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.