The Unspoken Nursing Skills of End-of-Life Conversations 

Posted on by Joseph Gerard

health care worker comforting a patientWritten by Marchelle Abrahams.

Some conversations are hard to have. And nothing can prepare you. Not a textbook. Not an online tutorial. Not a deep breath before delivering the bad news.

Once you have taken the Nurses’ Pledge of Service, talking to a patient about the end of their life is part of the package. Maybe you were warned how difficult it would be. Maybe you thought you’d cross that bridge when you got there.

The truth is that it doesn’t get easier. Sometimes the opposite. As long as you treat your patient and their family with dignity, the right words will form. Also, there are certain skills nobody has taught you until now.

Words Have Gravity

To you, words are something you speak to share information. An individual who doesn’t have the luxury of time can find comfort or hurt in them.

The journal Federal Practitioner published a paper titled The Meaning of Words and Why They Matter During End-of-Life Conversations several years ago. The advice still holds.

Author Grace Cullen goes into extensive detail on how essential effective communication is in healthcare delivery. However, misinterpretation can influence the quality of the care. 

The former palliative care nurse practitioner (NP) says that discussions must be handled with accuracy and precision. They must be conducted in a timely fashion and require skills that take practice to sharpen.

So, what are those skills?

With her years of experience, Cullen has learned that nurses don’t control how the conversation flows. 

“We approach patients with a blank canvas, open to receive messages that will be shared and reacted to accordingly.” – Grace Cullen, DNP, FNP-BC, ACHPN, AOCNP, RN-BC.

That’s why end-of-life (EOL) talks require compassion, an inherent human trait that isn’t taught in textbooks. Instead, it’s cultivated with training and application, advises Cullen.

Suggested Communication Phrases

Do not use medical terms. Talk in simple language and repeat the information. The truth should be gradually introduced to the patient.

Don’t leave families to their own devices. Offer administrative help, such as suggestions for hospice or palliative care. (Flugelman MY. How to talk with the family of a dying patient. BMJ Supportive & Palliative Care 2021;11:418-421.)

When speaking about advanced planning, Healthier Washington Collaboration Portal suggests the following:

  • What’s your understanding of your current situation?
  • If there ever came a time when you couldn’t make decisions for yourself, who would you trust to do that for you?
  • When you think about dying, have you thought about what the end would be like or how you would like it to be? 

Look to Mentors for Advice

You’ll probably get the best advice from your mentors. And yet, they’ll admit that no matter how many times you have the conversation, it still stings.

That’s why it’s important when finding a preceptor for a nurse practitioner to latch onto someone with years of experience in the EOL field. They can guide you on the best practices and share their wisdom on what works and what doesn’t.

In most cases, a nurse practitioner (NP) preceptor is a proficient clinician. They bridge the gap between classroom theory and real-world practice. In other words, you’re in good company.

ClickClinicals advises using professional NP preceptor matching services to ensure you’re matched with a preceptor aligned with your goals. They’re a sound option for nurse practitioner clinical placement help, and they’ll find you an NP preceptor fast.

Missed Opportunities for EOL Care Discussions

Timing is everything. Having the conversation too late can do more harm than good. A qualitative study published in the JAMA Network revealed a few insights. 

About 140 oncology patients were surveyed. Only 21 (5%) of encounters included EOL discussions. The study found that early EOL care preferences improve clinical outcomes. Unfortunately, most talks occur a month before death, despite most patients wanting information earlier.

Discussions about end-of-life care shouldn’t wait until a patient needs hospice, psychiatrist Natalie Jacobowski tells the Cleveland Clinic. She views it as counterintuitive.

Ask for permission to speak about the “what ifs” when starting treatment to prolong a patient’s life, advises Dr Jacobowski.

Create a Safe Space

Talking about someone’s imminent death is taboo, to say the least. It’s also uncomfortable and morbid.

A patient might not want to broach the topic, as it may appear weak or negative. Dr Jacobowski suggests taking your cue from them. Watch their body language. Acknowledge their fears. 

Take this as a step in the right direction. 

Frame the conversation as: “I imagine there are a lot of thoughts and worries. Is there anything that’s standing out to you that’s worrying you the most?”

That way, the patient will know you’ve created a safe space for them to voice their concerns.

Validate and Respond

Not every conversation goes according to script. Emotions are fraught. Anger. Sadness. Frustration. Grief. Patients are feeling them all at once.

Don’t gloss over their response and carry on like normal. Recognize their emotion and name it. For example: “I can see that this is incredibly difficult and upsetting to hear.”

Always lead the conversation, but also prioritize open-ended questions, because they’ll have many.

Validate their feelings. No judgment needed. Allow for silence. Remember, they’re only just processing the news. It takes time.

 

FAQs: End-of-Life Conversations in Clinical Practice 

  1. Why are end-of-life conversations delayed in healthcare settings?
    Many clinicians hesitate due to discomfort, fear of removing hope, or uncertainty about timing. 
  2. What is the most important communication skill during end-of-life discussions?
    Clarity paired with compassion. Using simple, non-medical language helps patients and families better understand and process the situation.
  3. How can clinicians create a safe space for these conversations?
    By asking open-ended questions, observing body language, and validating emotions without judgment.
  4. How do preceptors help nurse practitioners improve in end-of-life care?
    Experienced preceptors provide real-world exposure, model difficult conversations, and offer feedback that helps refine communication skills.

Key Statistics at a Glance 

Topic Finding Insight
EOL Discussions in Oncology Encounters  5% (21 out of 140 patients)  Very few clinical encounters include EOL discussions.
Timing of EOL Conversations  Often, within one month before death  Conversations are happening too late, limiting patient autonomy and preparedness. 
Patient Preferences  The majority prefer earlier discussions  Patients want transparency sooner, not at critical decline stages. 
Communication Risks  Misinterpretation affects care quality  Poor wording or unclear messaging can negatively influence patient understanding and care decisions. 

 

Parting Words

You chose to become an NP for a reason. And that reason is to care for and help people heal. Keep that in mind whenever sensitive patient discussions arise.

Lectures and textbooks can only teach so much. The rest is up to you. 

Whether you’re at the start or in the middle of this big, bold, beautiful journey called nursing, never forget why you are here.

References:

 

Author bio

Marchelle Abrahams is an award-winning writer (RDMA Awards 2019) who found her voice after carving a niche as a features writer for Independent Media. Currently, she freelances for various print and online publications, while ghost-writing blogs for several clients. 

 

 

Please also review AIHCP’s Grief Counseling Certification, as well as its Child and Adolescent Grief Counseling Program, Pet Loss Grief Counseling Program, Christian Grief Counseling Program, Grief Diversity Counseling Program, Grief Perinatal Program, Grief Practitioner Program and finally its Grief Support Group Leader Program.