Having difficult conversations

Many of you will be having sensitive conversations with patients or their relatives, often under challenging conditions. You may be on the phone, wearing PPE or just tired and emotionally drained. This guidance will help you to manage these conversations more effectively.

Professor Ruth Parry (Physiotherapist and Professor of Human Communication and Interaction, Loughborough University) and her colleagues have developed a set of guiding principles, using evidence from recordings of thousands of difficult conversations. We are grateful to Ruth and her colleagues and to the National Institute for Health Research (NIHR), who funded this research, for their permission to publish them.

Prepare yourself and the environment as best you can

Health workers should clarify in their mind what they want to say and why, and find a comfortable and private setting, as best they can.

Start the conversation with ‘signposting’

Conversations should be started by giving the person on the receiving end an outline of what will follow – for instance, if it is an update, and/or if there is a decision to be made.

Show compassion and empathy throughout

Use tone of voice, phrases that attend to emotion, and show understanding without claiming one can possibly fully understand how the person on the receiving end is feeling.

Establish what the person you are talking to knows, expects and feels

Health workers should find out what the person they are talking to already knows and how they feel about it as this will help them to fit what they go on to say to the individual person they are talking to.

Establish if they are with someone or can they talk to someone afterwards  

If the conversation is taking place via a phone call, find out who is with the person or who they could talk to afterwards. You should not ask this at the start of a conversation as it could easily be interpreted as very bad news. Even when there is very bad news to come, build towards it gradually to reduce the risk of sending the person into severe shock.

Bring the person (further) towards an understanding of the situation – how things are, what has happened or is likely to happen

Describe some of the things that are wrong with the unwell person, in such a way that the person speaking will be forecasting that bad news is going to come. The point is to bring about gradual recognition, rather than shock.

Dealing with crying

Modify and soften your delivery and try to be more lilting if this happens. Allow silence and repeat brief further sympathy – ‘I’m so sorry’ – and acknowledge the distress before moving on and giving more information

Move towards the end of the conversation with ‘screening’ – ‘Are there things you would like to ask, that I have not said, or explained enough?’

Avoid phrases like ‘anything else’ as this risks being misinterpreted as the speaker not expecting there to be anything else. Offering ‘Are there things I have not covered or explained enough?’ removes the implication that the person has not understood things.

Move towards the end of the conversation with words of comfort and attention to what happens next

If possible, try to deliver something that is of comfort and that you can say truthfully. Also, explain what happens next and advise who they can contact for support and, if necessary, explain how pain or other symptoms will be controlled.

Reducing the emotional burden on yourself

Find someone to debrief with before and after a difficult conversation.

Last updated: 11 May 2020

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