NURS 519 Week 2 Discussion Board Forum 1 on Serious Illness Conversations Example

Discussion Board Forum 1: Communicating Prognosis and Goals at the End of Life

NURS 519 Strategies for End of Life Care, Discussion Board Forum 1

Thread by [Student Name]

The patient example and the classmate replied to are composites written for a model discussion.

"Am I dying?" A 78-year-old patient with advanced heart failure asked me that at 3 a.m., after a third admission in two months. I said something about asking the doctor in the morning. I have thought about that answer many times, because it closed a door the patient had worked up the courage to open. This week's reading made me see that the question deserved a response, not a deferral, and that nurses can learn to give one.

Evidence suggests that structured conversations help, though not in every way we might hope. In a cluster randomized trial testing the Serious Illness Care Program with cancer clinics, clinicians were trained to use a conversation guide covering understanding, information preferences, prognosis, goals, fears, sources of strength and trade-offs (Bernacki et al., 2019). Most trained clinicians used it, and the median conversation lasted 19 minutes. The program did not change the trial's two main outcomes, care matching patients' goals and peacefulness at the end of life, but patients in the intervention group had about half the rate of moderate to severe anxiety at 14 weeks, and the reduction held at 24 weeks. Talking honestly about prognosis did not take away hope; if anything, it eased fear.

A practical structure follows from that work and from the textbook's guidance on communication (Matzo & Sherman, 2018). First, ask permission: "Would it be all right to talk about what is ahead?" Second, ask what the patient understands and how much they want to know. Third, share information in small pieces, pause, and respond to emotion before adding facts. Fourth, hold hope and worry together, as Back et al. (2003) recommend: "I hope the new medicine helps you feel stronger, and I worry that your heart is getting weaker. Can we plan for both?" Finally, ask what matters most and what the patient would not want to go through.

Nurses are not always the ones to give a prognosis, but we are often the ones asked. To my 3 a.m. patient I could have said, "That is an important question. What makes you ask it tonight?" and then listened, told the truth I knew, and made sure the team followed up in the morning. Documenting what the patient said and alerting the palliative care team would have carried the conversation forward instead of ending it.

Ecclesiastes reminds us that there is "a time to be born, and a time to die" (English Standard Version Bible, 2001/2016, Ecclesiastes 3:2). Death is part of the life God has ordered, not a failure to be hidden. Speaking about it gently and truthfully is one way to show Christ's love to patients who are afraid.

Reply to Stephanie

Stephanie, your example of the family who asked you not to tell their parent about the cancer diagnosis is one many of us have faced, and your instinct to slow down rather than refuse or comply was wise. Back et al. (2003) suggest that when patients or families resist hard news, clinicians can explore the hope behind the request before deciding what to do. A family asking for secrecy often hopes to protect a parent from despair, and naming that hope ("You love your parent and want to spare them pain") can open a conversation instead of a standoff. From there, a nurse can ask the patient directly how much they want to know, which respects the patient's autonomy without forcing information on someone who prefers to let family handle details. Some patients, especially in cultures that value family decision-making, will say, "Talk to my children." Others want every detail. Asking is the only way to know. I also liked your point about involving the chaplain, because the family's fear may be spiritual as much as medical. Did the family eventually agree to let the team ask your patient what they wanted to know, and how did the patient respond?

References

Back, A. L., Arnold, R. M., & Quill, T. E. (2003). Hope for the best, and prepare for the worst. Annals of Internal Medicine, 138(5), 439-443. https://doi.org/10.7326/0003-4819-138-5-200303040-00028

Bernacki, R., Paladino, J., Neville, B. A., Hutchings, M., Kavanagh, J., Geerse, O. P., Lakin, J., Sanders, J. J., Miller, K., Lipsitz, S., Gawande, A. A., & Block, S. D. (2019). Effect of the Serious Illness Care Program in outpatient oncology: A cluster randomized clinical trial. JAMA Internal Medicine, 179(6), 751-759. https://doi.org/10.1001/jamainternmed.2019.0077

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Matzo, M., & Sherman, D. W. (Eds.). (2018). Palliative care nursing: Quality care to the end of life (5th ed.). Springer Publishing Company.