Having difficult conversations

Years ago, when I moved from NHS physiotherapy into communication research, I was astounded at how much useful  evidence is buried in social science publications. If only I had known some of that stuff when I was a physio, it would have greatly helped my confidence and skills in communicating with patients and their family members. 

Many practitioners, including physiotherapists, are having to have sensitive conversations with patients or their relatives, and often in suboptimal conditions

Nowadays, a fair bit of my work focuses on making really useful findings about effective patient/practitioner communication more accessible. For instance, my team and I write ‘in a nutshell’ versions of our academic research on communication in palliative care, blog, and publish systematic reviews

Getting good evidence into practice is all the more urgent now – many practitioners, including physiotherapists, are having to have sensitive conversations with patients or their relatives, and often in  suboptimal conditions – on the phone, wearing PPE, tired and sad. Health Education England has published guidance for just these circumstances, and research evidence from my field fed into this.

The full version, along with printable summary sheets can be found here, and short videos here. The full guidance includes an explanation of the reasoning and research behind  the recommendations.  

The  principles though, are as follows:

• Prepare yourself and the environment as best you can. Including preparing for ending end  the conversation – what will happen next, who else will speak to them? 
• If on the phone, check they are able to talk now, and safely. 
• Signpost – is this an update, is there a decision to be made?
• Show compassion and empathy with tone of voice, referring to  emotion – balancing showing understanding with acknowledging you can’t possibly fully understand. 
• If appropriate, ask what the person you are talking to knows, expects, and feels – so that you can fit what  you go on to say to that individual person.
• Now ask who is with them, and who  can they talk to afterwards – asking this at the very start risks implying very bad news, inducing shock, and the person then not being able to take in anything you subsequently say. 
• Bring the person (further) towards an understanding of the situation –  how things are, what has happened or is likely to happen. Use ‘we’ to convey this isn’t just on you, it is the team’s assessment. 
• What to do if they cry – use a soft  lilting tone, allow silence, express sympathy – ‘I’m so sorry’, if they are sobbing they may apologise – reassure, and wait until they are a little calmer before giving more information.
• Move towards the end of the conversation with ‘screening’ – ‘Are there things I have not covered or explained enough?’
• Provide (truthful) words of comfort. If the patient has died, but someone was with them, say so. 

If they have not died but are unwell – explicitly assure that they are not being abandoned, that they are being cared for. Tell them what will happen next, and give information on who they can contact for support.

Ruth Parry receives funding from the National Institute for Health Research (NIHR) Academy in the form of a Fellowship. The views expressed are those of the author and not necessarily those of the NIHR or the Department of Health and Social Care.

Systematic reviews: 

• REVIEW ARTICLE Communication practices that encourage and constrain shared decision making in health-care encounters: Systematic review of conversation analytic research
• How to communicate with patientsabout future illness progressionand end of life: a systematic review

Ruth Parry is professor of human communication and interaction, Loughborough University, NIHR Career Development Fellow, honorary professor LOROS Hospice