The Conversation Part 3
How to open a dialogue about their death with someone facing their imminent demise? We provide some suggestions to facilitate the conversation.
Here are some pointers from former palliative-care consultant and author Dr Louis Heyse-Moore. He indicates elsewhere that in the UK doctors can only inform the relatives of the prognosis with the patient’s consent. That is to say: patients will know before their relatives. So in the UK it is the doctor rather than you – as a friend or relative – who needs to initiate this conversation.
First: Check in with how the patient is: If they are distracted by pain or are anxious about an upcoming procedure, this is not the right time! Wait until they are as pain-free as possible and when you both have the time and privacy.
Second: Find out what their current concerns are. This can provide an opening for your discussion.
Third: If needed, provide a preparatory opener such as, ‘You said the other day that you’ve had very little energy lately….’ Or ‘As we’ve heard, your latest test results indicated that your body is not responding to the treatment’…
*Keep your wording simple and be concise
*Slow down – provide any information in instalments.
*Stop frequently. This will allow time for what you are saying to be absorbed
* Use neutral language
This is significant throughout all your conversations. If you refer to what is happening as ‘bad news’ or ‘unfortunate,’ you are indirectly informing the dying person that dying is bad or unfortunate.
If you would like to support them in finding a different perspective (and that is what OSHO Sammasati is all about), avoid re-affirming the old thinking.
* Be honest 
How long have I got?
Rather than try and respond to this question yourself, suggest the patient asks the doctor. There is no straight answer because there are some variables (and, as some doctors will admit, they are often wrong in their estimates); but at least the doctor can explain this to the patient. See also How long have I got?
The Four Questions
Dr. Susan D. Block is a Professor of Psychiatry, Chief of Psychosocial Oncology and Palliative Care at the Dana-Farber Cancer Institute and the Co-Director of the Harvard Medical School Center for Palliative Care. She is also a nationally and internationally known researcher and prominent expert in palliative care and psycho-oncology.
She feels that it is up to the doctors to initiate a conversation about their patients’ prognosis because although patients might suspect they are dying, they may be ambivalent about asking outright about the outlook.
She has formulated four questions that can be asked of the patient and which will thus initiate the discussion. They are broad and open-ended questions. That is, they need more than a ‘yes/no’ response and they are not coloured in such a way to suggest the ‘right’ reply.
- What are your thoughts about your prognosis?
- What are your fears about what is to come?
- What are your goals as time runs out?
- What trade-offs are you willing to make? 
Most Cancer Patients Want to Discuss Prognosis
Putting the Practicals in Place
It is not easy for doctors to gauge how soon a patient may enter the phase of active dying. By their own admission they can and do get it wrong.(See How long have I got?)
So it may be more realistic – and less confronting – to initiate a discussion about the patient creating an Advance Decision and/or appointing someone as their Lasting Power of Attorney for Health and Well-being, if they have not already done so. That step is one we all are advised to take, however healthy we might seem! That is to say, to raise the subject is not to say, ‘You are facing imminent death.’
For our suggestions around communication, please see In-Rapport Skills.
- Speaking of Dying: a practical guide to using counselling skills in palliative care Louis Heyse-Moore (Jessica Kingsley Publishers)
- Dr Susan Block video: https://www.youtube.com/watch?v=coJA2Mxfdb0