We’ve all been there before: in the middle of performing a nursing task, a patient places their hand on your arm and looks at you imploringly, then asks a question you are not sure how to answer. What do you do? All the what if’s fill your mind. What if I say the wrong thing? What if the patient/family/doctor gets upset with me? What if I don’t really know the answer? What if I know the answer but am afraid to tell the patient? What do I do? No one wants to be the bearer of bad news. Because our work experience means we have taken care of other patients with the same diagnosis, we know better than they do what is coming next. That puts even more pressure on us when a patient asks a difficult question.
I was asked to give a short presentation on communication at a recent nursing skills day. My target audience was bedside nurses on the oncology unit, many of whom I knew well. My comfort level was high. I knew my topic and my audience. I put together a brief PowerPoint presentation and planned for several role-playing scenarios. And then I did what I always do in this situation: I practiced. Driving in the car, I practiced my presentation out loud. Walking the halls of the hospital, I imagined the questions I might be asked and, in my head, silently practiced answers. What we do as nurses is actually called a practice, which in itself is interesting. It implies, correctly I believe, that what we do as nurses is constantly changing and evolving. We are continuously adjusting. Our practice is built on our education and on our work experiences.
While I was planning the role-playing scenarios, I went around to bedside nurses and asked, “What is the most difficult question you are asked by patients?” Without exception, it was when a patient asked, “Am I dying?” There were other challenging questions such as “Should I do more chemo?” and “My family wants me to keep fighting but I’m tired. What do I tell them?” and “What is going to happen next?” I incorporated those questions into my talk. But before discussing how to answer difficult questions, I thought it important to step back and consider why patients ask such difficult questions, specifically why they ask nurses. Asking nurses is not a random choice.
Nurses spend more time with patients than any other member of the health care team, and they do so in some of the most intimate ways. Holding an emesis basin, helping them to the bathroom, changing dressings to name just a few. Normal barriers to interpersonal behavior are breached, and this allows a safe place for them to ask important questions. Sometimes they ask the nurse a question they plan to ask the doctor, practicing it on us. It may be less frightening to ask the nurse first, then work up to asking the doctor what they want to know and don’t want to know at the same time.
But there is more to it than proximity or familiarity. When I have a question to which I do not know the answer, I am particular in how I decide whom to ask. I want to ask someone who is knowledgeable on the subject. I want it to be someone who is approachable. Someone who is safe to ask, and someone who will take the time to answer. And I choose the person, zooming in on the one I think meets those requirements. Then I practice and revise how I will ask my question. I pick an opportune time. For a patient that may be when a nurse is changing a bedpan or giving a medication.
CAPC Center to Advance Palliative Care Fast Fact #26 has a section especially focused on communication and the importance of clarifying the question a patient asks.1 It may feel like a dodge to ask a patient what they are asking, but a big part of answering the question is having a full understanding of the meaning, of making sense of the question. Using the explanatory model, you ask questions that focus on what, why, how, and who.1
If a patient asks, “Am I dying?” there are several ways to answer. Unlike many of the nursing tasks we perform, there is not a proscribed right way to answer questions, as there is for med passing or dressing changes. You might ask, “What do you think?” and follow their lead. Or you might respond, “What is your understanding of what is happening?” or “Why are you asking? Has something happened or did someone say something to make you ask that question?” It may feel like an imperative to answer the question right away, but we can revisit almost all of the questions. You may say, “I’ve been thinking about that question you asked me earlier and I’d like to talk more about it.” Or even, “I don’t think I answered your question very well. Can we take another try at it?”