Challenges With The Application Of Palliative Care In Nursing

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Palliative care needs to be demonstrated in a way that makes sense and comes with mutual understanding of the patients and their families to reach its goal. A nurse having strong communication skills can positively influence palliative care patients’ understanding in order to promote satisfaction and overall comfort measures. Poor interaction that comes from health care professionals raise question and feeling refusal to some patient’s parents regarding appropriateness of medical information. Nurses can improve quality of life patients and their families following certain strategies in the area of palliative care communication.


The main aim of this article review is to describe challenges encountered by nurses and possible suggested approaches in delivering care of palliative care.


A systematic and comprehensive searching approach have been used in electronic database from 2010 to 2019. There are 10 articles found based on inclusion criteria with the chosen topic out of 10501 searches.


The major challenges faced by nurses are managing difficult conversations, lack of experience, skill and competency in dealing sensitive topics asked either by patients or their family members. In addition, insufficient, inappropriate nursing training program and limited literature in palliative nursing care result in diminished evidence to support understanding of nurse’s experiences during communication. However, the Humanistic Nursing Theory, COMFORT, Ask-Tell-Ask, Tell Me More and SBAR are definite strategies that contribute in providing integrative physical, moral, emotional and spiritual care to palliative care patients.


It is not easy to provide nursing care in palliative patients and their families unless they are experienced and skilled enough. The certain strategies are recommended to tackle the challenges encountered by nurses.

Keywords: Palliative Care, Communication, Nurse, Nurse-patient Communication, Quality of life, Mutual Understanding, Sensitive Interactions


Palliative care is defined as a distinguished care approach planned to enhance the quality of patients, and assure family members using accurate assessment and helps patients in relieving pain and symptoms instead of curing disease due to advancement of disease (França, da Costa, Lopes, da Nóbrega, & de França, 2013). The philosophy of palliative care is to provide further care with the maintenance of quality of life, dignified humanity in which comfort measure comes as a first priority for patients struggling with life threating and irreversible disease (da Silva, Moreira, Leite, & Erdmann, 2012). The goal of palliative care is to improve quality life of patients and their families due to diminished possibility of recovery (Brighton & Bristowe, 2016). So, palliative care needs to be demonstrated in a way that makes sense and comes with mutual understanding of the patients and their families to reach its goal (Brighton & Bristowe, 2016)

Nursing care communication plays significant role in palliative care in order to measure comfort care and improve quality of life for both patients and their families because it involves discussing and sharing a range of health related topics, patients’ concerns, feelings, expectation, treatment and help them in finding a sense of understanding in relation to purpose of care plan and goal (Wittenberg, Reb, & Kanter, 2018). Delivery of effective and caring communication paves the way easy in building therapeutic relationship with patients (child) and particularly families to provide appropriate and reliable information in terms of diagnosis and treatment and, also helps them in making informed decisions (Montgomery, Sawin, & Hendricks-Ferguson, 2017). It also promotes satisfaction of both nurses and patients’ families once a palliative care nurse provide honest and clear information (França et al., 2013). In addition, the application of palliative care communication skills builds confidence and competency of health care professionals in prioritizing of patients values individually and also helps patient’s families in promoting better understanding in relation to disease prognosis and treatment (Delgado, 2017).

If we take into account a child suffering from cancer as an example of palliative care patient, it lets us know he or she alter habits and daily activities, comes with certain restrictions, isolation and, obviously get admitted into hospital recurrently with severe suffering (França et al., 2013). In this situation, a nurse having strong communication skills can positively influence cancer patients’ understanding in order to promote satisfaction and overall comfort measures (Wittenberg et al., 2018).

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According to (Montgomery et al., 2017), parents of children suffering from cancer are highly satisfied with the care delivered by nurses. While providing care in palliative and end of care pediatric nurses are mostly prefer to communicate about psychosocial, spiritual and family issues, doctors are intended to emphasize on treatment issues with family members (Montgomery et al., 2017). “In hospital care settings, family members feel that nursing care delivery comes with a good, efficiency, agility, dedication, kindness, attention and empathy, especially considering the possibility that this is a moment of farewell from their loved ones (da Silva et al., 2012).

Poor interaction that comes from health care professionals raise question and feeling refusal to some patient’s parents regarding appropriateness of medical information (Montgomery et al., 2017). According to (Sawin et al., 2015), ineffective and poor communication causes patients to experience diminished quality of life for the percentage of 25 children patients suffering from cancer.

In delivering care to dying patients along with their families is too difficult, uncomfortable and insufficient while talking to them about palliative care and end of life and, often describes as “ the elephant in the room” reported by both adult and pediatric oncology nurse (Montgomery et al., 2017). Nurses are stressful while providing care and communicating with the child and parents in the context of child’s palliative care and end of life care (Sawin et al., 2015). The most challenging parts for nurses and doctors is to manage difficult conversations of end of life care. It comes up with negative emotional control when nurses share such sensitive interactions with patients and their families of palliative care and end of life care(Shannon, Long-Sutehall, & Coombs, 2011).

Though it is difficult for nurses to communicate with patients and their families in caring and sharing sensitive interactions, it is possible to address these challenges using some possible certain approaches.

Challenges faced by Nurse

The healthcare professionals particularly nurses confront serious challenges while managing difficult conversations with patients and their family members (Shannon et al., 2011). For example, a female patient who recently came to know she develops late stage ovarian cancer and suddenly asked a nurse at night with her frightened face whether this cancer can make her death soon. With another example, a referred elderly patient from nursing care home gets admitted in the emergency department of the same hospital with the diagnosis of apparent stroke.

The nurse gets struck what to tell when the overwhelmed son of this patient asked her his mother needs a “full code” because he understood from the explanation of physician his mother will not survive anymore and, god also wants it and her well-wisher will pray for her (&NA;, 2010). As a result, nurses report such sensitive interactions that comes up with negative emotional reactions (Shannon et al., 2011). These are the common obvious scenarios of communication challenges faced by the nurses in relation to palliative care.

Due to lack of experience and poor communication of nurses in dealing with sensitive topics asked either by patients or their family members’ results in compromises psychosocial care. It is also found that oncology nurses has communication gap with interprofessional team in terms of expected outcome, limited skills for providing care, difficulty in assessing patients’ outcome and does not know where to start and share into discussions about end of life and palliative care (Wittenberg et al., 2018).

Nurses are to face such challenges frequently because nurse communication training program concept itself is more or less new, and only very few training program delivered in the area of palliative care nursing. The existing training programs emphasizes to develop productivity, self-efficacy, discussions of death, dying, goals of end of life care, but unfortunately does not develop tools in approaching vital palliative care communication skills with patients and families in the context of social, spiritual, psychological care issues and interdisciplinary team based care. Overall, palliative communication skills program sets for physicians with only few offered to nurses (Wittenberg et al., 2018).

In addition, in the context of end of life and palliative nursing care, nursing literature is limited resulting diminished evidence to support understanding of nurse’s experiences during communication. Evidence based guidelines of communication for health care providers are yet to be published regarding planned discussion and deliver of it with pediatric patients and their family members (Montgomery et al., 2017).


Humanistic Nursing theory is defined as a live dialogue held between a nurse and a patient in which it is expected that nurses will provide care and patient will receive the expected care. It consists of presence, relationship and a call and answer. In presence the quality of life comes with being receptive and behave mutually toward another. The relationship is that in which both parties have a common goal and, call and answer are expected both verbally and non-verbally (França et al., 2013). For example, a children suffering from cancer gets admitted into palliative care whose goal of care is uncertain resulting distress for a nurse and his or her colleague. Using humanistic nursing theory this patient can receive integrative physical, moral, emotional and spiritual care following these communication:

  • Assessment of patients’ and families’ regarding what they have understood about the disease and treatment plan, and then it is important to identify gaps
  • While offering emotional support it is needed to find out the gap of understanding using application of communication strategies. One possible way of emotional support communication can be “hope-worry” statement for example, in the sentence of hope “I hope your children will recover soon and will stand in his feet and the worry part can be “ I am afraid he will not be as strong as he was earlier”.
  • Ask patients’ and families what they actually expect, value and then combine these all together to provide care.
  • Nurses will participate and share in the family meeting to convey disease diagnosis, treatment options, and goals of care and then patients’, families and health care team member have to come into mutual understanding (França et al., 2013).

According to (Wittenberg et al., 2018) the word “COMFORT” in which each of the letter generates especial therapeutic meaning where C-Communication, O-Orientation and options, M- Mindful communication, F-Family, O-Openings, R-Relating, T-Team). Later with subsequent research has evidenced that the addition of “COMFORT” in curriculum improved nurses’ attitude, comfort measures, self-efficacy while having difficult conversations with family caregivers.

C-Communication (Clinical Narrative Practice)

It means respect to the patient’s voice and lived experience while giving care. According to clinical narrative practice, the healthcare professionals need to understand the story of illness and helps the patient and family in adapting take control and look for “alternative ways of being ill”. Storytelling is exposed as a natural form of interaction with stories of illness, symptoms, management of care. It also defines patient’s understanding about the possible cause of disease and personal risk of cancer in which it is the responsibility of the healthcare professionals help the patients and families what the disease prognosis and share perceptions of reality (Wittenberg et al., 2018)

O-Orientation and Options:

In terms of orientation it is the nurse’s responsibility to deliver information to the patients’ and families’ elaborating the stage of cancer of the patient who is diagnosed with cancer and possible prognosis of disease. Similarly, it is essential to explain about possible options given to the patient and families and then combine the format and methods of information (Wittenberg et al., 2018)

M-Mindful Communication:

Mindful communication in palliative care is defined as avoidance of self-talk and judgment on the basis of patient and family’s interaction and shows the skills in bringing changes in the interaction. So it means a nurse should try to avoid pre judgment and concentrate in devoting self-monitoring of the inner experience (Wittenberg et al., 2018)


It involves assessment of the patient’s and family’s understanding of the disease and its possible course, and shows interest to meet patients and families in relation to their acceptance in understanding of changes generated by serious illness. Nurses have to be aware that they may need to repeatedly inform patient and family in reaching their awareness and also understanding of disease prognosis and treatment options (Wittenberg et al., 2018).

It is obvious that communication strategies need to be addressed in undergraduate and graduate education in nursing to pave the way in practicing communication in the clinical area (&NA;, 2010)

According to (Shannon et al., 2011), two communication strategies: Ask-Tell-Ask and Tell Me More, Situation-Background-Assessment-Recommendation contribute in sharing and caring sensitive information between patients or their families and members of health care professionals. (Shannon et al., 2011), also suggested Situation-Background-Assessment-Recommendation tool for exchanging information particularly at critical handovers in order to communicate at end of life care among the health care team professionals. Here Ask-Tell-Ask tool makes bridges with the patient’s or family member’s concern to know more deeply through Tell Me More. The SBAR tool brings unique communication among health care team to enhance their work for improving quality of care in end of life (Shannon et al., 2011),

It is evident that experience of nurses demonstrate highest level of skill to provide end of life and palliative care and, nurses who do not have enough experience can get benefitted from especial education conducted in the area of palliative and end of life care (Bunney, Zink, Holm, Billington, & Kotz, 2015). It means experience helps in building systematic approach to develop foundation, identification of care patterns, implementation of appropriate care in relation to intervention, development of professionalism and, build expert practice(Montgomery et al., 2017).

Ultimately, once a nurse is skilled and comfortable in providing end of life and palliative care through mutual understanding in which patients and families understand its goal, it improves quality of life and increases patient satisfaction (Bunney et al., 2015).

In conclusion, the findings of this article review provides insight into the challenges faced by nurses while communicating in the palliative nursing care need to be addressed in promoting quality of life of patients and their families. It is found nurses are stressful, confused and emotionally distress due to lack of skill, competency and proper training program, but the scenario of caring to palliative care patient is totally opposite with the experienced nurses.

In addition, insufficient and inappropriate training of nurses cause difficulty to deliver quality of care. However, the certain strategies like Humanistic Nursing theory, Ask-Tell-Ask, Tell Me More, Situation-Background-Assessment-Recommendation and COMFORT contribute to develop confidence, self-efficacy, mutual understanding with patients and their families to provide integrative care. Further research are obvious to expect and receive quality of care from Nurses in the area of palliative care.

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