The importance of communication
in sustaining hope at the end of life
Abstract
How can health professionals, especially those working in busy
environments, foster hope and communicate effectively and
therapeutically with patients at the end of their lives? Many authors
agree that failure to comprehend the essence of what patients are
communicating, either verbally or non-verbally, can adversely affect
the level of support that health professionals can offer, and risks
increasing patients suffering and isolation, leaving them feeling
hopeless. Anxiety and fear frequently invoke hopelessness and often
cause patients to reject advice and important information given
by clinicians. This article focuses on the importance of therapeutic
communication in sustaining hope for patients at the end of life.
Key words: Therapeutic communication Palliative care Hope
SPIKES protocol Holistic person-centred approach
H
ow can health professionals working in busy palliative
care environments communicate effectively and
therapeutically with patients to bring hope? This
article focuses on the importance of therapeutic
communication in sustaining hope for patients at the end of life.
The role of the health professional in the context of therapeutic
communication will be critically analysed and the evidence base
underpinning effective therapeutic communication considered.
The complex issues surrounding communication in palliative
care and the implications for improving and maintaining
a consistent high quality of practice will be examined and
evaluated. The Department of Healths (DH) End of Life Care
Strategy (DH, 2008) and more recently More Care, Less Pathway
(DH, 2013) both illustrate the importance of offering patients
approaching the end of life more choice regarding their care.
Involving patients in decision-making and regularly reviewing
and clearly communicating those decisions, in accordance
with the patients wishes, can only be achieved through good,
therapeutic communication (DH, 2008; DH, 2013).
The single biggest problem in communication
is the illusion that it has taken place. (George
Bernard Shaw: quoted by Caroselli, 2000:71)
Maureen Hawthorn, Macmillan Senior Nurse Practitioner, Integrated
Specialist Palliative Care Team, Wirral Community NHS Trust
Accepted for publication: June 2015
702
Maureen Hawthorn
Therapeutic communication
Baile et al (2000) acknowledged that communication within
clinical settings is a complex phenomenon involving gathering
information and transmitting relevant medical information
while providing support. Early in the literature, Rogers (1951)
hypothesised that for communication to be therapeutic, a
positive and beneficial change must result when people
engage with one other. Mearns and Cooper (2005) believed
that communication can only be described as therapeutic
if a helping alliance is established, within which healing
emerges. The document Essence of Care (DH, 2010) identified
therapeutic communication as a meaningful process within
which people convey thoughts, anxieties and emotions. The
process of therapeutic communication involves assessing the
patients perception, obtaining the patients invitation, and
responding to the patients emotions with empathic responses
(Baile et al, 2000). This process, through verbal and non-verbal
actions, positively influences patients to better understand
themselves and their situation (Laidlaw et al, 2002; Leplege
et al, 2007). Silverman et al (1998) argued that therapeutic
communication helps patients to adjust, dispels fears, and often
thwarts inappropriate hope. McIntyre and Lugton (2005) found
that patients feel supported, confident and secure when their
psychosocial needs are recognised and addressed. Hallenbeck
(2003) concluded that communicating therapeutically is often
the most valuable skill health professionals can offer patients.
The skills required to communicate therapeutically are vital
for all health professionals working in palliative care, as it is
only when patients are given opportunities to communicate
meaningfully that they feel less anxious and more hopeful
(Hagerty, 2005; Wilkinson et al, 2008). If health professionals
struggle to communicate effectively, patients may be left
anguished and in despair (Fallowfield and Jenkins, 2004). Since
The NHS Cancer Plan (DH, 2001), communication skills have
been a precondition of qualification, with the stipulation
that health professionals must demonstrate competence when
communicating with patients. Sllner et al (2001) called
for advanced communication training to improve the ability
to identify psychological distress in patients. Fallowfield and
Jenkins (2004) showed that advanced communication training
prevents health professionals relying on any natural abilities
to communicate, and drives them to improve and develop
evidence-based communication skills. Many government reports
identify the negative effect of poor communication within
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health care, which obstructs the delivery of high-quality care,
often leaving patients distressed and discouraged (Darzi, 2008;
DH, 2013; Francis, 2013). Moreover, Wilkinson et al (2008)
identified a particular link to burn out from the distress caused
British Journal of Nursing, 2015, Vol 24, No 13

to health professionals working in palliative care who feel
unable to communicate effectively with patients. The evidence
supports a person-centred rather than disease-centred approach;
as patients are given opportunities to communicate meaningfully,
they are enabled to control decision making around their present
and future care (Darzi, 2008; Francis, 2013)
Holistic person-centred approach
A holistic approach is fundamental if a patients problems are to
be thoroughly and accurately identified at the end of life (Carter,
2001; Maguire and Pitceathly, 2002). Holistic care is founded
on therapeutic communication and involves not only physical
issues, but also the psychological, social and spiritual needs of
patients and their families. Rogers (1951) developed a person-
centred approach (PCA) that realises the human potential
for personal growth, self-realisation and self-actualisation. He
believed that no matter how appalling conditions may be,
people will inherently strive to grow and improve.
The PCA is a holistic concept founded on a non-directive
and non-threatening approach, within which people are free
to explore their experiences and find their own way through
(Mearns and Cooper, 2005).The PCA is founded on therapeutic
communication, the self-actualising tendency and three core
conditions.The self-actualising tendency can be described as the
inner ability to realise and reach ones full potential and sense
of self (Merry, 1999). The three core conditions are empathy,
congruence and unconditional positive regard (Rogers, 1951).
Empathy is the capacity to sense accurately what another person
is experiencing; people communicate empathetic responses
by reflecting back another persons expressed emotions and
thoughts (Rogers, 1951). Carter (2001) argued that fear, distress
and anxiety can be quickly dispelled by health professionals who
show empathy and sensitivity to patients. Congruence is the
ability to be open, real and authentic with another (Mearns and
Cooper, 2005). Unconditional positive regard is an expression
of total acceptance of another, while adopting an attitude of
genuineness with that person, which prizes them totally and
unconditionally (Crisp, 2011). The PCA allows patients to
speak openly and honestly about their feelings and challenges
health professionals to explore different questions with patients,
other than questions solely focused on treatment strategies and
protocols. The PCA enables health professionals to build an
authentic and trusting relationship with patients. However, it is
important to remember that holistic care is an ongoing process
and not a tick-box exercise (Mearns and Cooper, 2005). While
research evidence of the impact of PCA is lacking, the theory
has received strong support from research in other fields of
counselling, psychotherapy and education, and the effectiveness
of the PCA can be expounded from meta-analyses in these
fields (Lambert and Barley, 2001; Crisp, 2011).
Communication skills
Wilkinson et al (2008) identified that establishing a rapport,
building a trusting relationship, concentrating on the salient
issues, and asking open questions are vital elements for assessment.
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During any assessment, it is important to clarify the patients
understanding and how much relevant information they may
have been given (Gordon and Daugherty, 2003). Actively
listening and sitting quietly through the moments of silence
British Journal of Nursing, 2015, Vol 24, No 13
PALLIATIVE CARE
with patients allows them time to reflect and explore their
thoughts and emotions (Regnard and Kindlen, 2002). Effective
listening involves concentrating on the main direction of the
conversation, staying with the patients agenda, and not thinking
of the next question while the patient is talking (Gagan, 1983).
Gagan (1983) understood that active listening requires focus
and full attention on the patients story, his or her expressed
emotions and body language. Silence is a powerful and dynamic
method of demonstrating support, and silence communicates to
patients that the listener is comfortable with them (Campbell et
al, 2010).Active listening is paramount if communication is to be
therapeutic and health professionals must stay with the patient
and resist the urge to interrupt or problem-solve (Clayton et al,
2008). The NHS Cancer Plan (DH, 2001) identified that patients
consider a willingness to listen and explain to be one of the
most essential attributes of any health professional.
Poor communication
She didnt give us any explanation about the
cancer [prognosis, treatment]. She didnt know,
I dont think. Or didnt care. I think she didnt
care. (Carter, 2001: 127)
More Care, Less Pathway (DH, 2013) reviewed the Liverpool
Care Pathway (LCP) in response to substantial criticism of its
use. It clearly identified poor levels of communication for the
patient and carers during the final stages of life, which, the
report concluded, rendered the LCP ineffective (DH, 2013).
Many authors have identified poor communication skills, such as
asking closed or multiple questions, giving inappropriate advice,
normalising and minimising the patients situation, jollying
patients along, and changing subjects to lesser issues. Use of
confusing medical jargon is also a barrier to communication
(Barnett, 2002). Poor communication leads to misunderstandings
and can easily damage an often fragile relationship between
patient and health professional. Good communication is about
the depth, not the length, of an encounter with a patient, and
it is imperative that health professionals recognise and defer
their own agenda to elicit the patients concerns and fears
(Regnard and Kindlen 2002; Hallenbeck, 2003). Heaven and
Maguire (2008) recognised a correlation between a patients low
disclosure of emotional concerns, and anxiety and depression.
Wilkinson et al (2008) believed that uninformed patients suffer
increased psychological distress, and that ambiguous, inconsistent
information increases anxiety.
Although many patients prefer full and open disclosure, health
professionals should never presume that patients always want
information concerning their prognosis (Case et al, 2005). They
may neglect the fact that some patients avoid painful information
as a protective coping strategy, guarding them against fear and
mental dissonance (Villagran et al, 2010). For this reason, it is
imperative to treat every patient as an individual, understanding
that patients may both seek and avoid information. Reflection
on practice helps health professionals engage in a process of
continuous learning while comprehending the complexities of
their role (Charalambous and Papastavrou, 2009).
However, reflection requires commitment and a desire to
develop self-knowledge and to strive to improve ones clinical
practice. Faull and Woof (2002) stipulate that, although record
703
 keeping is an essential part of clinical practice, writing notes
during assessments can form a barrier to communication
and notes should be compiled carefully and unobtrusively.
Ultimately, it can be seen that communication, whether good
or bad, has a direct impact on the degree to which patients cope
(Fallowfield and Jenkins, 2004).
Six-step SPIKES protocol
It is often a difficult balance for health professionals to assist
terminally ill patients in maintaining hope while receiving
information on their disease trajectory and prognosis (Hagerty
et al, 2005).To assist with assessments, Baile et al (2000) described
the six-step SPIKES protocol (Box 1). SPIKES allows for a
dynamic and flexible interaction between health professionals
and patients, and helps to encourage patient disclosure of
significant information in a comprehensive way (Baile et al,
2000). Sllner et al (2001) stipulated the need to gather relevant
information during assessment and the protocol helps to elicit
the patients collaboration in developing a future plan of care,
while ensuring patients are supported throughout assessment.
Barnett (2002) stressed the importance of conveying clinical
information and delivering bad news in a supportive and
constructive way, and the protocol helps to fulfil these objectives.
Importantly, Case et al (2005) believe that anxiety and fear
may cause patients to reject important advice and information
given by health professionals. Although the SPIKES protocol
is not completely derived from empirical data and further
research is required to understand how helpful patients find
this approach, the protocol does provide a specialised form of
effective communication-skills training for health professionals
(Baile et al, 2000). The key feature of the SPIKES protocol
is to provide a sure foundation for effective communication.
Health professionals who have used the protocol reported that
it increased their confidence and enabled them to encourage
patients to foster hope and realistic expectations regarding
prognosis (Baile et al, 2000).
Hope
Hope in the setting of palliative care is a wide and
multidimensional phenomenon, and can hold different
meanings for different individuals (Case et al, 2005; Hagerty et
al, 2005). According to Clayton et al:
Hope can be defined as a confident but uncertain
expectation of a future good that appears
realistically possible and is personally significant for
an individual. (Clayton et al, 2005: 1966)
Box 1. Six-step SPIKES protocol
Settingsetting
up the interview involves planning and
preparation
Perceptionassessing the patients understanding
Invitation obtaining the patients invitation to offer
information
Knowledgedelivering knowledge and information in a
sensitive and timely way
Emotionsaddressing the patients emotions using a
person-centred approach (PCA)
Strategysummarise and plan a future strategy
704
Every patient needs hope to give them the strength to
cope, especially when life expectancy is uncertain, and the
focus of hope often shifts over time as the patients illness
progresses (Hagerty et al, 2005). Hope is an essential element
of psychological wellbeing if patients are to experience relief,
quiescence and balance throughout the trajectory of their
disease (Clayton et al, 2008). Villagran et al (2010) believed a
sense of hope can be maintained if, once prognosis is coherently
communicated, the patient is offered some positive aspect of
their future care. By contrast, Carter (2001) believed hope
can be obliterated if false promises are given or information
delivered too bluntly to vulnerable patients. Furthermore, a
sense of hope often mitigates the stress and anxiety associated
with delivering bad news about the reality of the patients
prognosis (Villagran et al, 2010). Gordon and Daugherty (2003)
postulated that hope evolves from a therapeutic relationship
between patient and carer, within which the patient feels heard,
valued and respected.
Despite this evidence, some health professionals reject their
responsibility to bring hope to patients, believing it is not their
job (Gordon and Daugherty, 2003). Additionally, Holtslander
and Duggleby (2009) believed that hope can be easily eroded
by negative messages from health professionals, and once a
patients trust and confidence are lost, they may be impossible to
reclaim. Failure to comprehend the essence of what patients are
communicating, either verbally or non-verbally, will adversely
affect the level of support that health professionals can offer and
risks increasing patients suffering and isolation (Carter, 2001).
Fostering hope
Clayton et al (2008) hypothesised that, although health
professionals may understand the importance of their facilitative
role of fostering hope, they struggle with ways openly to discuss
important issues with terminally ill patients. They may avoid
meaningful discussions with patients, fearing that they will
intensify the patients anxiety (Hagerty et al, 2005). Nevertheless,
if hope is to flourish, listening accurately while acknowledging
patients emotional concerns is crucial (Clayton et al, 2008).
Health professionals can convey hope by demonstrating up-to-
date knowledge of the patients condition and reassuring them
that good symptom management is a paramount goal (Hagerty
et al, 2005). Hagerty et al (2005) found that hope diminishes for
patients if health professionals appear nervous, use euphemisms
or address information to family members rather than directly to
patients. Jablonski and Wyatt (2005) warned health professionals
to avoid obtuseness and small talk during assessment to facilitate
optimal disclosure. Helping to facilitate hope as patients come
to terms with the shifting sands of a deteriorating condition
is never easy, and it is important not to offer unrealistic goals
or collude with patients unrealistic expectations (Clayton et al,
2008). Information must be delivered sensitively and patients
often require timely advice about how they can cope on a
day-to-day basis (Clayton et al, 2008). In palliative care, hope
for a cure is erroneous and the challenge is to help patients find
hope in other ways (Campbell, 2010). Exploring realistic goals
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with patients, encouraging them to focus on day-to-day living
rather than dying, and planning for special times with family
all help to foster hope (Baile, 2000). In addition, exploring
symptom control, being well cared-for and supported, and even
British Journal of Nursing, 2015, Vol 24, No 13

a peaceful death, are all important aspects of hope in end-of-life
care (Villagran et al, 2010). Comprehending the broad concept
of hope empowers health professionals to engage meaningfully
and facilitates patients in expressing often unexpected features
of what encompasses hope for them (Villagran et al, 2010):
We can sometimes reinforce our relationship
with our patients by acting as a cheerleader for
their ideas and hopes, while still helping them
make plans for the less desirable outcome.
(Campbell, 2010: 446)
Conclusion
Communication extends far beyond the spoken word and
that therapeutic communication is a vital core clinical skill
that requires ongoing training and practice. Although the
complex issues surrounding communication remain a challenge,
the use of the tools and methods described in this article
provide effective ways to meet those challenges by structuring
assessments. However, further research is needed to determine
the negative impact of poor communication on the wellbeing
of health professionals and to what extent the SPIKES protocol
reduces the stress of breaking bad news.
Nevertheless, it can be seen that the relational depth that can
be achieved with a person-centred holistic approach is crucial
in preventing patients from retreating into themselves during
assessments. Health professionals can further develop and protect
the quality of their clinical practice and care provision through
reflection practice, keeping up to date with evidence-based
medicine and attending advanced therapeutic communication-
skills training at regular intervals.
Ultimately, effective communication with dying patients can
no longer be considered an optional, non-obligatory skill in
clinical practice, and More Care, Less Pathway (DH, 2013) called
for additional funding for research for further development
of education and training programmes in communication for
health professionals caring for dying patients. There is no area
of clinical practice more fascinating, challenging, and rewarding
than palliative care. Health professionals who value opportunities
to be with patients on a meaningful level often find that there is
nothing more agreeable, honourable or worthy. BJN
Conflict of interest: none
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British Journal of Nursing, 2015, Vol 24, No 13
PALLIATIVE CARE
KEY POINTS
Therapeutic
n communication is complex, and involves gathering and
transmitting relevant medical information while providing support
Many
n government documents expound the importance of offering patients
approaching the end of life more choice regarding their care
Comprehending
n the broad concept of hope empowers health professionals in
engaging meaningfully with patients
The
n SPIKES 6-step protocol is a foundation for effective communication;
health professionals who have used the protocol report that it has increased
their confidence and enabled them to encourage patients in fostering hope
Holistic
n care is founded on therapeutic communication and involves not only
physical issues, but also the psychological, social and spiritual needs of patients
and their families
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