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'To fulfill patients' end of life wishes we must know how to handle those tough conversations'

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Acronyms; we see them everywhere in healthcare.

As a student I have found some of them particularly beneficial in helping me recall key points of care. Of course they do not cover every aspect of care and cannot replace clinical judgement, yet they have certainly been helpful through my student nurse journey and have assisted me in planning and delivering care for my patients.

It has recently been highlighted that many healthcare professionals struggle when conducting difficult conversations with patients who have been given a terminal diagnosis. This got me thinking about the care my dad received when he was diagnosed with terminal cancer. On reflection, communication from the healthcare professionals was poor and this only served to make what was an awful time much worse.

The following acronym, ‘WISHES’, highlights some - although of course not all - points of discussion in reference to this most vital area of care.

W - What matters to the individual? 

This should be the main priority, and for me is the most important part of care. If it matters to my patient then it most certainly matters to me.

And it really shouldn’t matter what it is. We are all individuals so something that may not be of concern to you could be of enormous concern to another person. Care of pets, religious beliefs, finances, sexuality, prevention of pain, and making amends with people are just a few that we as nurses may come across.

When my dad was nearing the end of his life one of the things that mattered to him was that we sought-out a type of ice cream he ate when he was younger. A simple thing that he requested but this obviously mattered to him. This is just a personal example and there are many things that matter to our patients; asking conveys that you care about what they are.

I - Including family in your care

There are many considerations surrounding the inclusion of family members in our care and this is something we should be discussing with the patient.

For example, does the patient want their family to know about their diagnosis? If so, do they require your support when telling their family?

Are we ensuring that the family are receiving adequate support and communication on a regular basis? For example, are the family requesting that information of the patient’s condition be kept from them? I have witnessed these communication problems many times and in my experience it often results in the nurse minimising communication with the patient for fear of saying the wrong thing and being faced with angry family members - not at all beneficial for the patient. Effective communication with the patient and their family is crucial for ensuring that this is not a position we put our patient, or ourselves, in.

S - Services: are they being made accessible?

As advocates we should be making every service accessible that will be of benefit to the patient and their family and/or carer(s).

This may include religious, spiritual, charitable, or community services. The list is endless but if they can make their life a little easier then we should find out what our patient needs and work towards making these services accessible.

H - Hospital/Hospice/Home?

Has a preferred place of death been discussed?

This is not an easy discussion for any healthcare professional to have but the patient is the priority. This is not always a straight-forward situation but surely if the discussion is had as early as possible then there is a greater chance of the person’s wishes being met.

It was presumed that my dad would die in hospital. He was never asked and neither were the family. It only became a consideration after he became distressed and voiced that he wanted to come home. Eventually he did come home to die but it took a while and he spent a long time upset and lost valuable time in his own home. This is something that we can perhaps prevent if the conversation is had early on.

E- Encourage questions

Encourage questions from the patient and family members. We can get so caught-up in our work that often the impression that we are too busy can be conveyed to others. When sat at my Dad’s bedside I wanted to ask questions but felt like I would be bothering the nurses. And when I did ask they would say they would get back to me. They never did. This left us both in a state of unnecessary anxiety. As nurses we can prevent this by making ourselves available and approachable through encouraging questions or concerns to be voiced.

S- Symptom control

Symptoms of an illness should be explained to the patient and their family and so should the effects of medication. I wouldn’t want to take medication if I didn’t really understand the effects, so I don’t expect my patient to. Open discussions surrounding symptom control contributes to pain relief being tailored to the individual’s specific needs as symptoms can vary from person to person. A regular review of medication and its effect is also central for promoting the best quality of life possible.


Your patient may not wish to discuss any of the above - and this is okay. However, how will you ever know unless the discussion is initiated, perhaps by you, in the first instance?

Leanne Siekiera is Student Nursing Times’ student editor for adult branch

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