Bioethics Discussion Blog: Communicating Bad News: Does the Doctor Want to Tell, Does the Patient Want to Hear?

REMINDER: I AM POSTING A NEW TOPIC ABOUT ONCE A WEEK OR PERHAPS TWICE A WEEK. HOWEVER, IF YOU DON'T FIND A NEW TOPIC POSTED, THERE ARE AS OF MARCH 2013 OVER 900 TOPIC THREADS TO WHICH YOU CAN READ AND WRITE COMMENTS. I WILL BE AWARE OF EACH COMMENTARY AND MAY COME BACK WITH A REPLY.

TO FIND A TOPIC OF INTEREST TO YOU ON THIS BLOG, SIMPLY TYPE IN THE NAME OR WORDS RELATED TO THE TOPIC IN THE FIELD IN THE LEFT HAND SIDE AT TOP OF THE PAGE AND THEN CLICK ON “SEARCH BLOG”. WITH WELL OVER 900 TOPICS, MOST ABOUT GENERAL OR SPECIFIC ETHICAL ISSUES BUT NOT NECESSARILY RELATED TO ANY SPECIFIC DATE OR EVENT, YOU SHOULD BE ABLE TO FIND WHAT YOU WANT. IF YOU DON’T PLEASE WRITE TO ME ON THE FEEDBACK THREAD OR BY E-MAIL DoktorMo@aol.com

IMPORTANT REQUEST TO ALL WHO COMMENT ON THIS BLOG: ALL COMMENTERS WHO WISH TO SIGN ON AS ANONYMOUS NEVERTHELESS PLEASE SIGN OFF AT THE END OF YOUR COMMENTS WITH A CONSISTENT PSEUDONYM NAME OR SOME INITIALS TO HELP MAINTAIN CONTINUITY AND NOT REQUIRE RESPONDERS TO LOOK UP THE DATE AND TIME OF THE POSTING TO DEFINE WHICH ANONYMOUS SAID WHAT. Thanks. ..Maurice

FEEDBACK,FEEDBACK,FEEDBACK! WRITE YOUR FEEDBACK ABOUT THIS BLOG, WHAT IS GOOD, POOR AND CONSTRUCTIVE SUGGESTIONS FOR IMPROVEMENT TO THIS FEEDBACK THREAD

Wednesday, March 12, 2008

Communicating Bad News: Does the Doctor Want to Tell, Does the Patient Want to Hear?

The patient has cancer. The doctor has made the diagnosis and suspects a prognosis. The question I pose is “who should tell the patient the bad news and how should it be told and once told should it be retold?” Most of my visitors would probably reply with “yes, the doctor should tell the patient the bad news and later if the outlook is still poor after treatment, the doctor should tell the patient that too.”

The problem is there may be a resistance for the doctor to tell all the bad news and an interest to divert the patient’s attention from the longer term outcome, even if suspected as poor, to the more immediate shorter term potential benefit of treatment. The problem is also that the patient may also have a resistance to hear about the long term when there are tests and treatments readily available and seem to carry the potential for improvement of the patient’s current state.
This can lead to“collusion” between the doctor and the patient where the true poor prognosis will tend to be hidden during the doctor-patient communication about the illness.

This subject is very nicely discussed in a paper “Collusion in doctor-patient communication about imminent death: an ethnographic study” by
Anne-Mei The, Tony Hak, Gerard Koëter and Gerrit van der Wal published December 2, 2000 in the British Medical Journal.
35 patients with small cell lung cancer were followed over a 4 year period. Although this study is from the Netherlands, I suspect that this observation should be considered in other countries including our United States.

From the abstract of the article: “False optimism about recovery” usually developed during the (first) course of chemotherapy and was most prevalent when the cancer could no longer be seen in the x ray pictures. This optimism tended to vanish when the tumour recurred, but it could develop again, though to a lesser extent, during further courses of chemotherapy. Patients gradually found out the facts about their poor prognosis, partly because of physical deterioration and partly through contact with fellow patients who were in a more advanced stage of the illness and were dying. “False optimism about recovery” was the result an association between doctors' activism and patients' adherence to the treatment calendar and to the “recovery plot,” [yesterday the patient was healthy, today he is ill, but tomorrow he will be better again, thanks to the efforts of the doctor and the patient, with support of carers]. which allowed them not to acknowledge explicitly what they should and could know. The doctor did and did not want to pronounce a “death sentence” and the patient did and did not want to hear it.
Conclusion: Solutions to the problem of collusion between doctor and patient require an active, patient oriented approach from the doctor. Perhaps solutions have to be found outside the doctor-patient relationship itself — for example, by involving “treatment brokers.”


Relaying bad news to the patient and family is always a difficult exercise for the physician and some physicians are less skilled and have less experience in such communication. Although the estimation of when death will occur is always inexact, rough approximation can be made by published statistics. In addition, talking about failure is something difficult for many physicians who also worry that they do not take“hope” away from the patient. However, it is much easier for the physician to focus the discussion on tests and further treatment and tend to ignore the longer term prognosis all of which may correspond to what the patient wants to hear about from their physician. It may require in some doctor-patient relationships an “outside” professional, trusted by both parties, to tell the patient the realistic therapy and prognosis. ..Maurice.

3 Comments:

At Friday, March 14, 2008 8:15:00 PM, Blogger Chrysalis Angel said...

I can only speak for myself, as a cancer patient. I want that physician to tell me the truth. I want him/her to tell me what their knowledge tells them of the case that is before them. I need to know what you know.

I wanted it straight from my doctors. I wasn't a coward, and I didn't want them to be. It doesn't mean go ahead and blurt out "Your gonna die!" Set down. Look me in the eye, and talk to me as one human being to another now. I need you to feel human, and I need you to treat me the way you would want to be treated. Take a minute and stay and tell me - unhurriedly, calmly, and with compassion if you can. I'm being told my life is on the line.

I knew in my case before they did. I felt what I called my "life force" draining out of me. I could literally feel the energy (that I felt animated me)...draining. I was so,so tired. Not an I've had a long day and I'm tired, but an I've got nothing left to expend tired. I'd dropped 17lbs. in only a couple of weeks. I was the first one to use the word cancer. My poor doctors afraid to tell me at 36, you may die. I'm no longer 36 and I think I've surprised them. I have a high chance of recurrence and am well aware that a second showing will be terminal for sure, but I advocate to tell them straight. A physician needs to get to terms with how they feel about the whole thing themselves - we can't be your courage too, when we need to lean.

 
At Friday, March 14, 2008 9:47:00 PM, Blogger Maurice Bernstein, M.D. said...

Thank you for presenting us with a revelation of your needs as a cancer patient in terms of information about your illness and suspected prognosis and how it should be revealed.

Sometimes I wonder whether nurses rather than doctors are in a better position to discuss prognosis with patients. Often nurses spend more time with patients, particularly when hospitalized rather than doctors who rush in and rush out. Nurses may learn more about the values and goals of their patients, through conversation, and understand better than the attending physician what desires the patient has regarding the future short or longer term quality of life, I don't advocate nurses disclosing their views of the prognosis to the patient without the attending physician's approval but I think nurses, particularly those who have had experience in the caring for patients with the disease, have something to contribute to the description of the prognosis. ..Maurice.

 
At Saturday, March 15, 2008 4:25:00 AM, Blogger Chrysalis Angel said...

I worried after I posted my comment. I do feel for the person that must give this kind of news. It is never an easy task, and every patient is different.

I just believe that honesty is always the best policy, no matter who it is that discusses the situation with the patient.

 

Post a Comment

<< Home