Conversations about end of life with patients and families are never easy; however, physicians need to have such discussions in order to benefit the patient (Lo and Snyder 1999). The importance of providing honest information has been described in the previous section, outlining the importance of telling the "truth" to patients about their illness, treatment, as well as prognosis.
In addition to telling the truth, using appropriate language is also fundamental in communicating with patients and their family (Fallowfield et al. 2002). It is important to use unambiguous language and to make sure that the patient understands what has been said. It is not uncommon for patients to leave the consultation without having fully understood what has been said (Fallowfield et al. 2002; Quirt et al. 1997).
Ong et al. (1995) describe two types of physician behaviour whilst communicating with patients: instrumental and affective. Instrumental behaviour describes "cure-oriented" behaviour that is "task oriented", and affective behaviour describes "care-oriented" behaviour that is "socio-emotional". Friedrichsen et al. (2000) found that there were many different types of physicians, for example (1) the inexperienced messenger, (2) the emotionally burdened, (3) the rough and ready expert, (4) the benevolent but tactless expert, (5) the distanced doctor and (6) the empathic professional. They found that the character of the physicians and their ability to create personal relationships also influence the patients' ability to cope with the situation and with the information given to them.
There is no consensus on what may be considered to be the best form of communicating (Friedrichsen et al. 2000). Physicians who are able to empathise and care—as well as provide hope, trust, interest and commitment—are important to patients, as is allowing the patient and family the opportunity to ask questions (Friedrichsen et al 2000). In addition, using non-verbal as well as verbal communication has been considered important, particularly in re-enforcing messages (Fallowfield et al. 2002).
Some have suggested methods that may help in communication with dying patients particularly with regards to breaking bad news, including Fallowfield (1993), Faulkner and colleagues (1995), Morton (1996), and Girgis (1998), for example.
Maintaining open communication between health professionals and patient may, however, not be as easy in practice as it may appear on paper (Field and Copp 1999). Bolmsjo and Herm-enen (1998) describe a situation where a person's response to health professionals can change from time to time, making it less clear what form of communication may be most appropriate at each stage.
Although much of what has been described so far relates to doctor-patient communication, nurse-patient communication is also very important to consider, although it has received much less attention in the literature to date. Kruijver et al. (2000) highlight effective communication behaviours by nurses in cancer care. Behaviours thought to be facilitating effective communication by nurses included empathy, touch, comforting and supportive care behaviours. They confirm Raudonis's, (1993) finding that "empathic relationships between nurses and hospice patients had a positive impact on patients' physical and emotional well-being" (Kruijver et al. 2000). Morales (1994) found that touch is important in transmitting confidence and in enhancing the patient's ability to cope and feel accepted as a person (Kruijver et al. 2000; Morales 1994). Bottorff et al. (1995) reported that comfort involves more than pain relief but that it also includes "humour, physical comfort, emotionally supportive statements, and comforting and connecting touch" (Kruijver et al. 2000). Kruijver and co-workers (2000) believe that the types of behaviours described above can contribute to helping or hindering patients in expressing their informational needs or concerns, as well as affecting their satisfaction with care.
In their study of 103 cancer patients, Sapir et al. (2000) found that 87% felt that eye contact was important, 53% were strongly in favour of having the doctor sitting across the desk, while 38% felt strongly in favour of having the doctor sitting next to them. Supportive touch had as many in favour as it had against, with 15% having a strong disapproval to this.
Communicating news, particularly regarding transferring from curative to palliative care, is very stressful for physicians and health professionals, and many are often left unsatisfied with their consultation (Fallowfield et al. 2002). For this reason it is also important to consider the needs not only of the patient and their family who are receiving the information, but also of those individuals who are providing the information. Fallowfield et al. (2002), for example, express a need for adequate support for health professionals working in this area to help deal with such stressful situations.
Since communication has been identified as an important aspect of palliative care, and since it has been found that health professionals, e.g. physicians and/or nurses, have been less than optimal (Kruijver et al. 2000; Lo and Snyder 1999), education in this area has increased in the last decade. The effectiveness of such communication skills programmes has been supported by some authors (Wilkinson et al. 1998).
Although honest communication and information is wanted by both patients and their family and friends, it is also important to consider that their needs may differ in nature to some degree. Field and Copp (1999) suggest that patients and relatives face different threats, "relatives have to cope with bereavement, whereas the dying patient has to face the end of their existence, and for them there may be the need to escape into the comfort of mental avoidance and/or denial of the outcome".
In terms of the content of communication, two important areas described by Kirk et al. (2004) were those of prognosis and of hope. The participants in this study described a great need for hope and to be given "hopeful messages at all stages". The authors go on to describe two dimensions of hope that are relevant. The first, "patient/family orientations to hope", involves needing to believe in a miracle and living parallel realities—that is, hoping for a cure or remission whilst at the same time realising the terminal nature of the illness. The second dimension of hope described involved "messages from the healthcare providers supporting hope" including using words and approaches that left the door open, retained professional honesty, pacing the move towards palliative care, and respecting alternative paths (Kirk et al. 2004).
The importance of hope as part of effective communication is described clearly in this study; however, the importance of hope is not by far limited to this one study. Many have described hope as a crucial aspect of communication within palliative care patients and their families. The following section will explore the role and importance of hope as a major aspect of communication in palliative care.
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