An effective approach for difficult, end-of-life communication

Nasreen Sulaiman Lalani |

Amidst these difficult times of the pandemic—social distancing, scarce resources, and limited availability of medical interventions—bearing witness by listening and being able to compassionately communicate with dying individuals and their grieving families becomes an even more important skill. But this is challenging, stressful, and presents additional responsibilities for nurses while they are also completing their caring roles and duties. Unfortunately, literature indicates that current disaster and emergency trainings often involve minimal to no training in palliative care and how to respond to difficult communication. 

One relatively new communication tool we’ve found to be very beneficial is the COMFORT model (Wittenberg-Lyles, et al., 2010). It emphasizes the importance of effective, open, and genuine communication with both the patient and their family members. Additionally, the model highlights how intertwined nurses and family members are for the best outcome for the dying patient, long-term healing for family members following the death, and for easing some of the emotional load that nurses carry during the emergencies. 

Specifically, the COMFORT model includes:

  • C represents “Communicate,” focusing on the importance of discussing both task messages (i.e., relevant information needed for the treatment and physical care of the patient) and relational messages (i.e., talk about how participants are feeling and thinking about their pertinent relationships—nurse with the patient, patient with family members, and nurse with family members). 
  • O represents “Orientation and Options,” concentrating on determining the level of understanding of the illness by the patient and their family members, assessing their literacy level, prioritizing a discussion about their care options, and assessing the impact of their culture on their decisions and expectations. 
  • M represents “Mindful Communication,” acknowledging the importance of both verbal and nonverbal messages, the value of staying in the moment, accepting the fluidity of the situation, and adapting messages as the need arises.
  • F stands for the “Family,” signifying the role and involvement of the family throughout the entire healthcare process; addressing the complex communication needs and concerns of the family and the patient during stressful, health crises. 
  • O represents “Openings,” highlighting that there are critical transitions in illness trajectories (i.e., diagnosis, change in severity that may limit treatment options, being placed on intubation machines, move into hospice, etc.) that present healthcare professionals with opportunities to reframe the situation, thereby building resilience and coping skills. Quality of life is of utmost importance during this time. 
  • R stands for “Relating,” supporting the value of meeting the family and patient where they are at in regard to acceptance, understanding, and willingness to make the necessary impending care decisions. 
  • T refers to “Team,” acknowledging the significance of a multi-disciplinary approach to treating both the needs of the patient and the family, as well as honoring the knowledge gained from the various areas of expertise. This may include bringing in additional support members such as clergy, social workers, etc.

The skills that the COMFORT model details are important because they highlight the critical role that effective, compassionate, and authentic communication plays, especially during times of extreme stress and illness. Nurses often carry the bulk of the responsibility and spend the most time interacting with the patient and family members. This model recommends including family members’ needs and voices throughout the process for greater clarity, less frustration, and if fortunate, greater assistance and less resistance from family members during the patient’s treatment. Times like these remind us all how human we really are, and calls for specific attention to palliative care, communication at end of life, and grief support at a level that many of us haven’t experienced before. 

Wittenberg-Lyles, E., Goldsmith, J., Ragan, S. I. (2010). The COMFORT Initiative: Palliative nursing and the centrality of communication. Journal of Hospice Palliative Nursing, 12(5):282-292

  • end-of-life care
  • COVID-19
  • comfort
  • Education
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