COMMUNICATION

WITH PALLIATIVE
PATIENTS
Outlines
 Definition of palliative care and palliative
patients.
 Loss.
 Stages of loss.
 Grief.
 Types of grief.
 Communication strategies to relief grief.
 General guidelines to communicate with
terminally ill patients.
 Talking about death.
 Family care and needs at the end of life.
Objectives
 At the end of this lecture, we will be able
to:
1. Identify the characteristics of palliative

patients.
2. Differentiate between grief and loss.

3. Recognize the types of grief.

4. Follow the guidelines in communication

with grieved and terminally ill patients.
5. Identify the common family needs.
What is palliative care?
 WHO(1998) defined Palliative care as
“an approach that improves the quality
of life of patients and their families
facing the problem associated with life-
threatening illness, through the
prevention and relief of suffering by
means of early identification and
assessment and treatment of pain and
other problems, physical, psychosocial
and spiritual”
Who are the palliative
patients?
1. Patients have a progressive, life-
threatening disease with no possibility
of obtaining remission or stabilization.
2. Holistic interdisciplinary approach
focuses on supporting the quality of the
end of life.
Loss
 Corless defined loss as “ a generic term
that signifies absence of an object,
position, ability or attribute”.
 Some are minor and easily resolved,
while others are monumental, require
significant time to be resolved.
General assumption about
loss
 The experience of loss is universal.
 Loss involves pain.
 Losses that are significant produce
emotional upheaval‫هيجان\ثورة‬.
 it requires change and adjustments to
situation.
 Can impact many lives.
Stages of loss
1. Denial stage “This can’t be happening to
me.”
2. Anger Why is this happening? Who is to
blame?”
3. Bargaining “Make this not happen, and
in return I will ____.”
4. Depression “I’m too sad to do anything.”
5. Acceptance “I’m at peace with what
happened.”
Identify the patients stage
of loss??
1. ‘’I'm fine, there is nothing wrong with
me’’
2. "I understand I will die, but if I could
just have more time”.
3. "I can't fight it, I may as well prepare
for it.“
4. “Why me? Why is this happening to
me? It's not fair”'.
Grief
 Corless defined grief as “ a person’s
emotional response to the event of loss”
and
 “ the state of mental and physical pain
that is experienced when the loss of a
significant object, person, or part of the
self is realized”
 It is adaptive process with two major
goals: healing from self and recovering
from loss.
 As a person absorb a loss common
emotional behaviors can includes
sudden mood swing or wave like feeling
occur mostly when the person is alone or
when something in the environment
reminds the person of the loss.
Types(Pattern) of grief
1. Anticipatory grief:
 The grieving process can begin before

the actual loss occurs.

 It may provide time for preparation of

loss,
acceptance of loss, finish unfinished
business,
life review, resolve conflicts.
 For example:
With acute illness, chronic illness,
accidents and
other changes in health, a patient may
experience loss of general health, loss of
functionality, loss of independence or loss
of
role in the family.
2. Grief in sudden traumatic situation:
unexpected loss may exceed the coping
abilities
of a person, which often results in feelings
of
being overwhelmed and/or unable to
function.
3.Complicated grief:
it is incapacitating‫ تعجيزي‬form of grief,
usually long in duration more than one
year and associated with depressed or
disorganized behaviors.
 Note: Complicated grief reactions can
include any of the normal grief reactions,
but the reactions may be intensified,
prolonged, last more than a year and/or
interfere with the person's psychological,
social, and physiological functioning
 Predisposing factors to complicated
grief:
1. History of depression or substance

abuse.
2. Death of parent during childhood.

3. Dependency on the deceased person.

4. Succession of death within short period

of time.
Symptoms of complicated
grief:
 Extreme hostility toward person held
responsible of the loss.
 Deterioration to the state of depression
(insomnia, feeling worthlessness,
agitation..etc)
 Lack of initiative and poor decision
making that reflect on the functional life.
4. Delayed Grief:
Normal grief reactions that are
suppressed or postponed. The survivor
consciously or
unconsciously avoids the pain of the
loss
Communication strategies to
support grieving persons:
1. Listen with compassionate:
- Accept and acknowledge all
feelings. Let the grieving person know
that it’s okay to cry in front of you, to
get angry, or to break down.
- Be willing to sit in silence. Don’t
press if the grieving person doesn’t feel
like talking.
- Let the bereaved talk about how
their loved one died. People who are
grieving may need to tell the story over
and over again, sometimes in minute
detail. Be patient. Repeating the story is
a way of processing and accepting the
death.
- Offer comfort and reassurance
without minimizing the loss.
2.Offer practical assistance such as
suggest specific practice that can be
performed together.
3. Provide ongoing support.
4. Watch for warning signs that indicate
development of depression such as
withdraw from others, inability to enjoy
life or talking about dying and suicide.
General guidelines to
communicate with terminally
ill clients
1. Avoid autonomic response. Each person
and family is unique.
2. Use your mind, eyes, and ears to hear
what is said as what is not said.
3. Respect the individual pattern in
communication. Support clients desire
to control his/her life.
6. Humility and honesty are essential. Be
willing to admit that you do not know the
answer.
5.Mentain a sense of calm improve
feeling of comfort.
6.Never force the client to talk.
7.Let the client lead the discussion for the
future.
8. Be willing to allow the clients to see
some of your fears and vulnerabilities.
9.Provide short, frequent times for family
members to be with the dying client.
 A study of Garfinkel,Natan&Shachar(2010)
performed to compare the patients needs
at the end of life with perceived needs
from their families and care providers. The
study used descriptive, cross-sectional
study recruited a convenience sample of
451 subjects, including 73 terminally ill
older adult patients, 58 family members,
71 physicians and 249 nurses, from two
Israeli geriatric center
 The results were there are five needs
identified:
- not suffering pain,

- having no difficulty breathing,

- maintaining dignity,

- having someone who listens and

- receiving adequate nursing care.
Talking about death
 Talking about death with the clients is
not something that comes easily to the
nurse.
 Nurses feel ill prepared to deal with
emotional aspect of the clients.
 A qualitative study of Carter(2006) which
conducted on 12student 4th year student
at Scottish University to investigate the
students concern related to the
communication with dying patients and
their families in acute setting. The results
were the communication with those
patient is difficult and the issues about
death and dying were ignored related to
the lack of support in the clinical settings.
What are your roles when
dealing with a dying
patients???
1. Healing presence.
2. Provide the care to the dying person at
the same time act on the behalf of the
clients to facilitate expression of their
needs.
3. Help the client come to terms with
unfinished business and spiritual needs.
4. To provide privacy to the families and
patients to talk , comfort each other and
to share thoughts and physical
closeness.
5.The care should be guided by the
preferences and values of the patients.
6. Relief the physical symptoms especially
the pain.
Family care at the end of
life
Inclusion the family is an important
dimension
of end of life care.
 The care provided to the family can be

illustrated as the following:

 1.include them in the decision making

and every aspect of the clients’ death.

2. Allowing them to access to the clients.
3. Support the family members by
preparing family meeting to reduce
anxiety and allow expression of feeling.
4. Compassion presence and quiet
reassurance.
5. Provide anticipatory guidance about
what will happen in the dying process
and the process of grief.
 A study of Hebret et al.(2009) conducted
to determine the factors that family
caregivers believe are important to
preparing for death and bereavement. A
33 family caregiver were interviewed.
The results were all caregivers reported
medical, practical, psychosocial, and
religious/spiritual uncertainty.
 The conclusion of this study were health
care providers must develop a trusting
relationship
with caregivers, provide them with
reliable information tailored to their
uncertainty, and allow time for
caregivers to process the information
and complete important tasks.
Family needs at the end of
life
 Honest and complete answers of the
questions.
 Update about the clients condition.
 Frequent opportunities to express their
concerns.
 Short private time to communicate with
the clients.
 Discussion whom to call, legal issues and
funeral plan.
 Appreciation of the family conflict when
illness dedicates few options.
Conclusion
 The palliative care consist providing a
holistic care to the whole persons and
their families.
 The most common issues at the end of
life are grief and loss.
 The nurse must understand those
concepts and provide care to the
patients and their families at least by
active listening.
References
 Arnold, E., and Boggs, K. (2007)
Interpersonal Relationships: Professional
Communication Skills for Nurses. 6th
edition. Saunders.
 Sigal, J. & Smith, M.(2012). Coping with
grief and loss. Help Guide,12,10-20.
 Sigal, J. & Smith, M. (2012). Supporting
a grieving person. Help Guide,12,25-30