THE VALUE OF SILENCE: DIFFICULT CONVERSATIONS IN HOSPICE & PALLIATIVE CARE

As a hospice and palliative care provider, we are being welcomed into a patient’s life, sometimes even their home, at the most vulnerable time in their life. It is a time where we can easily feel awkward and confused during moments of high-emotions.

Prior to moving into hospice care, I was a nurse in the intensive care unit (ICU) as well as the inpatient palliative care team. In both of these situations, there were many times where myself or my co-workers had to break the news to the patient or the family members that they were nearing the end and the only medical treatments we had left to offer were that of the palliative nature. These moments are heavy. These moments are emotional. And these moments are awkward.

As a new nurse, I often felt compelled to immediately fill the void of silence with words – that I perceived, at the time, to be comforting. I wasn’t alone in this thinking. Especially in the ICU setting. We would pull the family aside into a quiet room to break the news that our medical treatment was not working. Then, after the physician would say “there’s nothing left we can do” he or she would often seamlessly go into every detail and treatment they tried. Anytime there was silence or an increase in tears, the physician would bring up another treatment that was tried and failed. This is unnecessary, but we were doing this to make ourselves feel better. What we were forgetting is that it wasn’t about us or what we had done in that moment.

 As I became more seasoned with these conversations and more comfortable with delivering the difficult news, I also learned the value of the silence. It is important to note that although the awkwardness seemed to lessen, my empathy did not! These times were not easier because I didn’t care as much. On the contrary, they were easier because I understood the importance of letting the patient and family process this information and lead the conversation when they were ready!

To put things into perspective, think of it like this: According to the Kubler-Ross Model, there are 5 stages of grief (Please note – not everyone goes through each stage and these are not completed in any particular order).

Denial

Anger

Bargaining

Depression

Acceptance

So, let’s just assume (for the purposes of getting my point across) that you are delivering detrimental news to someone who will theoretically go through all these stages of grief.  Here we go…

Hospice Provider: “I’m sorry, Mrs. Smith, but it appears that Mr. Smith’s condition has drastically changed very quickly and I don’t think he’ll survive the night.”

Mrs. Smith: *silence* Because her brain is going through rapid fire processing all at once trying to wrap her brain around the fact that she will be a widow and her children will be fatherless in less than 24 hours…

So why on earth would I want to fill this silence?!

The truth is, it’s because we are often uncomfortable and have an element of guilt about the situation, even though we have very little control over the situation.

End of life care is so much more than pain management and cleaning wounds. It’s about being a support system for the patient and his or her family. It’s about creating a safe environment that welcomes questions and honest concerns. And finally, it’s about allowing silence when necessary and being willing to allow silence because that might be exactly what is needed in that moment.

Jaymie Wilson, MSN, APRN-CNP, ACHPN

Clinical Director of Client Services, PDCRx