Learning to Have Difficult Conversations With Your Patients

The other day at work I informed an elderly patient and her family that unfortunately she had a large brain mass.  At her age, treatment was not likely an option.  The conversation was expectedly intense.  When I left the room, one of the newer nurses in the ER approached me and asked "That was intense.  Do they teach you to have conversations like that in school?".  Well, "No", I responded.

This got me to thinking.  How did I learn to have tough conversations with patients, to deliver bad news in an appropriate manner?  My nurse practitioner program courses certainly did not devote time in the curriculum to this topic.  Although I never look forward to delivering bad news I have developed a skill for doing so.

I think my initial influence in developing this skill came from my first clinical preceptor.  He didn't beat around the bush when it came to difficult conversation.  He routinely told patients they would die if their blood sugar readings remained at their current levels or that they could expect to drop dead of a stroke before their children graduated from college if their hypertension wasn't kept in check.  From this preceptor, I learned not to avoid addressing unpleasant, serious issues.  I pulled from his straightforward style and learned to be a bit more blunt while maintaining a compassionate tone.

Once I graduated from my nurse practitioner program and made it out into the real world, I had to practice delivering difficult news on my own.  Telling someone they have cancer never comes easy.  But, you get better at these conversations with time.  I have learned to adapt to the patient's reaction.  Some patients want facts, others simply cry while some react with anger.  All are appropriate responses to receiving such information and you must be prepared with a response in all cases.

When I began my career in emergency medicine, I had to hold difficult conversations more frequently.  It's not entirely uncommon for me to discover carcinoma in a smoker presenting with bronchitis or glioblastoma in a patient who "is just not acting right".  Uncomfortable delivering this news to my patients, I initially accompanied physician as they informed patients of serious diagnoses.  This helped me hone my skill even further.

Aside from practice, one thing I have found helpful in presenting bad news is preparation.  Before you enter the room to speak with the patient and family, know a bit about how this diagnosis will affect their life.  Will their condition require surgery?  How large is the tumor?  Can they expect permanent disability as a result of their diagnosis?  Take a few minutes to gather basic information.  If you don't know the answer to a questions, don't guess.  Assure the patient you will involve a specialist in their care who can answer further questions.

Delivering bad news to patients is certainly not a highlight of my job.  But, I place great weight on the fact that is it my professional responsibility to develop this skill.  As a nurse practitioner, tense and potentially uncomfortable moments come with the job and you must be prepared to handle them appropriately.  Until nurse practitioner programs start teaching students these skills, and maybe even after, find a mentor you respect and observe their difficult patient interactions.  You will have a more positive impact on your patients in the toughest moments of their lives.