Having Difficult Conversations

Having conversations about your parent’s desire for their future care can be difficult. The abilities we have with our patients don’t always translate to our parents. But, there are tips and tricks that can help.

I sat with Sandy.  She looked as if she’s aged years since I had seen her just one year before at a medical conference.  She was telling me about the loss of her mother and her regrets.  She had to make so many decisions about her mother’s care from a progressive neurological disorder, she struggled with the decisions, she struggled with her siblings, she struggled with the healthcare system.  She was worn out and sad and full of guilt.  She asked, “Why is this so hard?”

Much of the difficulty comes from making choices for someone else – we think this will be easier for us as physicians because we do it every day in our profession.  And maybe it is easier for us…..but that shows how difficult it is for everyone else.

The Usual State of Advance Planning

• Very few people state their choices on how they would like their life or their end-of-life to be.  

• If they do state their choices, they are less likely to receive burdensome care. 

• The best ‘gift’ of speaking of their choices is that the surviving relatives have less stress, anxiety and depression. 

What can we do to facilitate these discussions? 

Being Direct and Honest

Being honest seems difficult.  

But, not being honest creates so much more difficulty. 

Let’s figure out a way to be honest and sensitive at the same time.  

Whether you agree or disagree with your family member about issues of their health and safety,  the conversation needs to occur so that you can deepen your relationship and uncover their r wishes.

Your family member may not want to have the conversation with you. Many people are uncomfortable discussing sensitive topics.  

Create opportunities for these conversations to occur.

Look for signs that the time might not be right; the signs may include:

•  hesitation,  
• guarded answers, 
• attempts to change the subject, 
• charged or absolutes in the conversations such as “I hate speaking about this” ,  “I never want to discuss this with you”, or “You ALWAYS get so morbid”.  

Don’t be put off by their discomfort, but use the reluctance to show compassion and gently and firmly ask for contemplation and a follow up time to discuss. You may soften the approach by beginning with “I know this is going to be a challenging conversation and it is important to me.

If this is not a good time, let’s schedule a time in the near future.” 

Do your best to keep the conversation as neutral as possible

Try not to tread into their emotional trigger points if you know what they are.

Start with Understanding 

It’s helpful to start with understanding. For example, you may begin with, “I know you’re not interested in talking about death and……” or “I understand that you may find this disease distressing….”. You can then make your points from there.  

It’s helpful to put  boundaries around the problem. Llook for places where you agree. For example, you could begin with we both love each other very much. And the thought of losing one or the other is heartbreaking.

And then pause and listen for their response. 

Sometimes it’s good to remember to talk less and allow for some breaks in the conversation so that your parent  can process and formulate a response.

Be Careful not to Negate their Thoughts

Experts believe that you should try to take the word “but “ out of many of these conversations as that is a negative or subtracting sign in a conversation. It often ‘erases’ what was just said.

You can use ‘and at the same time’ or begin a question with ‘What do you think”? Remember that when you hear “Yes, but “ it seems that somebody is trying to win the conversation rather than have a conversation

Finally, if possible, tell a story. To help elucidate your points bring it back to times when you’ve agreed on things. Take time before meeting with your parent to remember stories that will help move your conversation forward.   You may want to practice some of these stories and imagine how they will land with your parent. 

Keep the Discussion Open

Finally – remember, you can always put a placeholder in.  Deep subjects such as this take time and contemplation.  Small bites.  New information to help you if you should become the decision maker.  Absolutes are not necessary. You need to have information to help you make decisions for them in their future.  This is not a race.  You can end each conversation with ‘We’ve talked about a lot today. I would really love to think about this more and come back to this conversation. Would that be okay with you?’

Conclusion

We’ve covered a lot today – I hope we can come back to it in the future as well. 

Remember – small steps. This likely cannot be done at once. Build the trust that is needed for these conversations.

Thank you for having the courage!