To Talk or not to Talk About Existential Questions - An Interview Study With Elderly Persons and Patients With Fatal Disease.

Background: Existential experiences often come to the fore in the case of a severe and/or life-threatening disease and in old age. This can evoke a variety of thoughts and emotions. The existential dimension is a concept that encompasses spiritual, religious and secular perspectives. Objective: The aim of this study was to gain a deeper understanding of how patients describe the existential dimension of life and whether and in what way the existential questions are raised in conversations and other forms of support within care. Methods: A qualitative design, with in-depth semi-structured interviews with patients admitted to an out-clinic oncology department at one hospital and participants living in a nursing home. The interviews were analysed using qualitative content analysis. Results: A total of 15 persons were interviewed. The respondents varied in age from 44 to 96. Two main themes emerged: What are existential questions? and Talk about existential questions. The existential questions refer to life as a whole and death as an end of life. It was summarized into three subcategories: The experience of the life, Existing within context and Spirituality and religion. About half of the participants thought it was important to talk about existential questions. They wanted to choose who to talk to, when and about what. Support was received from loved ones, professionals and experiences beyond conversations. Conclusions: The study provide new knowledge of how patients and elderly experience the existential dimension. The respondents emphasized a desire to be selective with whom they shared these questions and thoughts.

"It doesn't Always Have to Be an Expert": Professionals' Perceptions of Practical Aspects of the Existential Dimension of Care for People Approaching Death.

'Existential' can be seen as a broad term for issues surrounding people's experiences and way of thinking about life. This study examined availability of existential care and found that many different staff categories performed existential care. Existential care is associated with conversations and experienced as both easy and difficult; several factors were cited, e.g. insufficient time, stress and the difficulty of addressing existential questions for oneself. Respondents reported need for education, guidance and reflection around existential issues and care. Existential care is described as a natural part of patient care that all professional categories have a responsibility to offer.

"They must have seen it, you know." Body talk, extension talk, and action talk: A qualitative study on how palliative care patients and their significant others express experiencing these nonverbal cues.

Communication about life-threatening disease and palliative care is essential but often experienced as difficult by those concerned and has mainly been studied in terms of its verbal components. Despite the fundamentality of nonverbal communication, its dimensions in care, especially in the communication by patients and their significant others, has not been as extensively examined. Drawing on a secondary qualitative content analysis of data from 23 interviews-15 with patients in specialized palliative home care in Sweden and 8 with their significant others-this study aims at understanding and characterizing how patients verbally express experiences of conveying nonverbal cues about life-threatening disease and its consequences and how their significant others express perceiving these cues. Patients expressed experiences of nonverbal communication in the form of cues conveying meaning about their disease and its consequences, often beyond their control. Whether and how the patients reinforced these cues verbally, depended on individual needs, care for others, and evaluations of relationships. Significant others acknowledged the presence of nonverbal cues and tried to interpret their meaning. Both patients and significant others emphasized the importance of nonverbal cues and actively related to how cues in the form of bodily appearance, aids, objects and acts, serve communicative functions about disease and its consequences. These dimensions of nonverbal communication are characterized as: body talk, extension talk and action talk. This study contributes to an international knowledge base on the complexities of nonverbal communicative aspects in these dimensions and how it affects patients and significant others. Professionals should be aware that dimensions of care, such as prescribed aids, from the patients' perspective can be perceived as nonverbal cues that might "speak of" disease progression.

"What it is like to be human": The existential dimension of care as perceived by professionals caring for people approaching death.

OBJECTIVES: Existential/spiritual questions often arise when a person suffers from a serious and/or life-threatening illness. "Existential" can be seen as a broad inclusive term for issues surrounding people's experience and way of thinking about life. To be able to meet patients' existential needs, knowledge is needed about what the existential dimension includes. The aim of this study was to investigate how professionals caring for people with life-threatening disease perceive the existential dimension of care. METHODS: This study is based on a mixed method design utilizing a digital survey with open- and closed-ended questions. Descriptive statistics were applied to closed-ended questions and a qualitative descriptive approach was used for the responses to the open-ended questions. Healthcare professionals at specialized palliative care units, an oncology clinic and municipal healthcare within home care and a nursing home in Sweden answered the survey. RESULTS: Responses from 77 professionals expressed a broad perspective on existential questions such as thoughts about life and death. Identifying existential needs and performing existential care was considered a matter of attitude and responsiveness and thus a possible task for any professional. Existential needs centered around the opportunity to communicate, share thoughts and experiences, and be seen and heard. Existential care was connected to communication, sharing moments in the present without doing anything and was sometimes described as embedded in professionals' ordinary care interventions. The existential dimension was considered important by the majority of respondents. SIGNIFICANCE OF RESULTS: This study indicates that with the right attitude and responsiveness, all professionals can potentially contribute to existential care, and that existential care can be embedded in all care. The existential dimension of care can also be considered very important by health professionals in a country that is considered secular.

Sharing Bad News: Communication Between Patients and Their Loved Ones in a Palliative Care Context.

Background: Although communication is strongly emphasized in palliative care, not much research has focused on communication between patients and their loved ones. The purpose was to increase understanding of communication around severe illness between patients with a life-threatening disease, receiving palliative care, and their loved ones. Secondary intention was to identify strategies making easier for patients to talk about their condition with loved ones. The article is based on in-depth interviews with 15 patients and 8 loved ones. Interviews were analysed using qualitative content analysis. Communication about patient's illness was often described as balancing between wanting to inform or know and wanting to protect. Both patients and loved ones deliberately talk in a way that reflects their relationship. They act, negotiate and communicate aiming at not wanting to create situations that are perceived as uncomfortable, either for themselves or for others. Patients also take everyday practicalities into account. In these interactions, some people become the patients' inner circle - people with whom information is shared and co-owned. Other people find themselves outside the circle and patients may use them as test-subjects - speaking to them about things they might not dare reveal to their inner circle. These considerations are reflected in the themes: What is communicated, How communication is performed, and When it takes place. Our findings show that acting on the ideals of an "open and honest" form of communication is not always to be recommended. Professionals must instead strive to understand and respect the intentions of those involved.

Metaphors in End-of-Life Dreams in Patients Receiving Palliative Care: A Secondary Qualitative Study.

Background: Metaphors are used by patients and professionals in the discourse of disease and can facilitate conversations about difficult topics. There is little information about metaphors present in patients' end-of-life dreams. Objective: Identify and interpret metaphors in end-of-life dreams, directly reported by patients in palliative care. Design: A qualitative study with a secondary analysis of transcribed face-to-face interviews with patients. Setting/Participants: The study includes 25 patients with end-stage disease receiving advanced end-of-life palliative care. In total, 41 interviews were performed. Results: Metaphors applicable to 3 themes were found: the journey toward death, the inevitability of death and death itself. The underlying meaning of the metaphors is often related to topics and emotions commonly relevant in dialogue with patients near death. Patients, however, often seemed unaware of the meaning of their dream metaphors. Conclusion: Metaphors pertaining to death are present in end-of-life dreams in patients with end-stage disease. We hypothesize that encouraging patients to talk about their dreams can expose metaphors that could facilitate end-of-life discussions.

Pandemic impact on patients with advanced non-COVID-19 illness and their family carers receiving specialised palliative home care: a qualitative study.

OBJECTIVES: To investigate the experiential impact of the COVID-19 pandemic on patients with non-COVID, life-threatening disease and their family carers. DESIGN: An interpretative qualitative design informed by phenomenological hermeneutics and based on data from in-depth interviews, performed between June and September 2020. SETTING: Patients receiving specialised palliative home care and their family carers living in Sweden. PARTICIPANTS: 22 patients (male/female 11/11) and 17 carers (male/female 5/12) aged 50 years and older. All the patients received specialised palliative home care and most were diagnosed with cancer. INCLUSION CRITERIA: aged 18 years or older, diagnosed with an incurable life-threatening, non-COVID disease, sufficient strength to participate and capacity to provide informed consent. Participants were selected through a combination of convenient and consecutive sampling. RESULTS: The significance of the pandemic for both patients and carers showed a continuum from being minimally affected in comparison to the severe underlying disease to living in isolation with constant fear of becoming infected and falling ill with COVID-19, which some likened to torture.The imposed restrictions on social contact due to the pandemic were particularly palpable for this group of people with a non-COVID-19, life-limiting condition, as it was said to steal valuable moments of time that had already been measured.Most patients and carers found access to specialised palliative home care was maintained despite the pandemic. This care was of paramount importance for their sense of security and was often their sole visiting social contact. CONCLUSIONS: In the pandemic situation, highly accessible support from healthcare and social care at home is particularly important to create security for both patients and carers. Thus, to provide appropriate support, it is important for healthcare and social care personnel to be aware of the great diversity of reactions patients in palliative care and their carers may have to a pandemic threat.

End-of-life dreams and visions as perceived by palliative care professionals: A qualitative study.

OBJECTIVE: End-of-life dreams and visions (ELDVs) have been suggested to be prevalent psychic phenomena near death that can provide meaning and comfort for the dying. There is a lack of studies from the secular Nordic countries. The aim of this study was to determine whether palliative care professionals in a Nordic country have experience of patients expressing dreams, visions, and/or inner experiences and, if so, how they are perceived. METHOD: Focus-group interviews with 18 professionals in end-of-life palliative care were subjected to qualitative content analysis. RESULTS: Most (15/18) professionals had experience of patients with ELDVs. A dominant content was deceased loved ones. According to most professionals, many patients perceived their ELDVs as real and could report them with clarity. The experience could result in peacefulness for patients, as well as loved ones, and reduce fear of death. Some professionals themselves perceived ELDVs to be real and a normal part of dying while a few found them scary. Most professionals, however, found ELDVs hard to grasp. Many tried to explain the phenomena as the result of medical circumstances and confusion, although reporting that they considered most patients to be normal and of sound mind in connection with their reports on ELDVs. Most patients wanted to talk about their ELDVs, but some could be reluctant due to fear of being considered crazy. The professionals were open-minded and reported having no problem talking about it with the patients and tried to normalize the experience thereby calming the patient and loved ones. SIGNIFICANCE OF RESULTS: The results strengthen the suggestion that ELDVs are common phenomena near death, worldwide. Although most professionals in palliative care recognized ELDVs as beneficial to patients, many found the phenomena hard to grasp and sometimes difficult to distinguish from confusion, indicating a continuous need for exploration and education.

End-of-Life Experiences (ELEs) of Spiritual Nature Are Reported Directly by Patients Receiving Palliative Care in a Highly Secular Country: A Qualitative Study.

INTRODUCTION: Patients with life-threatening diseases have reportedly end-of-life experiences that are perceived positively. Loved ones and healthcare personnel may mistakenly interpret the phenomena as confusion and patients can be reluctant to talk about it due to fear of ridicule. Studies addressing patients directly are scarce and there is a lack of studies from highly secular countries. The aim was to establish whether end-of-life experiences are present among patients, oriented in time, place and person and receiving palliative end-of-life care in one of the world's most secular countries. If present, examine the content and patients' subjective experiences. DESIGN: Qualitative design with semi-structured, in-depth interviews. 25 participants, receiving end-of-life palliative care at home or in a hospice inpatient unit. RESULTS: Patients were interviewed on 1-3 consecutive occasions. 16/25 patients reported end-of-life experiences of which the majority were perceived to be positive. Four themes were identified: vivid dreams while asleep, experiences while awake, references to medical circumstances and communication about end-of-life experiences. Prevalent content was deceased and living loved ones and journeys. Some patients distinguished between hallucinations/nightmares and end-of-life experiences. CONCLUSIONS: End-of-life experiences are present among oriented patients in a highly secular country and can have a profound positive impact, which warrants clinical attention. Education for healthcare personnel about end-of-life experiences is needed in order to support patients and loved ones and not mistakenly medicalize. Further directions for research could be to study the experiences of the phenomenon among health care personnel in the same context, which could strengthen the present findings.

Living with a chronic disease: A quantitative study of the views of patients with a chronic disease on the change in their life situation.

OBJECTIVES: Chronic diseases have an impact on and change patient's lives which means that they need to find ways to cope with the new situation. The aim was to describe how the chronic disease has influenced patients' views of their life situation. METHODS: The study was quantitative in design with data collected using a semi-structured questionnaire. Descriptive statistics were used to compare similarities and differences between patients with asthma-allergy, diabetes mellitus, cancer and inflammatory rheumatoid arthritis. RESULTS: Changes in their life were experienced as a negative outcome for the majority of participants. Support can be in the form of interpersonal support from various persons, but also from activities and beliefs/religion. Family and friends as well as healthcare professionals were identified as being most supportive. Sadness and worry were the most common emotions among the participants and their surrounding networks. CONCLUSION: People with a chronic disease have to live with the consequences the disease has for their life situation. They need to find strategies to cope with the negative outcome in their new life. Support from their own network and healthcare professionals can be helpful in the new life situation.

Early integration of palliative care: translation, cross-cultural adaptation and content validity of the Supportive and Palliative Care Indicators Tool in a Swedish healthcare context.

BACKGROUND: Timely identification of patients with palliative care needs is a prerequisite for being able to carry out effective and equal palliative care. The Supportive and Palliative Care Indicators Tool (SPICT) identifies patients likely to benefit from a palliative approach. AIM: The main objective was to describe the translation, cross-cultural adaptation and content validation process of the SPICT-SE. In this process, the prefinal SPICT-SE was tested in focus group interviews to explore how the tool was perceived and interpreted by healthcare professionals in a Swedish healthcare context. METHODS: In this qualitative descriptive study, the translation, cross-cultural adaptation and content validation process of the SPICT-SE was based on a recommended method for cross-cultural adaptation of self-report measures. The process included two independent forward translations, a synthesis, and one independent back-translation. An expert committee consolidated all the versions and developed the prefinal version of the SPICT-SE. The prefinal version of the SPICT-SE was tested in four focus group interviews with physicians and nurses engaged in inpatient or outpatient care in south-west Sweden. A thematic analysis of the transcribed interviews was performed. The SPICT-SE was then revised to the final version. RESULTS: In the thematic analysis, four themes were constructed that together described how the SPICT-SE was perceived and interpreted by healthcare professionals: The mindset is familiar and relevant; the tool needs to be adjusted in order to be clearer; the purpose and consequences of the tool are ambiguous; and the tool supports a palliative approach. CONCLUSION: The SPICT-SE has now been successfully translated, culturally adapted and content validated in a Swedish healthcare context.

"Not Thinking that This Means the End When You Are Seriously Ill but Doing Something Positive about It"-A Qualitative Study of Living with a Life-Changing Disease.

BACKGROUND: Chronic diseases have an impact on and can change the lives of the persons affected by them. This study examines how a disease can influence patients' daily lives, the strategies they adopt to cope, and their experiences of support. The study focuses on four chronic diseases: asthma-allergy, cancer, diabetes mellitus, and inflammatory rheumatic arthritis. METHODS: The study has a qualitative design and includes 41 transcribed in-depth interviews and a content analysis. RESULTS: The participants' new life situation was changed for a very long time or forever, and this was not a voluntary choice. The new life situation comprised the following themes: life-changing-the disease could be a turning point in a negative or positive way, strategies-designed to create ways of coping with daily tasks to find a good quality of life, and support-that could be obtained from the participants' private network or the healthcare professionals. CONCLUSIONS: The patients had to make changes in their daily life, and these could bring about different feelings and restrict activity. Healthcare professionals need more knowledge of the process of coping with such life-changing matters and what could strengthen patients and give a sense of empowerment in their lives.

The rate of deterioration of erectile function increases with age: results from a longitudinal population based survey.

Background: Increasing age as a risk factor for erectile dysfunction (ED) is in most studies assumed to be a linear function. If this is not the case the assumption could lead to bias, e.g. when men of different ages are compared in interventional studies on ED. Objective: To explore the risk of developing ED over time for men from different age groups. Materials and methods: A questionnaire was sent to a number of male residents in Gothenburg, Sweden, in 1992 (n = 10,458). Men were randomly selected according to year of birth to obtain several cohorts at 5-year intervals of ages 45, 50, 55 years, etc., up to the age of 85 or older. In 2003 an analogous, slightly expanded, questionnaire was sent to a random sample of men from the age cohorts 46, 51 years, etc. (n = 10,845). A total of 4072 men received both surveys, thereby constituting a group of men followed longitudinally for 11 years. The future risk of developing ED in the different age cohorts, adjusted for a number of ED risk factors, was then assessed. Results: A total of 3257 men responded to both questionnaires (response rate = 80%, age range = 56-103 years). The risk of having ED increased substantially with increasing age, both within each survey and longitudinally between the surveys. The adjusted risk of developing ED within the next 11 years increased with a factor of 10, from 1.8% at the age of 45 years at baseline to as much as 11.4% at the age of 65 years. Conclusion: Age as a risk-factor for ED is a non-linear function and should be adjusted as such to avoid bias when including men of different ages in interventional studies on ED.

Public awareness of palliative care in Sweden.

OBJECTIVE: The aim of this study was to investigate the awareness of palliative care (PC) in a general Swedish population. DESIGN: We developed an e-survey based on a similar study conducted in Northern Ireland, consisting of 10 questions. Closed questions were primarily analyzed using descriptive statistics. Open questions were subject to inductive qualitative analysis. SUBJECTS: The study utilized a population sample of 7684 persons aged 18-66, of which 2020 responded, stratified by gender, age and region. RESULTS: Most participants reported 'no' ( n = 827, 41%) or 'some' ( n = 863, 43%) awareness of PC. Being female or older were associated with higher levels of awareness, as was a university-level education, working in a healthcare setting and having a friend or family member receiving PC. Most common sources of knowledge were the media, close friends and relatives receiving PC, as well as working in a healthcare setting. Aims of PC were most frequently identified as 'care before death', 'pain relief', 'dignity' and a 'peaceful death'. The preferred place of care and death was one's own home. The main barriers to raising awareness about PC were fear, shame and taboo, along with perceived lack of information and/or personal relevance. The term 'palliative care' was said to be unfamiliar by many. A number of strategies to enhance awareness and access to PC were suggested, largely reflecting the previously identified barriers. CONCLUSIONS: This survey found limited awareness of palliative care in an adult sample of the Swedish general public ≤ 66 years, and points to a more widespread disempowerment surrounding end-of-life issues.

A Qualitative Study of the Experiences of Parents With an Adult Child Who Has a Severe Disease: Existential Questions Will Be Raised.

A prominent existential concept is that elderly parents should naturally become severely ill or die before a younger person does. If the reverse should happen, it may influence the parent's existential view of life. The aim of this study was to investigate the existential issues during illness time. This was a qualitative study with in-depth interviews and was conducted in a University Hospital in western Sweden. Eleven parents agreed to participate in individual interviews at baseline and 1 year later. The total number of interviews completed was 19. The study identified 5 areas according to an existential perspective: life took the wrong path, the age of the child, difficult to see the child as sick, worrying about the child, and the relationship with the adult child. Existential questions are often present in those circumstances and can be raised in conversations with parents. Existential questions began to arise for the parent when the child was diagnosed with the severe illness. The situation of having a severely ill child caused both fear and anxiety that the worst-case scenario they could imagine, that the child will die, might happen. Further research is required on this rarely investigated subject of having an adult child with a severe disease.

Developing organisational ethics in palliative care.

BACKGROUND: Palliative carers constantly face ethical problems. There is lack of organised support for the carers to handle these ethical problems in a consistent way. Within organisational ethics, we find models for moral deliberation and for developing organisational culture; however, they are not combined in a structured way to support carers' everyday work. RESEARCH OBJECTIVE: The aim of this study was to describe ethical problems faced by palliative carers and develop an adapted organisational set of values to support the handling of these problems. RESEARCH DESIGN: Ethical problems were mapped out using focus groups and content analysis. The organisational culture were developed using normative analysis and focus group methodology within a participatory action research approach. Main participants and research context: A total of 15 registered nurses and 10 assistant nurses at a palliative unit (with 19 patient beds) at a major University Hospital in Sweden. Ethical considerations: The study followed standard ethics guidelines concerning informed consent and confidentiality. FINDINGS: We found six categories of ethical problems (with the main focus on problems relating to the patient's loved ones) and five categories of organisational obstacles. Based on these findings, we developed a set of values in three levels: a general level, an explanatory level and a level of action strategies. DISCUSSION: The ethical problems found corresponded to problems in other studies with a notable exception, the large focus on patient loved ones. The three-level set of values is a way to handle risks of formulating abstract values not providing guidance in concrete care voiced in other studies. CONCLUSION: Developing a three-level set of values adapted to the specific ethical problems in a concrete care setting is a first step towards a better handling of ethical problems.

The effect of conservative treatment of urinary incontinence among older and frail older people: a systematic review.

BACKGROUND: urinary incontinence (UI) is a common symptom among older people, with a higher prevalence among frail older persons living in nursing homes. Despite consequences such as reduced health and quality of life, many older people do not seek help for their symptoms, resulting in missed opportunity for treatment. OBJECTIVE: the aim of this study was to investigate the evidence and the effect of conservative treatment of UI and the quality of life among older and frail older persons. METHODS: a systematic review of randomised controlled studies and prospective, non-randomised studies was conducted, evaluating interventions of conservative treatment of UI in an older population (65 years or older). A total of 23 studies fulfilled the inclusion criteria and 9 were of high or moderate quality. Fourteen studies were of low quality and were therefore excluded from the analysis. RESULTS: documented and effective conservative treatments are available even for older persons with UI. Pelvic muscle exercise, physical training in combination with ADL, prompted voiding and attention training, and help to toilet are important treatments. In some studies, however, the evidence of effectiveness is limited. CONCLUSIONS: this systematic review concludes that there are conservative treatments for UI for older and frail older persons that reduce leakage and increase quality of life. There is however a need for further high-quality studies.

Effect of pharmacological treatment for urinary incontinence in the elderly and frail elderly: A systematic review.

AIM: The prevalence and severity of urinary incontinence (UI) increase with age and comorbidity. The benefits of pharmacotherapy for UI in the elderly are questionable. The aim of the present study was to systematically review the efficacy of pharmacological treatment for UI in the elderly and frail elderly. METHODS: We searched PubMed, EMBASE, Cochrane library and Cinahl databases through October 2013 to identify prospective controlled trials that evaluated pharmacological treatment for UI in persons aged ≥65 years. Elderly persons living in nursing homes were regarded as frail elderly. Outcomes were urinary leakage, quality of life and adverse events. RESULTS: We screened 1038 abstracts and assessed 309 full-text articles. We identified 13 trials of high or moderate quality; 11 evaluated anticholinergic drugs and two evaluated duloxetine. Oxybutynin, the only drug studied in the frail elderly population, had no effect on urinary leakage or quality of life in elderly with urgency UI (UUI). Seven trials evaluated the effects of darifenacin, fesoterodine, solifenacin, tolterodine or trospium. Urinary leakage decreased (standard mean difference: -0.24, 95% confidence interval -0.32-0.15), corresponding to a reduction of half a leakage per 24 h. Common side-effects of treatment were dry mouth and constipation. Data were insufficient for evaluation of the effect on quality of life or cognition. The evidence was insufficient to evaluate the effects of duloxetine. No eligible studies on mirabegron and estrogen were found. CONCLUSIONS: Anticholinergics have a small, but significant, effect on urinary leakage in older adults with UUI. Treatment with drugs for UUI in the frail elderly is not evidence based.

How to estimate understanding: professionals' assessment of loved ones' insight into a patient's fatal disease.

BACKGROUND: Loved ones of a patient with an incurable disease will accompany the patient to the end of life. Health care professionals must discuss difficult matters with loved ones and be sure that they really understand the seriousness of the patient's disease. The study explore how the professionals do when they explore the grounds on which they make their assessment of loved ones' insight into a patient's fatal disease. METHOD: A qualitative design was chosen to gain deeper knowledge of professionals' perception of loved ones' understanding. The transcribed interviews were analysed using content analysis giving a richer understanding of the meaning of the content. RESULT: The participants assessed loved ones' insight into the fatal disease based on the course and content of the conversations they had with the loved ones. The professionals' assessments were based on how the loved ones talked and expressed themselves in words and behavior and on the type of questions posed by the loved ones. The loved ones' observations and hope as denial or a strategy also contributed to their assessment. CONCLUSION: Ways to communicate with loved ones are crucial when making an assessment. The different ways loved ones use hope and other strategies made it problematic for the professionals to use these as indicators of state of mind in this matter. Training in conversation skills could be one way to support professionals when discussing and managing these difficult situations.

Challenging conversations with terminally ill patients and their loved ones: Strategies to improve giving information in palliative care.

OBJECTIVE: The aim of the study was to explore the skills and strategies employed by professionals when having difficult conversations to provide information to loved ones as part of palliative care. METHOD: A qualitative design was chosen with in-depth interviews with nurses, assistant nurses and doctors a Hospital in Sweden and were analysed using content analysis. RESULTS: The interviews produced examples of strategies used by professionals when imparting difficult information to patient and loved ones. The results fell into three areas: 'Who is giving information', 'Structuring the conversation' and 'Different ways to convey a difficult message'. CONCLUSION: Using conversational skills and strategies in combination with a carefully planned structure appeared to facilitate difficult conversations with patients and loved ones. Further research is required, related to the specific circumstances in which the conversation takes place.