Recent research has looked at how good communication at end-of-life can help family members in their grief. Conversely, poor communication at the end of a loved one’s life has been associated with higher levels of depression, anxiety, and PTSD among family members. This means that providing thoughtful and effective communication in times of crisis has a much longer-term impact than people realize.
Luckily, experts working in hospital and hospice settings have put together research-based communication during crisis tips and tools. Unfortunately, those tools haven’t been as widely distributed as we might hope. They are skills and tools that are not just useful in hospitals and hospices, but in funeral homes and even in conversations with family and friends. So, today we’re going to engage in a little transfer of knowledge:
Here is a quick overview of a communication course developed by Dr. Robert M. Arnold and colleagues. They used existing research, evidence-based practices in end-of-life family communication, and their critical care experience to establish 5 Communication Principles to Help Professionals Talk with Families. We’ve summarized their principles below and hope you can adapt them to whatever situation in which you might be communicating with others at end of life:
5 Communication Principles to Help Professionals Talk with Families
Principle #1. Use the Ask-Tell-Ask Method
Ask: This involves first asking the family what they understand. In the hospital, this might mean about diagnosis, prognosis, or treatment. For funeral directors, this may involve asking the family about their previous experience and knowledge with funeral planning, what they are expecting, and eventually asking permission to provide the family with information about the funeral planning process.
Tell: The “tell” step is just what it sounds like. Beginning the process of sharing information. Discuss details of options or what comes next, and be direct and concrete.
Ask: Finally, ask the family to restate what they have understood and to ask any questions they have about the next steps.
Principle #2: Use the Phrase “Tell Me More” When Things Get Off Track or People Seem Stuck
It isn’t uncommon for people to struggle with comprehension, remembering information, managing emotions, and making decisions when dealing with the stress and crisis of a death. If this seems to be impacting the conversation, applying a “tell me more” approach can help you determine what a family needs from you. Arnold et al. suggest statements like:
Could you tell me more about what information you need at this point?
Could you say something about how you are feeling about what we’ve discussed?
Could you tell me what this means for you?
Principle #3. Use Reflections Rather Than Questions to Learn More
…in instances when you are hoping to ensure you understand how a person is feeling, establish empathy, or seek clarification. Reflections (restatements of what the person has said) can assist. These may be simple restatements, using their exact language. For example:
Wife: We never discussed what type of funeral he wanted so I just don’t know how to make these decisions.
You: You don’t know how to make this because you never discussed his funeral wishes.
Wife: Exactly, so how can I possibly make these choices when we never discussed it.
In this instance, you’ve now confirmed that the lack of a specific conversation is where the wife is feeling stuck and can now begin the process of assisting her in using her other knowledge and experience of her husband to make the decisions that are consistent with what he would want.
In some cases, reflections are more complex and include restating what the person has said while also adding your impressions of the person’s emotions, values, or beliefs. As Arnold points out, these can be riskier because you might get it wrong. But even that is important, as it will allow the person to then re-explain and ensure you truly understand how they are feeling. An example of a more complex reflection Arnold suggests is:
Daughter: I just don’t know how I’m going to tell my kids about this. They will be devastated.
You: I can see that you care deeply for your kids and do want them to understand what has happened.
Daughter: Yes, I do love them and want them to be ok. I just am not sure about so many things… how to talk with them… if they should come to the funeral…
Principle #4: Respond to Emotions
Families are often experiencing waves of intense emotions in the days, weeks, and months following a death. During these intense waves of emotion, it can be especially difficult to process and can make decisions even more complex. Additionally, people want to know that others acknowledge the depth and pain of those emotions. As such, Arnold and colleagues emphasize the importance of accepting and empathizing with what a family member is feeling. Arnold et al. suggest using the pneumonic “NURSE” to support a family member’s expression of emotions:
N – Name the Emotion
U – Understanding the Emotion
R – Respect the Emotion
S – Support the Emotion
E – Explore the Emotion
Principle #5: Assess the Other Person’s Informational, Decision-Making and Coping Style
Arnold suggests good communication during crisis means being aware that some people are ‘monitors’ and others are ‘blunters’. Monitors often seek lots of information and like planning, whereas blunters tend to engage in more denial, distance themselves, and avoid practicalities. It can be helpful to identify where family members lean to better tend to their needs. It can also be helpful to ask families how they have coped, supported one another, and made decisions in the past so you can better understand their family dynamics and their strengths. If you’re unsure what the family needs from you or needs you to do differently, just ask!
This is just a quick overview of these five principles to get you started. If you would like to learn more about communication during crisis, read Arnold et al.’s course module in full. You can find it here.