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.
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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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