COVID-19 and difficult conversations in critical units: A practical guide for nurses.

Abstract

The editorial published in this journal in April 2020, entitled “Has COVID-19 forced us to implement better practices?,”1 brought up a relevant and emerging theme. Nurses are the largest group of health care professionals on the front line providing care in the COVID-19 pandemic, working in multidisciplinary teams and participating in the planning of coping strategies in health institutions. Working in a health emergency of such magnitude tends to generate physical and psychological stress that cannot be underestimated.2 Nursing critical care patients of any age group can cause emotional tension and physical exhaustion, and this experience is accentuated when caring for patients infected with COVID-19 at the end of their lives.3 In this context, fear, incapacity, and anxiety regarding breaking bad news can be high because many professionals (especially those who have been relocated to critical units because of the pandemic) are working outside their original units and may possess limited experience to serve families of patients at the end of their lives.2, 4, 5 The term “communicating bad news” or “communicating difficult news” is a communication process that occurs before, during, and after the communication of some bad news and is considered health information that alters a person's perception of the present and future in a negative way.6 Usually, it is the medical team who disclose difficult news to patients and their families. However, nurses who work at the bedside are fully involved in this activity because they spend more time with the patient and often know the details of the needs of both the patients and the families.7 Nurses help families in many instances during the process of communicating bad news; for example, following up conversations to clarify technical terms and jargon, ensuring understanding of difficult information or clarifying the implications of the diagnosis or potential treatments. In addition, families may have a preference for conversations with nurses because of their proximity in the nurse-family-patient relationship and the fragility of the relationship with other professionals from the team.7-9 The task of communicating bad news is a complex skill that requires empathy, appropriate body language, and a welcoming voice tone, among other measures that are impaired in the context of the COVID-19 pandemic.10 Physical distancing prevents touching or hugging, impedes face-to-face conversations regarding the side effects or symptom evolution, and often makes family farewells unfeasible when the patient dies. In turn, the use of personal protective equipment leaves the facial non-verbal language subsumed, weakening both communication and interaction,10, 11 especially in critical care units. We call on all nurses to reflect on the communication of bad news in critical units in the context of the COVID-19 pandemic. In a quick review of the scientific literature on communicating bad news, we observed that there are several protocols in the area of oncology and palliative care, which are widely used in the context of critical care. In the COVID-19 pandemic, such protocols are being rapidly reformulated to a telehealth strategy, which has been useful for several professionals who make up the health team.8, 10-13 However, when it comes to clinical situations that involve nurses in critical units, for example, the communication of death of a patient with COVID-19 diagnostic, mostly young people, there is little evidence about the application of bad news protocols. Our objective was to systematize a practical guide for communicating bad news based on the SPIKES protocol,14 to provide clinical guidance for nurses when caring for family members of patients with COVID-19 in critical care units (Table 1). Communicating difficult news is a highly complex activity and nurses need to feel confident that their participation in the communication process is effective. Although nurses face many challenges participating in this process, this practical guide can facilitate family-centred care centred for patients in critical care units.