MARCH 2008
VOLUME 5 NO. 3

PATIENTS & PRACTICE

Is it ever OK to withhold bad news from patients?

Open talk is key to allaying family fears, says MD. There is a middle way


Disclosure negotiating tips

1 Arrange an appropriate place and time to meet.

2 Find out why the family is making the request. Respond with empathy. Discover what the family thinks the patient would want and learn the patient's role. It may emerge that the patient clearly indicated they don't want to be informed of bad news. "In many cultures it isn't the patient who makes the decisions. That responsibility is deferred to the family," adds Dr Hallenbeck. In these cases, it's essential to speak with the patient and ask them what they want without providing disclosure in the process.

3 Offer help in understanding the implications of the request and discuss the practical issues of withholding the diagnosis.

4 Negotiating may conclude with family members playing a key role in disclosing the diagnosis.

A 75-year-old woman is admitted to the hospital with abdominal pain and severe depression. Her work-up reveals cancer. The prognosis is less than three months. When her family gets word, they're adamant she shouldn't be told. It would "kill her," they say. But her physician feels like they're asking him to lie.

On the one hand, patients have a right to know what is happening to them. Yet, on the other, there is the question of what the patient will gain from knowing — and the necessity of having the family on your side. One physician, Dr James Hallenbeck, wants doctors to consider a compromise between keeping a patient in the dark and full disclosure.

'DON'T TELL MOTHER'
"We saw this issue causing a great deal of stress in physicians," says Dr Hallenbeck, a palliative care specialist at Stanford University and co-author of the case review "A Request for Nondisclosure," in November 2007's issue of the Journal of Clinical Oncology. "Clinicians find it an odd thing for families to come and say 'don't give them the bad news'" — especially since it's essentially impossible to hide the side effects of treatments like chemotherapy.

Doctors commonly respond to nondisclosure requests with a categorical 'no,' says Dr Hallenbeck. That 'no,' however, may lead to a time-consuming and stressful conflict with the family that could fairly easily be avoided.

NEGOTIATION SKILLS
First of all, Dr Hallenbeck advises doctors not to overreact to the request. "These are critical events in the patient's and family's life, and how they're handled has a huge effect on what happens and how the survivors think about the episode of care."

How things are done, suggests Dr Hallenbeck, is every bit as important as the end result. "Some basic negotiation techniques can greatly ease the process," he says. (See "Disclosure negotiating tips".)

But don't neglect your legal responsibilities. "Nondisclosure can be a very grey area," says Robert P Kouri, a health law expert at University of Sherbrooke. "Quite often it's good to take the family's advice, but on the other hand the basic principle is that the patient has a right to know what's happening. If they ask you, you have no choice but to tell them."

 

 

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