Barriers to communicating well with patients: what we heard from clinicians
Clinicians gave us a range of insights into why communicating well with patients about end of life care can be so challenging.
Managing complex emotions
Clinicians acknowledged that these are difficult conversations, even for those with significant experience. We heard that it can be especially challenging for less experienced clinicians to feel confident managing their own emotions and those of patients:
‘It’s really hard and really painful for people to sit with distress in a conversation and just accept that’s ok… You do need to make sure that your clinicians or whoever's having those conversations are not themselves carrying an unreasonable amount of grief, and we are really bad at teaching that to our resident doctors.’
Clinicians highlighted the importance of providing staff, particularly resident doctors, with space and time to reflect before and after these discussions:
‘You do need to debrief and offload to someone else about how it made you feel… and within a ward setting that can easily be missed… Just somebody who says, you know, “are you alright? Right, that was that was a tough one, what are your reflections?” And then sit down and take 15 minutes and just document how that conversation went.’
Even where formal reflection is not required, clinicians felt that simply making support visible and accessible can help to build resilience and confidence.
Recognising own scope of practice
Clinicians emphasised that developing communication skills and growing confidence happens with experience rather than formal training. Clinicians highlighted the importance of recognising personal limits and knowing when to escalate conversations or get support from more experienced colleagues. Having an experienced colleague available on the ward is critical, particularly when conversations become more complex or emotionally intense. This allows staff to step in, support one another and make sure that families receive clear, sensitive and consistent communication at a highly vulnerable time. A senior nurse told us:
‘Training and education should be around people recognising their scope of practice and their boundaries and when to get help.’
Getting the timing right
Clinicians working in acute settings described feeling as though they were often ‘playing catch‑up’ on conversations with patients who have had long histories across multiple clinics or specialist services. In some cases, it is clear that these patients have an illness where the prognosis could end their life or contribute to their end of life. Frequently, they arrive in acute settings without having had conversations that might help them understand their prognosis and feel prepared:
‘A frustration of all of us working in acute care is the lack of clarity during care of chronic progressive illnesses regarding the vulnerability and the potential for deterioration. Patients don’t appear to routinely have conversations about the progression of their illness and about what is reasonable expectation of the length of life with their chronic disease team.’
Though there was also an understanding of why these conversations might be missed earlier in someone’s care journey:
‘If you do look after someone for years, knowing when the best time to bring it up is difficult. Do you do it at the beginning, but then you risk frightening someone about something that may happen 10 years away. Or do you do it in five years? It can be really difficult pitching it at the right time for the patient to talk about these things. And that’s why we might miss the opportunity to talk about end of life planning for some patients.’
Limited time during appointments was also acknowledged as a barrier. Not wanting to start a sensitive conversation without being able to give it the time it deserves is another reason why these earlier conversations may not happen.
Continuity of care
We heard that transitions between care settings can disrupt communication. When patients move between settings, responsibility shifts to new clinical teams, and relationships and trust often need to be rebuilt. This can make it difficult to maintain the same level of personalised communication and continuity of care.
In some cases, a clinician who has had little previous contact with the patient may need to have very difficult conversations, including speaking to families about a loved one approaching the end of life:
‘It can be incredibly problematic to get communication to the right individuals in a timely way, and for the family and the patient to feel that the same level of individualised care has been continued into that new setting.’
An avoidant culture
It is also important to recognise the broader culture in which clinicians and patients are working and living. Death and dying remain taboo topics for many, and this inevitably creates additional barriers to having open conversations about the end of life, as one clinician observed:
‘Not everyone is very open about what they will talk about, even though it is totally inevitable. That all feeds into it - there is just a general culture of not talking about these things openly… I think because of the sensitivities of talking about these difficult things, people avoid the discussion a bit. Patients avoid it and so do families.’