Since communication with the terminally ill is covered in the chapter "Maintaining Hope: Communication in Palliative Care" (by V. Kennedy and M. Lloyd-Williams), this section will be restricted to a few thoughts on the situation of the dying patient (Guex et al. 2000).
Due to exhaustion and a certain withdrawal of patients when facing the end of their life, communication with the treating physician is often limited to short conversations. Communication is less dominated by the transmission of specific medical information. More often, non-verbal communication and therefore the attitude of the clinician becomes crucial. He has to contain the patient's suffering: communication should then not be restricted to medical facts, and trying to cover up the unpleasant aspects of the situation is inadequate. If a physician wants to be open to understand "where a patient is at a given moment", he has to free himself from prejudices of how someone has to face death. While in prior stages of the disease, the clinician often plays an active role, in the terminal phase, he is invited to listen and to try to understand the patient; he is in a more "receptive" position.
A 28-year-old man of Italian origin, suffering from a very advanced lymphoma, used to ask the treating physician every morning during rounds, "Is there a possibility to operate?" and would then change the topic and inform the physician about the latest news from the Italian football league. The physician always respectfully denied a surgical option for that moment and then stayed a while to listen to the football news.
Being with the patient "where he is at this moment in time" implied that the daily question of this patient was respectfully answered without irritation, and understood in the context of the patient's denial. This question, which had become a ritual, was this patient's way to express that he knew he is ill, but that he had not given up hope; the football news can be interpreted as the patient expressing that he is not only ill, but that healthy parts still exist and that he continues to be interested in his lifelong hobby, which he shared with the physician.
Being close to the patient also means including the family; very often clinicians can enhance the understanding of significant others, that each patient has the right to die his own death and that the most important and active task family members have is to be close to the patient and respect his way of coping with the situation. The key elements of communicating with the family are discussed in the chapter "The Patient and His Family", by P. Firth.
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