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Communication in end-of-life cardiac care 2: Skills

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This is a two-part unit on communicating with patients with end-stage heart failure. Part 1 identified the potential issues patients may face. This second part aims to enable nurses to develop an awareness of the skills needed to help patients identify and express their fears and anxieties.

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article found under “related files”


Peter Stuart, BA, RGN, is clinical nurse specialist in palliative care; Deborah Knott, RGN, is Macmillan palliative specialist sister; both at University Hospitals of Leicester NHS Trust.

Stuart, P., Knott, D.
(2008) Communication in end-of-life cardiac care 2: skills. Nursing Times; 104: 11, 26–27.

Learning outcomes

  1. Identify behaviours that facilitate communication

  2. Identify styles that block communication


Communication skills

In order for nurses to communicate effectively with patients, it is important that they recognise and implement the necessary skills. The following is a basic guide to raise awareness of certain behaviours that can facilitate or improve communication between patients and nurses. The aim is for nurses to develop skills that can be adapted to form a strategy to deal with difficult situations.

Behaviours that facilitate communication

Listening: Active listening requires great concentration. Attentive body language will help demonstrate this. This is achieved by: maintaining eye contact; having an open posture; and offering encouraging gestures such as nodding at appropriate times.

Cues: Patients will give cues about their real concerns several times but will give up if these are not recognised. Active listening helps patients to give the cues but listeners need to acknowledge problems and follow them up. For example, with: ‘I’m better today thank you, it’s my husband I feel sorry for,’ the cue here is the patient’s concern for her husband.

Reflection: This involves using patients’ own words to reflect back on issues, for example: ‘You told me yesterday how difficult you were finding [a particular aspect]… how do you feel about that today?’ Reflection is a good way of demonstrating active listening and encouraging patients to expand on problems.

Clarifying: This involves asking patients to give more information about an issue or to confirm what they are thinking. For example, a patient may be anxious not to ‘suffer’ but this word is open to interpretation. Asking ‘Could you tell me more about what you mean by suffering?’ helps to clarify their view.

Empathy: This encourages patients to disclose problems by demonstrating some understanding of their situation, for example: ‘From what you tell me it sounds as though you have had a very tough time recently.’ It is not saying to patients: ‘I know how you feel.’

Silence: This is an important skill that enables patients to organise their thoughts and feelings and broach painful subjects.

Open questioning: This gives patients the opportunity to express their feelings, for example: ‘You had a rough day yesterday. How are you feeling today?’

Challenging questions:Clarifying discrepancies in what has been said, for example: ‘You said you’re OK but you look very upset to me. Do you want to talk about this?’

Behaviours that blockcommunication

Normalising: Normalising patients’ problems belittles them and moves the focus away from patients, for example: ‘Everybody gets pain after an operation, even little operations like yours.’

False reassurance: Although the intention is often to reassure patients, the results can be harmful, for example: ‘I’m sure the scan will show everything is fine.’ This may make both nurses and patients feel better in the short term but can result in greater distress if the result is not fine.

Leading questions: This is a question that influences the response, for example: ‘You seem better today, don’t you?’

Deferring: Sometimes patients may ask a question that is uncomfortable to answer. The temptation is to say: ‘I’ll ask the doctor to answer that.’ Although nurses may not have all the information to answer a question, they should remember that patients have trusted them with the question, so it may be possible to follow it up with questions about their worries or anxieties.

Multiple questions: Avoid asking more than one question at a time, for example: ‘How are you today? Did you eat your lunch?’ It suggests nurses are not interested in
the answer.

Platitudes: The intention may be to cheer somebody up but the reaction can make things worse, for example: ‘It can’t be that bad – give us a smile.’

Helping patients to address the issues

By using good communication skills, nurses can help patients to explore their feelings and worries, and facilitate ways of helping them to cope with their emotional suffering.

Patients’ and carers’ communication needs and decision-making preferences vary considerably. Often all patients want is to be listened to and be heard – they are not expecting an immediate resolution of their problems.

The aim of this section is not to give nurses detailed guidance on how to address every situation but to give direction on how to approach difficult communication issues using the facilitation skills identified.

Case studies exploring each of the issues outlined are given in more detail in the Portfolio Pages online corresponding to this unit. All involve acting on patient cues.

Eliciting patients’ concerns
As mentioned previously, patients often give hints or cues about their real worries but are too afraid to tackle the issues directly. The challenge for nurses is to identify these issues and sensitively bring them to the fore.

Patients will give cues until they are heard, or they give up trying (Lang et al, 2000). If they give up, their real concerns are not identified, which can have a damaging effect.

The skill for nurses is to listen and elicit patients’ real concerns. These can often be hidden in trivial comments. Often patients are relieved to be heard and nurses should not feel pressured to find solutions to problems – patients just need time to reflect.

This case study in Portfolio Pages concerns a patient who has had to give up work. Open questioning, backed with empathy, are used to elicit whether the patient is ready to discuss the progression of her disease. Open and challenging questions are later employed to explore feelings around hopelessness and the loss of independence.

Loss of hope and dealing with hopelessness
Nurses can enable hope by developing patients’ awareness of life, identifying a reason for living, establishing a support system, incorporating religion and humour into their practice, and helping patients set realistic goals (Rustoen and Wikland, 2000).

Issues around loss can be difficult to identify and, if these are not explored, patients can be left with feelings of hopelessness and despair. The temptation is for nurses to try to make everything better for patients but the reality is that they cannot do this. Most patients in this situation are grateful for having someone to listen to them and do not expect nurses to make them better.

Palliative care seeks to help people acknowledge their losses and assist them in finding ways of coping (Horne and Payne, 2004). Facilitating choices for patients dying from heart failure can encourage a sense of control and promote hope. By nurturing hope, and with gentle communication skills, nurses can help broaden patients’ coping repertoire (Felder, 2004).

In this Portfolio Pages case study, a patient who is normally particular about her appearance has become unkempt and her partner says she is ‘in one of her moods today’. Her anger is recognised as a cue, and challenging questions are used to discuss what is making her angry. Open questions backed with empathy are used to explore her lack of self-worth and sense of loss.

Helping patients to recognise they are dying
There can be a reluctance among healthcare professionals working in the area of heart failure to recognise a patient is dying when there is still hope of improvement. In these situations, it is often better to discuss this with patients and their family rather than give false hope and betray trust. In order to help patients deal with this, it is essential to diagnose dying (Ellershaw and Ward, 2003).

Helping patients to recognise that they are dying is often the first step in coming to terms with their death. Asking them to reflect on how they are feeling and what the future may hold for them is one way of helping them recognise deterioration in their condition. This can lead on to thoughts of mortality and dying.

As previously discussed, patients often feel they are dying at times of illness exacerbations and discussions are often not facilitated by practitioners. The key is to pick up on patient cues and explore these further.

In this case study in Portfolio Pages, a very unwell patient is in a low mood and he asks what can be done to make him better. Challenging and open questions are used to explore what he means by ‘getting better’ and whether he knows he is dying, leading to discussions around dying.


Patients with end-stage heart failure have identified a lack of open communication about end-of-life issues with healthcare professionals. However, most patients express a willingness and a need to explore these feelings and needs.

For patients with this condition there are a number of difficult communication issues that have been identified, such as thoughts on dying, considering the preferred place of death, preparation for death and dealing with loss.

Good communication is an essential component in the delivery of care to patients with end-stage heart failure and also forms the basis for good palliative care.

Nurses can, by using the skills discussed here, help address these problems in the absence of heart failure nurses or specialist palliative care teams. Further advice and ways of developing communication skills can be found by accessing advanced communication courses.

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