Difficult Conversations…Let’s Talk

November 4-8, 2019

During the week of November 4-8, 2019, NSHEN will highlight health ethics cases, with discussion questions, for National Health Ethics Week 2019. Each case will explore the theme from a different perspective, and we will highlight the video presentation by Dr. Christy Simpson discussing ethics considerations in relation to difficult conversations.

“Difficult” conversations happen all the time in health care, but that does not necessarily make any particular conversation easier. Discussions about diagnosis, prognosis, and treatment decisions are often clinically and emotionally challenging for patients, families, and health care providers, and it is important that we do these conversations well. 

It’s also the case that conversations with colleagues, staff, leaders, learners and volunteers may sometimes be difficult. These may include discussions about changes in practice or policy, performance issues, disagreements about treatment and discharge plans, and health services planning.

This year for National Health Ethics Week we are exploring difficult conversations in greater depth, addressing questions such as:

  • What makes these conversations difficult?
  • How do we have a “good” difficult conversation?
  • What do we mean by “difficult” when describing these conversations?
  • How do difficult conversations shift, depending on one’s role in the conversation?
  • Why are difficult conversations a challenge from an ethics perspective?
  • Why is it important to have difficult conversations?
  • Whose job is it to have difficult conversations?

Some quotes that relate to difficult conversations:

“A family meeting is a procedure, and it requires no less skill than performing an operation.”

Susan Block, quoted in Atul Gawande’s Being Mortal, p. 181.

“The truth may be brutal, but ‘the telling of it should not be’.”  Philip C. Hébert, et al. “Bioethics for Clinicians 7: Truth Telling.” 

Canadian Medical Association Journal 156 (1997): 255-258.

“The words of a serious diagnosis or a grave prognosis carry an emotional weight that makes them especially challenging to comprehend.  This underscores the need for specific training for medical caregivers in this realm of “difficult conversations”….But no matter how much we prepare, these conversations never will be – and never should be – easy.  These are momentous, harrowing occasions.  Such conversations are among the hardest things that doctors are ever called upon to do.”

Danielle Ofri in What Patients Say, What Doctors Hear, p. 206.

Dr. Christy Simpson discusses ethics considerations in relation to difficult conversations.

Case 98: A Conversation with a New Parent About Vaccination. https://nshencases.wordpress.com/2019/04/01/case-98-a-conversation-about-vaccination-with-a-new-parent/

Case 99: Talking About An Adverse Event. https://nshencases.wordpress.com/2019/04/02/99-case-talking-about-an-adverse-event

Case 100: Discussion With Staff About New Scheduling.

Case 101: Chatting About Hopes and Goals.

Case 102: A Question from Family About Outcomes.

General Resources – Video

A guide to effective communication

Brown, Brené on Blame

Counterproductive Communication: Examples of Common Verbal Barriers

Getting Called Out: How to Apologize

How Should Providers Deliver Bad News?

Medical communication skills challenge — Interprofessional conflict, information gathering

For the Birds

Video Review for Crucial Conversations by Kerry Patterson

Dalhousie University video series on Difficult conversations https://www.dal.ca/dept/hres/conflict/videos_difficult_conversations.html  

General Resources – Articles

Brené Brown. 2017. Braving the Wilderness. The Quest for True Belonging and the Courage to Stand Alone. Random House Publishing.

Rosenberg, A.R., Wolfe, J., Wiener, L., Lyon, M., Feudtner, C. 2016.Ethics, Emotions, and the Skills of Talking About Progressing Disease With Terminally Ill Adolescents: A Review. JAMApediatrics, Dec. 1, 170 (12): 1216-1223. https://www.ncbi.nlm.nih.gov/pubmed/27749945  

Tulsky, James A. 2005. Beyond Advance Directives. Importance of Communication Skills at the End of Life. Journal of American Medical Association (JAMA). July 20, 2019 – Vol. 294, no. 3, p. 259-265.

Workman, Stephen. 2011. Never Say Die? – As treatments fail doctors’ words must. The international Journal of Clinical Practice. 2011; 65; 2; p. 117-119. https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1742-1241.2010.02585.x      [note: this article was triggered by an article in NYT: https://newoldage.blogs.nytimes.com/2011/12/14/plain-speaking-at-the-end-of-life/  ]

General Resources – Practical

NSHA Library Services: Conversations about serious illness:


Division of Medical Education, Dalhousie University. Communication Skills Pocket Cards. Communication Skills Program. https://medicine.dal.ca/departments/core-units/DME/communication-skills/program/pocket-cards.html

The Canadian Medical Protective Association (CMPA). Good Clinical Practices Guide https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/index/index-e.html  

CARNA. Difficult conversations: End-of-life decisions.