Communication in Palliative Care

Communication is widely recognised as the most important clinical skill in palliative care. The quality of conversations about dying, prognosis, goals of care, and treatment decisions profoundly influences patient and family experience, psychological outcomes, and the appropriateness of care delivered. Despite this, many clinicians report feeling inadequately prepared for these emotionally demanding discussions.

In Australia, approximately 168,000 deaths occur annually, with the majority preceded by a chronic illness trajectory that offers opportunities for advance care planning and goals-of-care conversations. The Australian Institute of Health and Welfare (AIHW) estimates that around 70% of Australians could benefit from palliative care, yet access and quality vary significantly between metropolitan, regional, rural, and remote settings.

The National Palliative Care Strategy 2018 (updated 2023) identifies communication as a core domain, recognising that high-quality palliative care requires clinicians across all disciplines — not only palliative care specialists — to possess foundational communication competencies. The Palliative Care Australia (PCA) Standards emphasize that every health professional involved in care of people with life-limiting illness should be able to initiate and facilitate goals-of-care discussions.

Research from Australian tertiary hospitals demonstrates that structured communication training (such as the Serious Illness Conversation Guide adapted for Australian settings) improves clinician confidence, increases the frequency and quality of goals-of-care discussions, and is associated with earlier referral to palliative care services, reduced non-beneficial interventions at end of life, and improved family bereavement outcomes.

This section provides evidence-based frameworks and practical guidance for the four most challenging communication domains in palliative care: talking about dying, breaking bad news, discussing prognosis, and responding to emotions.

Despite death being universal, many clinicians find it difficult to initiate conversations about dying. Cultural discomfort, fear of causing distress, prognostic uncertainty, and lack of training all contribute to avoidance. However, evidence consistently shows that most patients with life-limiting illness want to discuss death and dying, and that unasked questions cause more suffering than honest answers.

Why Talking About Dying Matters

Conversations about dying serve multiple purposes: they allow patients to express fears and preferences, enable advance care planning, reduce unwanted interventions, support family preparation, and facilitate referral to appropriate palliative care and community services. In Australia, the lack of such conversations is associated with higher rates of intensive care admissions at end of life and lower rates of dying in a place of the patient's choosing.

When to Initiate the Conversation

The conversation about dying should be initiated when the clinician recognises a realistic possibility of death within the foreseeable future. Triggers include:

• Diagnosis of an incurable illness (metastatic cancer, end-stage organ failure, progressive neurodegenerative disease)
• Functional decline or recurrent hospitalisations despite optimal therapy
• Clinician concern that the patient may die within the next 12 months (the "surprise question": "Would I be surprised if this patient died in the next year?")
• Patient or family-initiated questions about prognosis or end-of-life care
• Transition to palliative care or cessation of disease-modifying treatment
• Acute clinical deterioration in a patient with a known life-limiting illness

Framework for Talking About Dying

Language Guidance

Breaking bad news is one of the most common and most feared tasks in clinical medicine. "Bad news" is any information that results in a patient or family perceiving their situation as worse than expected — it includes not only terminal diagnoses but also disease progression, treatment failure, need for escalation of care, and transition to palliative care.

The SPIKES Protocol

The SPIKES protocol (Baile et al., 2000) is the most widely validated framework for breaking bad news and has been endorsed by the Royal Australasian College of Physicians (RACP) and the Cancer Council Australia. It provides a structured, six-step approach that can be adapted to any clinical setting.

Common Pitfalls in Breaking Bad News

• Information dumping: Delivering excessive medical detail before assessing understanding overwhelms the patient and reduces retention to near zero.
• Premature reassurance: Saying "It'll be fine" or "We caught it early" before the patient has processed the information invalidates their emotions.
• Avoiding the word "cancer" or "dying": Research shows patients prefer clear language; using clinical jargon or euphemisms delays understanding.
• Standing over the patient: Physical positioning matters — sitting at or below eye level conveys partnership; standing conveys authority and distance.
• Not having a plan: Bad news delivered without a next step creates helplessness. Always end with "Here is what I suggest we do next."

Breaking Bad News by Telephone or Telehealth

Telephone and telehealth consultations are increasingly common in Australian healthcare, particularly in rural and remote settings. Breaking bad news by phone requires additional care:

• Verify the identity of the person you are speaking with and confirm who else is present.
• Ask whether the patient is in a safe and private space before proceeding.
• Use deliberate pauses and explicit check-ins: "I'm going to pause for a moment. How are you feeling hearing this?"
• Avoid leaving bad news on voicemail or in patient portal messages without prior verbal discussion.
• Arrange a face-to-face or video follow-up within 24–48 hours where possible.
• Send written summary and offer contacts for support services (e.g., Palliative Care Australia helpline, Cancer Council 13 11 20).

Discussing prognosis is one of the most challenging aspects of palliative care communication. Clinicians frequently overestimate survival, and patients and families often overestimate the benefits of disease-modifying treatment. Honest prognostic communication is essential for informed decision-making, advance care planning, and ensuring care aligns with patient values.

Why Prognostication Is Difficult

• Clinician optimism bias: Studies show physicians consistently overestimate survival by a factor of 3–5.
• Statistical imprecision: Population-level median survival data may not apply to individual patients.
• Emotional discomfort: Delivering a time-limited prognosis feels like "taking away hope."
• Legal and cultural concerns: Fear of litigation or causing distress leads to vague language.
• Genuine uncertainty: Prognosis is inherently uncertain, especially in non-cancer conditions such as heart failure, COPD, and dementia.

The Best Case / Worst Case / Most Likely Framework

This framework, validated in Australian and international settings, allows clinicians to communicate prognosis honestly while acknowledging uncertainty and preserving hope.

The "Ask-Tell-Ask" Approach

Tools to Support Prognostic Estimation

MBS and Prognostic Communication

In Australia, prolonged consultation items (MBS Items 53, 54, 57, 58 for GPs; Items 99, 104, 105, 110 for specialists) may be used when extended discussions about prognosis and goals of care are conducted. The GP Management Plan (MBS Item 721) and Team Care Arrangement (MBS Item 723) items are relevant for coordinating palliative care in the community. Ensure adequate time is booked — prognostic discussions require a minimum of 20–30 minutes and should not be compressed into a standard 15-minute appointment.

Emotional responses are a normal and expected part of difficult conversations in palliative care. Patients and families may express sadness, anger, fear, guilt, denial, or numbness. How clinicians respond to these emotions has a profound impact on the therapeutic relationship, patient coping, and the ability to continue meaningful conversations about care.

The NURSE Mnemonic

The NURSE mnemonic provides a toolkit of empathic communication techniques that clinicians can use to acknowledge and respond to emotions during difficult conversations.

Responding to Specific Emotional Reactions

Sadness and Grief

Sadness and anticipatory grief are the most common emotional responses. Allow the patient to cry. Do not rush to stop tears. Offer tissues without speaking. A gentle touch on the hand (if culturally appropriate and with consent) can convey more than words. Simply saying "I'm here" during tears is often sufficient.

Anger

Anger may be directed at the clinician, the health system, God, or the situation. It is rarely personal. Do not become defensive. Acknowledge the anger: "I can hear how frustrated and angry you are, and I don't blame you." Explore the underlying emotion — anger often masks fear, helplessness, or grief.

Denial

Denial is a protective mechanism. Do not force a patient out of denial. Instead, gently plant seeds: "I understand this is hard to take in. I wonder if we could talk about what you'd want if things didn't go as well as we hope." Revisit the conversation over time. Persistent denial that prevents planning should be explored with psychology or psychiatry input.

Guilt

Patients and family members frequently express guilt — about past behaviours, not being present, treatment decisions, or perceived failures. Address guilt directly: "Many people in your situation feel guilty. I want you to know that this illness is not your fault." For families: "You are doing everything you can for your loved one."

Anxiety and Fear

Fear of pain, abandonment, loss of control, and the dying process itself are universal. Specific information is the best antidote to vague fear: "If pain becomes a problem, we have very effective medications. You will not be left in pain." Offer referral to counselling, psychology, or psychiatry if anxiety is severe or persistent.

Non-Verbal Communication

Non-verbal cues often communicate more than words. Key principles include:

• Eye contact: Maintain comfortable, culturally appropriate eye contact. In some Aboriginal and Torres Strait Islander cultures, prolonged direct eye contact may be considered disrespectful — follow the patient's lead.
• Body posture: Sit down, lean slightly forward, avoid crossed arms. Open posture conveys attentiveness and empathy.
• Facial expression: Match your expression to the emotional tone. A neutral or slightly concerned expression during delivery of bad news is appropriate; a smile while telling someone they are dying is inappropriate.
• Silence: Silence of 5–10 seconds after delivering difficult news is therapeutic. Resist the urge to fill pauses with medical information.
• Touch: A hand on the arm or shoulder can convey empathy, but always assess cultural appropriateness and obtain implicit consent. Avoid touch with patients who have experienced trauma unless it is clearly welcomed.

Communication in palliative care must be tailored to the unique needs, developmental stage, cultural background, and clinical circumstances of each patient and family. The following special considerations apply to specific populations commonly encountered in Australian clinical practice.

Communication skills in palliative care are inseparable from advance care planning (ACP). ACP is "a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care" (Advance Care Planning Australia). Effective ACP conversations require all the communication skills discussed above — the ability to talk about dying, break bad news, discuss prognosis, and respond to emotions.

Australian ACP Framework

Advance Care Planning Australia (ACPA), funded by the Australian Government and hosted by Austin Health, provides a national framework for ACP. Key documents include:

• Advance Care Directive (ACD): A legally binding document (legislation varies by state and territory) recording a person's preferences for future care. In Queensland, this is the Advance Health Directive under the Powers of Attorney Act 1998.
• Substitute Decision-Maker (SDM): Appointed under state/territory guardianship legislation. In most jurisdictions, the SDM is automatically the spouse, then adult children, then parents — unless formally appointed otherwise.
• Goals of Care (GOC) documentation: Completed by the treating team in hospital settings, documenting agreed treatment direction (e.g., full active treatment, ward-based palliative care, end-of-life care).

When and How to Start

ACP is best initiated before a crisis. The "3-step model" recommended by ACPA:

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