Making impossible conversations possible

Researchers from the Child and Adolescent Psychiatry group at the University of Oxford Department of Psychiatry have developed resources for professionals and families faced with the task of breaking bad news during the COVID-19 pandemic. Dr Louise Dalton and Dr Elizabeth Rapa explain the work they have been doing. 

Making impossible conversations possible

In these exceptional times, we are constantly bombarded with news and opinions about the immediate and far reaching consequences of the COVID-19 pandemic. For many, this has understandably resulted in heightened levels of stress and anxiety as we adapt to the uncertainty of our situation. Children are astute observers of their environment and are acutely aware of changes to their day to day lives, as well as the behaviour and emotions of the adults around them. When children are not given a coherent explanation for what they see, they may attempt to create their own narrative, which can be ‘more dire than the truth’.

Even the youngest children need developmentally-appropriate and emotionally authentic communication about how COVID-19 has changed our day to day lives. Our team at the University of Oxford Department of Psychiatry has developed a video, in partnership with Blackpool – A Better Start, to help parents and carers talk to children under 5s about these issues.

For healthcare staff, the current pandemic has necessitated immediate changes in how we communicate with patients and relatives. Routine face-to-face communication is now much more limited, with a greater reliance on telephone calls. This can heighten levels of anxiety and stress for all concerned, particularly when sharing the news of a bereavement or difficult test results.

Given the pressures on staffing and the high number of deaths, junior staff or those who have little experience of breaking bad news have been tasked with informing families of a relative’s death. Moreover, the high frequency of these calls during the outbreak is having an emotional impact on even the most experienced and specialised staff. Importantly, current evidence shows that the quality of communication has a long-term impact on both professionals’ and families’ psychological and physical wellbeing.

The absence of relatives’ hospital visits means that the patient’s role as a crucial figure for children within the family (e.g. as a parent or grandparent) is often invisible. However, these important relationships must not be overlooked.  Research shows that the effectiveness of communication with children about illness and death can have far-reaching consequences for their psychological wellbeing. Although adults understandably want to protect children from the devastating news of a loved one’s serious illness or death, studies indicate that silence does not prevent children from being aware of what is happening within the family, but rather leaves them to cope with their feelings alone.

We have previously published a series in the Lancet on how children are told about the diagnosis of their own or a parent’s, life-threatening condition which concluded with a framework to guide healthcare professionals with these life-changing conversations. In response to the pandemic, the team have adapted this framework to create COVID-19 specific resources.

Of critical importance is 1) ensuring that staff identify if the deceased had important relationships with children (under 25 years old) and 2) supporting families with sharing this devastating news with children. The team have developed animations and step-by-step infographic guides with suggested phrases to help structure these important conversations. These include resources for healthcare and care home workers, and guides for adults who have the unenviable task of telling children about the death of a loved one. The latter is particularly pertinent when families are isolating together in close proximity, affording adults little time or privacy to plan how to break the news to their children.

As children begin returning to school, the team have also created guidance for school staff, to whom children may turn for explanation and reassurance about the pandemic.

The far-reaching impact of COVID-19 extends to many other areas of healthcare which have had to move rapidly to telephone consultations. For example, paediatric oncology teams must now give test results such as diagnosis/relapse or changes to treatment over the phone. Again, parents are then faced with conveying this information to their children at home, without the direct support of the oncology team. In response, the team have also developed guides for staff and parents to help them with this unenviable task.

All of these resources are freely available to download and share here and include translations into Spanish, Urdu, Portugese and Cebuano with Tagalog, French and Polish currently being finalised. The challenges we address are also explored in more detail in a comment, published in the Lancet Child and Adolescent Health.

Please contact Louise Dalton and Elizabeth Rapa if you would like further information or to provide feedback.


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Published: 20 July 2020