-up, or they are on follow-up and in between a chemotherapy check and can be managed via telehealth. Clinic appointments for patients with a pump should now be done remotely whenever possible. And, postponing elective procedures or annual exams must be evaluated on a case-by-case basis.

How Has Communication Changed?

The crisis is shaping up to be a marathon, not a sprint, and empathy and thoughtful communication are critical. The “how" and “what” are the two key elements that have dramatically changed. 

Telehealth Calls

In terms of how communication has changed, many health systems are encouraging a shift to telehealth to discuss a patient’s clinical symptoms, rather than having them physically going to the cancer center. Some states have ordered health systems and insurers to move all possible visits to telehealth.

For the advanced practitioner, sitting in a private room and phoning patients is quite different from our clinic day with face-to-face visits. Informing patients that this will be the approach is important. When being involved in this type of interaction, be cautious about taking on additional or unnecessary workload. Involve your information technology department or health-care system to enlist call support. Be patient with your patients, and ensure that you have a schedule that can accommodate extra time. Also, inform patients about what to expect with the time frame of the call and the questions you will ask; this will ease anxiety. Once you call them, it is not that much different from regular visits. Be enthusiastic to engage your patients so that they will be comfortable answering your questions and feel at ease. Make eye contact and smile to convey support.

The Mask Effect

A second “how” is that in some clinical instances, we may need to wear PPE. In both inpatient and outpatient settings, wearing a mask can limit your ability to ask questions or deliver your message effectively. With a mask, you have minimal ability to express nonverbal cues. This may result in your message being misunderstood, unclear, or you could be perceived as stoic. This may result in miscommunication and unnecessary stress on your relationship with your patient. Our connectedness, especially face-to-face, through communication is undeniable. A mask on a virtual visit will require you to slow your pace, increase your volume, and have an expressive tone. If you have a low register voice like me, you will need to raise your pitch to a middle range to be heard. Overall, to accomplish your goal, this may require more time.

Conveying Difficult News

Adeptness with conveying difficult news to patients has been central to our APP practice. This requires being prepared, having patience, and having well-developed communication skills. Also, you must approach the patient and caregivers with empathy, understanding their situation and considering their feelings.

There are several ways to deliver bad news to patients successfully on a virtual call using patient-centered communication. You don’t have to feel like an expert when you need to break the news about disease progression or a loved one’s death. Realize that communication is one of your clinical strengths and try to minimize the emotions that can cloud your mind. There are many different approaches to this conversation, and none are perfect. There are no right words.

Set Up and Be Prepared 

If possible, getting support may be beneficial. If you are fortunate, an experienced nurse, social worker, or chaplain can make a huge difference. Not only can these individuals be communication experts, but in many instances, they already have knowledge of the family. Their presence also ensures that someone is available in case you are forced to leave the patient due to clinical duties.

Make sure you have plenty of time. Specifically, set the time aside and be 100% present. Take a minute to sort your thoughts beforehand, review what you need to say, and make notes. You can use them later to incorporate what was discussed in the EMR. Make sure you know the patient’s name! Choose the right location. Hopefully, there is somewhere appropriate that is private, quiet, comfortable, and if possible, preferably non-clinical. Look at your background before making a call or determine if you can change the background of your virtual call. Before you begin, check your appearance, and if you have mask marks, briefly explain this before beginning.

Delivering the News

Sit down, introduce yourself, and include anyone accompanying you. Establish who is on the other end of the call. Remember to make eye contact and talk slowly. Your tone and pace are important; a gentle and slower pace portrays empathy. Speak even more clearly and concisely than you normally do in person. Preface the conversation that you have difficult news, such as “I am afraid I have difficult news,” or “I have some news that may be difficult to hear,” and then get to the point: “Your disease has advanced” or “ John died.” Think about nonclinical terms; however, if you use clinical terms, qualify them, such as explaining that progression means the spread of the cancer. If you are delivering news about death, after you share this information, try to include positive aspects of the person, such as “They were extremely courageous.” Patients or family may be able to sense the news from body language, so minimize belaboring the message. It may be useful to think of the listeners as your patients.

Be ready for anger, denial, guilt, hysteria, and shock. In the instance of death, the onus of convincing the bereaved family members about the circumstances which lead to the demise of the patient lies on the health-care team and should be carried out with utmost priority.

Provide information if it is requested, but make sure you check with the patient or family, either by monitoring non-verbal signals or simply by asking how much they want to know. Try to provide the information in short segments, allowing time to process the information. Allow time to reflect and in the event of disease progression, offer the next steps. Make sure you know all the practical details about the future plan, whether it be new therapeutic options, palliative care, or bereavement support.

Summarize the Call

Perhaps the least human part of delivering difficult news is that we are forced to deliver the message and then get back to work. Ideally, you would sit quietly until the family had time to process their emotions. If you do, get used to silence, as opposed to trying to fill the conversation void. This is one reason to bring another individual into the room with you. When it is time to leave and terminate the call, keep in mind that you may be talking to someone on one of the worst days of their life. If necessary, share how the family members can spend some time with their loved one, especially in instances where social distancing is in effect or there is an inability to visit.

Conclusion

Flexing your communication skills to be effective when breaking bad news is now more necessary to incorporate into your clinical practice than ever. Following an established format while integrating empathy makes this challenging task more comfortable for you as an advanced practitioner and helps to improve the communication between the patient and family. The act of kindness shown during the hour of need will help to strengthen the advanced practitioner-patient relationship and the advanced practice role further. I hope COVID-19 encourages us to be more nimble and open to learning new strategies to enhance discussions.

Lastly, I commend you for your devotion and compassion as a care provider, sacrificing yourself for others. Hasn’t it been humbling? Stay safe.

Related:

Delivering Bad News During a Pandemic (April 23)

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