Conversations in endoflife care: communication tools

PRACTICE DEVELOPMENT

Conversations in end-of-life care: communication tools for critical care practitioners Sarah E. Shannon, Tracy Long-Sutehall and Maureen Coombs ABSTRACT Background: Communication skills are the key for quality end-of-life care including in the critical care setting. While learning general, transferable communication skills, such as therapeutic listening, has been common in nursing education, learning specific communication tools, such as breaking bad news, has been the norm for medical education. Critical care nurses may also benefit from learning communication tools that are more specific to end-of-life care. Strategy: We conducted a 90-min interactive workshop at a national conference for a group of 78 experienced critical care nurses where we presented three communication tools using short didactics. We utilized theatre style and paired role play simulation. The Ask-Tell-Ask, Tell Me More and Situation-Background-Assessment-Recommendation (SBAR) tools were demonstrated or practiced using a case of a family member who feels that treatment is being withdrawn prematurely for the patient. The audience actively participated in debriefing the role play to maximize learning. The final communication tool, SBAR, was practiced using an approach of pairing with another member of the audience. At the end of the session, a brief evaluation was completed by 59 nurses (80%) of the audience. Summary: These communication tools offer nurses new strategies for approaching potentially difficult and emotionally charged conversations. A case example illustrated strategies for applying these skills to clinical situations. The three tools assist critical care nurses to move beyond compassionate listening to knowing what to say. Ask-Tell-Ask reminds nurses to carefully assess concerns before imparting information. Tell Me More provides a tool for encouraging dialogue in challenging situations. Finally, SBAR can assist nurses to distill complex and often long conversations into concise and informative reports for colleagues. Key words: Communication in critical care • Critical care nursing • Family care in critical care • Nurse–patient communication

INTRODUCTION End-of-life care continues to hold an important focus for health care practitioners and health policy makers alike. The key goal of any end-of-life initiative is to improve choice and quality of care for dying patients and their families (Mularski et al., 2006; Department of Health, 2008). One of the most challenging aspects of end-of-life care for nurses and physicians is managing difficult conversations (Back et al., 2005; Reinke et al., 2010a). This article introduces three communication

tools to critical care nursing practice to facilitate effective communication that have been applied in other arenas. To demonstrate how these tools may be useful for nurses’ end-of-life conversations, excerpts from an interactive workshop are shared. Evaluation data drawn from this event are presented to illustrate what attendees at the workshop found applicable to their critical care practice.

BACKGROUND Authors: SE Shannon, PhD, RN, Associate Professor, Biobehavioral Nursing & Health Systems, Box 357266, University of Washington, Seattle, WA 98195-7266, USA; T Long-Sutehall, C. Psychol, PhD, NIHR Post Doctoral Fellow, Faculty of Health Sciences, University of Southampton, Southampton, UK; M Coombs, MBE, PhD, RN, Consultant Nurse Critical Care, Senior Lecturer, Southampton University Hospitals Trust, Southampton, UK Address for correspondence: SE Shannon, Associate Professor, Biobehavioral Nursing & Health Systems, Box 357266, University of Washington, Seattle, WA 98195-7266, USA E-mail: [email protected]

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Effective communication around end-of-life care is one of the most important skills needed by any critical care practitioner (Molter, 1979; Nelson et al., 2006). Demonstrating care and concern for seriously ill patients and their families is an intrinsic part of critical care nursing philosophy (Beckstrand and Kirchhoff, 2005). There is clear evidence of the importance of informational and communication needs for ICU patients and their family members (Molter, 1979; Paul and Rattray, 2008). While nurses have a key role in meeting such

© 2011 The Authors. Nursing in Critical Care © 2011 British Association of Critical Care Nurses • Vol 16 No 3

Conversations in end-of-life care

information needs, communication around sensitive areas of end-of-life care can be challenging for even the most experienced critical care nurse needs (McClement and Degner, 1995). For example, nurses may feel that they are limited in what they can talk to patients or families about especially if there is disagreement about the patient’s diagnosis or prognosis (Reinke et al., 2010b). Nurses report challenges approaching such sensitive interactions and resulting negative emotional reactions for all involved (Coombs et al., 2009; Long-Sutehall et al., 2009). Education of health care professionals includes training in communication skills; however, the different professions have adopted different approaches. Undergraduate nursing education often has focused on teaching general, transferable communication skills, such as therapeutic (or active) listening, the use of silence or motivational interviewing (Edwards et al., 2006). These strategies are useful across multiple situations involving communication with patients. In contrast, medicine more commonly has focused on teaching communication skills that are specific to a particular communication event such as breaking bad news, obtaining informed consent or advance care planning. For example, Baile developed a mnemonic (SPIKES) to guide breaking bad news in oncology and other settings (Baile et al., 2000). In this article, we will discuss three communication tools that can be used in end-of-life care conversations. Two of the tools (Ask-Tell-Ask and Tell Me More) facilitate the accumulation and sharing of sensitive information between patients or their families and members of the health care team. The third tool Situation-Background-AssessmentRecommendation (SBAR) has been used primarily as a tool for information exchange at critical handovers, but can be used to communicate end-of-life information among the health care team. We recently presented these communication tools at a workshop entitled, ‘Managing difficult End-of-Life conversations’, at the British Association of Critical Care Nurses annual conference held in September 2010 in Southport, UK. Seventy-four critical care nurses attended a highly interactive, 90-min workshop taught by three faculty (S. S., M. C. and T. L. S.). The educational event consisted of a short didactic session introducing the first two communication tools (Ask-Tell-Ask and Tell Me More). Then two of the authors (M. C. and T. L. S.) enacted a clinical encounter of a nurse interacting with a family member around an unusual and difficult scenario, that is a family member who wanted more treatment for a patient than most physicians or nurses would feel was advisable. The audience watched the role play

for approximately 7 min. Then the third author (S. S.) debriefed the audience for approximately 10 min on what they saw the nurse do that they found effective in communicating with the family member and how to proceed further in the role play with the family member. Following the theatre approach to role play and debriefing, a second short didactic was offered on the final communication tool, SBAR. This workshop showcased the use of SBAR as a means for ICU nurses to share the information they obtain in their discussions with patients or family members regarding end-oflife wishes, with their medical colleagues. This is a novel use of SBAR, but a logical extension. We asked the workshop audience to take the information they had just observed in the role play and to construct an SBAR report. After a few minutes of preparation time, members of the audience practiced sharing their SBAR reports in pairs with the person sitting next to them. After a short practice period, the audience again debriefed (T.L.S) on what they found helpful about using SBAR, what they liked about their colleague’s report and what was essential information that had not been included in either report. To illustrate the use of the tools, the following sections will intersperse content from the workshop with descriptions of the communication tools.

COMMUNICATION TOOLS FOR END-OF-LIFE COMMUNICATION FOR CRITICAL CARE NURSES Ask-Tell-Ask Hancock et al. (2007) in a review of 51 studies examining communication of prognostic information with adult patients experiencing life-limiting illnesses found that health care professionals consistently underestimated patients’ needs for information, while they simultaneously overestimated patients’ understanding of prognosis and awareness of end-of-life issues. These authors suggested that one communication skill that physicians and nurses needed to develop was to continuously check their patients’ understanding of their situation and preferences for additional information. This receptivity to individualized information needs was reflected in a study of relatively experienced nurses caring for patients with life-limiting illnesses where Reinke found that nurses reported providing prognostic information by assessing what the patient already knew and then following their lead in the conversation (Reinke et al., 2010b). Providing information, including prognostic information, to patients or their families in an effective manner, is a communication skill. Rather than delivering

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information in the form of a lecture, the provision of information needs to be responsive to, and guided by, what is already known and what information is desired. A communication tool to assist practitioners in this task is the Ask-Tell-Ask model (Back et al., 2005). This model has been recommended for use in clinical practice and attempts have been made to empirically assess its use (White et al., 2010). • Ask: The first ask is used to assess patients’ (or family members’) perceptions and understanding of the diagnosis, prognosis, treatments or specific questions (Box 1). Information is then targeted specifically to questions and concerns raised by the patient or family member, essentially allowing the practitioner to enter the ongoing conversation that a patient or family has with a health care team; Text box 1 Ask-Tell-Ask: The First Ask Nurse: Good morning Mrs Jones. I wonder if you remember me? My name is Jane and I looked after your father two weeks ago. I heard that you had a meeting with the medical team yesterday. I was wondering if you could tell me about the meeting? (Ask) Mrs Jones: Well as you’ve asked, I’m really furious. They’ve told me that they are going to take him off the ventilator. So basically, they’re going to kill him. For the last month, they have told me he was stable. I know he is old – I mean he is 78 – but he was healthy before all this happened. I’ve been here every day to visit dad and I don’t see what has changed. He’s had his ups and downs but for the last two weeks things have seemed pretty much the same. He’s been on the breathing machine of course. I’m not sure he always knows that I am here but I think they give him medicine that makes him sleepy. He is just the same. • Tell: The tell portion occurs when the practitioner has identified the patient’s or family member’s most pressing needs or desires for information. Back and colleagues recommend offering not more than three pieces of information during each Tell portion of the conversation and avoiding medical jargon (Back et al., 2005); • Ask: The second ask provides health care professionals with the chance to check understanding of what they have said and patients with an opportunity to ask additional questions. The Ask-Tell-Ask cycle is repeated throughout the clinical encounter with a final Ask occurring as a summary of any 126

decisions made or plans agreed upon during the interaction. The practitioner used the first Ask to learn more about Mrs Jones’ concerns. Two pieces of information were gained that the practitioner can now choose to pursue: Mrs Jones shared her emotional reaction to the meeting with the medical team (furious) and her perception about her father’s overall condition (stable). The next communication tool provides the critical care nurse with guidance for how to proceed in this potentially challenging clinical interaction.

Tell Me More As in the example above, family members sometimes raise difficult topics with critical care practitioners including loss, guilt, fear, anger or anxiety (Curtis et al., 2005). Practitioners may be uncertain as how to react when a family member or patient makes a statement that is surprising or even shocking. Yet, they need to be ready to respond empathetically and nonjudgmentally in these situations to encourage continued dialogue. A communication tool to assist in these situations is Tell Me More (Back et al., 2005), which has two purposes. First, it is a way of getting back on track when the conversation seems diverted by a statement that may seem irrelevant or unrelated to the discussion. Tell Me More allows the clinician to directly address a patient’s or family member’s question or issue that has pulled the conversation off track and to address the concern. Second, Tell Me More helps health care professionals to get past their own initial reactions when patients or family members say things that trigger defensive or emotional reactions. When it is challenging to respond therapeutically, nurses and physicians need a tool to help them to respond in a less reactionary mode. Tell Me More (Box 2) can be used to address three levels of understanding such as factual, emotional or the meaning to one’s life. The practitioner talking with Mrs Jones might choose to address any one of these levels as illustrated in the example below. Text box 2 Tell Me More Level 1: Facts Nurse: Mrs Jones, it sounds like the meeting yesterday has left you with questions. You said that the doctors had described your father as stable. So that I can help sort out the information with you, could you tell me more about how your Dad has been doing over the last couple of weeks?



Mrs Jones: Well basically, he’s been okay. He has not changed. His ventilator settings have stayed the same. He hasn’t needed any more transfusions. He hasn’t woken up any more but I think he’s getting medication. He still has pneumonia I think. I’m not really sure but I think he’s on antibiotics still. He’s just the same. He isn’t getting worse. He’s not dying. But, now they are saying that stable isn’t good enough because it has lasted too long without improving. I thought stable was good? Nurse: Would it help if I talked about each of those things you mentioned and what stable means for us? Level 2: Emotions Nurse: Mrs Jones, it sounds like you were shocked by the turn yesterday’s meeting took. You said you are really furious now. Can you tell me more about how you are feeling? Mrs Jones: I just feel so angry and helpless. My dad was healthy a month ago. My brothers can’t come to visit very often so this is really up to me. I just want to be sure I am doing the right thing for my dad. Nurse: Mrs Jones, I can really hear how angry and upset this has left you. You had a healthy father a month ago and now all this has happened. PAUSE. Can you tell me what is it that makes you most angry/feel most helpless? Level 3: Meaning Nurse: Mrs Jones, it sounds like yesterday’s meeting may have caught you by surprise. Sounds like you weren’t expecting that conversation with the doctors. Can you tell me more about what your father’s illness has meant for you and your family? Mrs Jones: I just wasn’t expecting this at all. My dad has always been there for us. He’s been healthy. I mean, I knew it was serious when he was admitted to critical care unit, but he seemed to be doing okay. Everyone seemed so nice and so friendly. So to have this just sprung on me! I feel like the rug has been pulled out from under me. How am I supposed to face my brothers now? I don’t even understand why suddenly this decision has been made and I haven’t exactly done a very good job of taking care of dad now have I? I’m pretty ashamed of that. Not sure what I’ll even tell them. I’ve been calling every day or two and telling them how well he’s been doing and now what am I supposed to say?

Nurse: I can understand how this has been a shock. You talked earlier about wanting to do the right thing for your father. Can you tell me more about what that means to you? And to your brothers? The practitioner uses Tell Me More to learn more about Mrs Jones’ concerns and her experience of the situation. The three levels of facts, emotions and meaning yield different but inter-related information. In clinical interactions, it may be helpful to address all three levels or to target one that seems the most relevant to a particular situation. In the example above, the nurse used Tell Me More to address all three levels to gather information about Mrs Jones’ concerns, prioritized them internally, and then focused on the chief concerns in the Tell portion of Ask-Tell-Ask: the meaning of the term stable and how it relates to her father’s prognosis, the feeling of having been caught by surprise, and the issue of doing the right thing for her father, while maintaining her relationships with her brothers. Assessing comprehension and effectiveness of the communication is carried out with a second Ask. This is also the opportunity to clarify what the next steps will be. The example below illustrates the final Ask for the illustration (Box 3). Text box 3 Ask-Tell-Ask: The Second Ask Nurse: So if I can summarize, we’ve talked about how stable has meant different things for all of us. We also talked about why not improving – staying ‘stable’ – particularly when a person is on the ventilator, is not good. Does that make more sense to you now? Perhaps you have some additional questions? Mrs Jones: Well, this was hard to hear, but no, I don’t have questions. I mean, I feel like I understand now. I just kept hearing that dad was doing well, doing okay. But, I understand what you are saying. I understand that he hasn’t been improving and that at this point, the chances of him improving and being able to be like he was have pretty much disappeared. I think I just stopped listening as I was so upset yesterday. Nurse: It can be hard to hear when we are upset. I’m sorry that you were caught by surprise. PAUSE. If I can ask you now, what would be helpful for me to do next? Mrs Jones: Could you talk with the doctors for me? This has put things in a different light. I can now see where the doctors are coming from. I don’t want dad to die but I think I see that they were


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wanting to warn me in a way. I’d like to call my brothers. Maybe they will want to talk to the doctors too. I’d like for all of us to be here when it happens, or at least know when it was happening. Could I talk with the doctors again? I need to leave to call my brothers, but could I call around 4 pm and perhaps meet with them? Could you be there?

Situation-Background-AssessmentRecommendation As the above role play excerpt demonstrates, nurses play a key role as intermediary between families and other health care professionals (Liaschenko et al., 2009). However, if the information gained from the use of tools such as Ask-Tell-Ask and Tell Me More is not effectively communicated to other members of the health care team, then little may change for the patient or family. Communicating information about family concerns and wishes among the health care team is the final challenge addressed in this article. SBAR is a tool used to frame conversations, especially critical ones, between health care professionals. Originally used in the military and aviation industries, SBAR was developed for health care by Leonard and colleagues from Kaiser Permanente in the USA (Kaiser Permanente of Colorado, 2011). SBAR consists of standardized prompt questions within four sections that structure sharing of concise and focused information. It allows staff to communicate assertively and effectively, reducing the need for repetition (NHS Institute for Innovation and Improvement). Table 1 gives an

example of how SBAR was used with the case example from the workshop. While the tool can be used to shape communication at any stage of the patient’s journey, it has been used predominantly in situations involving handovers between two different settings or care teams and situations where staff may be uncomfortable about making a recommendation i.e., where staff may be inexperienced or need to communicate up the hierarchy (Featherstone, 2005). As far as we are aware, the SBAR format has not been used in end-of-life discussions, specifically those about withdrawal of treatment in critical care environments. However, end-of-life care discussions involve complex and nuanced demands of an individual’s communication skills and hence, offer a natural extension to the original use of SBAR.

ARE THESE TOOLS HELPFUL TO CRITICAL CARE PRACTITIONERS? To help answer this question, we distributed paper evaluations to members of the audience at the workshop. The evaluation had three items assessing personal characteristics (type of critical care unit; number of years of ICU experience and employment grade), one open-ended item assessing previous end-of-life education, and one item asking, ‘Please share a skill you learned in this workshop that you plan to apply in your practice.’ Responses to the final question were considered to assess participants’ interest in the workshop’s content and applicability to practice. Fifty-nine of the seventy-four respondents returned completed evaluations (80% response rate). Respondents were employed across a range of settings

Table 1 Situation-Background-Assessment-Recommendation (SBAR) tool Situation: Describe your concern. Background: Case history. (who, what, when, why)

Assessment: Think critically when informing others about your assessment. Distil information to the essential. Include sources of information/evidence accessed to support your recommendations. Recommendations: Explain what you need – be specific about request and time frame. Make suggestions. Clarify expectations.

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Nurse: Dr Smith, there is an issue that Mrs Jones has raised with me and that I need to talk with you about. As you know Mrs Jones’ father has been with us for several weeks and has shown no sign of making progress. Mrs Jones met with the team yesterday, when treatment withdrawal was discussed. She spoke with me today and told me how angry she was as she felt we were going to kill her father. I was able to have an in-depth discussion with her about this. Her understanding of the term stable indicated that her father was getting better, rather than that he was not making progress. Therefore, it has come as a major shock that now, in her view, we are discussing withdrawal of treatment. We reviewed her father’s medical condition and care and she now better understands what our concerns are. She has now gone to talk this through with her brothers. She has been the primary person from her family with her father and stated that she’s feeling she must not have done a very good job of caring for her dad based on this outcome. What we have agreed is that I will talk with you about the conversation I had with Mrs Jones, and she would like to meet with you later today to re-visit the options for her father. She may request that you also talk with her brothers at some point. She will phone the unit at 16·00 to arrange a mutually convenient time to talk with her. What time would you be free to meet?



Table 2 Workshop evaluation written comments on skills believed to be applicable to critical care nursing practice ‘Holding back my information, so family can fully explain their understanding’. ‘Emotions are not to be ignored’. ‘Use of terms can mean many things, e.g. stable’. ‘Ask much more than tell. Allow plenty of time for them to answer’. ‘The use of simple terms like ‘tell me more’ to further explore the facts and emotions of the individual’. ‘Giving relatives time to explain, don’t interrupt and give answers, gain the information from the relatives of what things mean for them’. ‘Not to interrupt or immediately correct a misunderstanding/misperception of conversation, instead allow person to talk and ask and encourage more information’. ‘Not to jump straight on shocking facts from patients (or families) e.g., Mrs Smith saying the Doctors were trying to kill her dad’. ‘(I) will ask the relative ‘what do you want me to do’? ‘Utilizing the Situation-background-assessment-recommendation (SBAR) tool with EOL’. ‘SBAR communication tool: workshop presented a new perspective on how to use this’. ‘Tools to structure (communication) – helps when get tongue-tied’.

(intensive care n = 38, intensive and high dependency care n = 10, outreach n = 4, education n = 3, not specified n = 4). Most were experienced critical care nurses with between 1·5 and 29 years in intensive care nursing (mean = 11 years). Of those completing the evaluation forms, 61% (n = 36) had attended previous end-of-life education including Liverpool Care Pathway training or classes on bereavement, organ donation, general palliative care or breaking bad news. Most respondents identified at least one of the three end-of-life communication tools as applicable to their clinical practice with many identifying two or more. In addition, many made specific comments that illustrated the usefulness of the communication tools (Table 2). Many expressed an ‘ah ha’ moment from watching the role play. In the debrief, members of the audience reflected on how easy it is to respond to patients or family members by talking at them rather than by seeking further understanding through questioning. Many made comments about the value of the communication tools for extending their skills in the challenging arena of end-of-life conversations.

CONCLUSION Communication skills are central to critical care practitioners, particularly in caring for patients and their families at the end of life. The tools presented in this article offer nurses three new strategies for approaching what can be difficult and emotionally charged conversations. The case illustration provides examples for how to apply these skills to a clinical situation. While general, transferable communication skills have been common in undergraduate nursing education, learning specific communication tools for dealing with challenging situations may be useful. There is some evidence suggesting that when nurses learn what to say, they decrease active listening in favour of initiating communication techniques such as targeted

questioning or motivational counselling (Edwards et al., 2006). While active listening and use of silence are important techniques to use in end-of-life conversations with critically ill patients and their family members, often the challenge for nurses and others is knowing how to skilfully explore perceptions, respond to difficult statements and then concisely communicate patient or family members’ complex concerns among the health care team. The communication tools discussed in this article offer nurses strategies to use in these difficult encounters around end of life. Comments from participants affirmed the usefulness of having specific skills to gain additional information from patients and families in challenging conversations and a structured format for sharing information with other members of the health care team. These communication tools are useful for novice and experienced practitioners. Improving communication skills is identified as a need for both student learners (Bowles et al., 2001; Edwards et al., 2006) and experienced nurses (Reinke et al., 2010a). We would argue that experts also can use these strategies to coach new nurses who are encountering difficult situations. Ask-Tell-Ask is the foundational skill for coaching. Guiding a colleague to explore the patient’s or family member’s concerns more deeply through Tell Me More, or to communicate critical information with one’s colleagues through SBAR will ultimately enhance communication among the health care team and work towards improving end-of-life quality of care.

ACKNOWLEDGEMENTS The authors wish to thank the British Association of Critical Care Nurses (BACCN) for providing support for the workshop, the workshop attendees for their participation and feedback at the event and the World University Network (WUN) for financial support of their ongoing intellectual collaboration including generous travel support.


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WHAT IS KNOWN ABOUT THIS TOPIC • Good communication between the health care team and the patient and family, and among the health care team, is important to high quality end-of-life care. • Nursing and medical education approach teaching communication skills differently. In general, nursing has been more apt to focus on general, transferable skills such as active listening, while medicine has focused on skills specific to a communication task such as breaking bad news. WHAT THIS PAPER ADDS • This article presents three communication tools that are new to critical care nursing or end-of-life care: Ask-Tell-Ask, Tell Me More and Situation-background-assessment-recommendation (SBAR). • The three tools assist critical care nurses to move beyond compassionate listening to knowing what to say. • Ask-Tell-Ask reminds nurses to carefully assess concerns before imparting information. • Tell Me More provides a tool for encouraging dialogue in any situation. • SBAR, used in this new application, can assist nurses to distill complex and often long conversations into a concise and informative report for a colleague.

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