quote:Should you ever lie to a patient?
Lidia Schapira, MD, Oncology, Hematology/Oncology, 10:04AM Feb 20, 2012
Medscape's video of Art Kaplan discussing truth telling has made the academic rounds. If you haven't seen it yet, you may want to do so. Kaplan is a compelling speaker and respected scholar. In this short segment he discussed a new study of truth telling practices among doctors and then uses the opportunity to tell us exactly what he thinks is going on and what passes ( or not ) his ethical bar.
I haven't actually read the study but I too have opinions. It seems that we all do. Just as we cannot avoid eating and sleeping, we too must communicate with patients all the time. And what we intend to say or choose to say is not always what we would ideally say if we could really stop to think about it. So for some, softening the truth or prescribing placebo, may be acts of kindness and to others look like deliberate deception.
But the 'truth' is that we are constantly censoring our verbal output guided by our own moral code and sometimes affected by circusmtances that have little to do with the acutal ethical issue at hand. If you are really busy or distracted, you may find the quickest way to finish a meeting and that may involve either witholding information, delivering it in such a way that it will not unsettle or frighten the patient. Perhaps you will prescribe a medication that may not be strictly necessary but could help the patient via a placebo effect.
Whether you consider witholding certain facts which form part of 'the truth' or dosing the truth so that you deliver it over a few installments is your choice. How others interpret your actions is another matter. One thing that remains opaque to others who either observe or interpret your behavior is your intent. So many colleagues lie or soften the truth to protect or help patients. That is as variable as individual styles of practice.
It's the 'music' of the exchange between clinician and patient that may, in the end, determine whether that meeting was therapeutic for the patient. Words matter, but are not the only mediators of truth.
As a patient, I think the best option is to ask your patient if she would like the whole truth or not. Why should the doctor make this decision alone?
you make it sound easy... sometimes doctors struggle not only with what to say but how and how much. Anxiety about hurting somebody, for example, can lead to a more paternalistic or directive approach. Those who feel really confident can almost always find a way through a difficult conversation. On the other hand, some patients don't help either!If the doctor senses the patient is really anxious or terrified, then it may be harder to discuss information that will undoubtedly cause even more fear or anxiety!
#3, Added By: An_23716330, Other, 02:25PM Feb 20, 2012
That's fair. What I am talking about is doctor and patient having a discussion early on, if the seriousness of the illness warrants it. The doctor could feel out her patient: "Shall I be completely honest with you about your illness every step of the way?" and "Please tell me if you wold like me to protect you if I have discouraging news or do you want to know when things are looking bad?" In other words, getting a baseline understanding of how important the whole truth is to each patient early in the treatment relationship is important. I have been in the position of not knowing that someone was actually dying because the docs were so "considerate" and didn't want to upset me or my sister. It wasn't helpful.
Doctors should never, ever lie to a patient. Lying is totally unprofessional, and immature. No matter how you present a lie in order to justify your action, it always comes down to one fact, one truth, the doctor is dishonest.
From the first visit with a patient, the doctor should establish the expectations so the patient knows what and how information will be relayed to them, good or bad. I find all patients want full disclosure and find it always best and the only way to maintain a trusting relationship. It is equally important to couple any bad news with a plan of action. No one wants to hear bad news but if they must they also want a plan of action, whether that be more testing or a plan of therapy. This may translate into a few days delay between testing and discussing the results but I have never had a patient complain when I also provide them a well thought out plan of action at the same time.
You bring up some very important issues and I agree that aligning expectations, earning your patient's trust over time and being clear and supportive as well as providing a direction are fundamental ingredients of a solid doctor-patient relationship. There are some patients, however, who prefer not to know 'everything' and there are also doctors who find a way of delivering news without really explaining what it means. It's hard to know what folks actually "do" and "say" in the consultation or exam rooms.
A dementia patient presents a different set of challenges from cancer patients, but perhaps this is not the place to discuss that dilemma. How much they can understand and participate is determined by the stage of their disease. Where is the ethical obligation? Liz
The problem with not disclosing everything to the patient, even if the intention is to be kind, is that physicians forget what they have and have not said. The more serious the situation, the more necessary it is to be completely honest. It is devastating to have healthcare providers imply (or allow patients to infer) that things aren't so bad, only to find through a casual comment later that it's worse than you thought. The comment might come from another healthcare provider who assumes the patient knows everything, or from a busy doctor who can't keep straight what has and has not been disclosed. I agree completely with the previous comment about patients always wanting full disclosure and how that bolsters trust. If doctors don't know how to deliver news without explaining it, they need to correct their poor communication skills. Being able to talk with a patient is as essential as any other skill.
It seems to me that if the patient is demented and lacks the capacity to understand complex health information and thus the capacity to give true informed consent for treatment, then the 'ethical' obligation is to identify a proxy and help the patient/family to formalize this arrangement. After that I think we owe it to the patient to provide good care but not to burden him or her with information that they cannot process and, instead, work with the proxy in the most humane way. It's hard for cancer patients with dementia who often hear the same bad news over and over, each time seems to be the first time!
Having recently gone through the death of a family member this is still fresh in my mind. Prior to diagnosis I was pretty sure what the eventual diagnosis would be. Exploratory surgery confirmed my suspicions.
While I would not suggest any of the physicians actually lied, I would say they presented an overly optimistic treatment and outcome potential.
Were I not retired, my professional opinion would be that significant harm was done the patient as well as the husband and other family members. (Not to mention age peers based on the information shared with them by the family.)
Based on my professional and personal experience over many years of dealing with severe disability and terminal patients it would be my opinion that honesty is the best policy. Many people do not like facing facts and reality. However, there are times when we all must. I would think the most reasonable approach is to be honest and present the material in a considerate and thoughtful manner. If necessary seek some information and support from other family members or friends of the patient as to how to approach and present the material. Some like bad news straight. Some like it with sugar. It seemed to me it was part of my job to figure that out and provide the straight story, all of it, as often as necessary. Many of the above points deserve consideration and incorporation in determining this approach.
Your relationship is with your patient. That is the basis of the patient physician relationship. The patient deserves the truth. There are many ways to deliver this softly, respectfully and as needed. Lying is morally wrong and breaks the relationship.
Telling bad news is difficult and painful to the physician. I feel that mostly the real reason for lying is to make it easier on the physician, not for the patient's benefit.
Let's be clear, physicians cannot accurately prognosticate. It doesn;t diminish you to simply admit it and act accordingly. There is no question that clinical decision making requires deception in the use of placebos but outside of that relinquish the omnipotence and give yourself and the patients a break; evryone's life will be easier.Truth doesn't usurp hope, our jobs are to guide through reality even when it hurts and is not to our benefit or comfortable.
As a patient I deal better with the known versus the unknown. I agree that trust is the number one thing between physician and patient. In order for a patient to trust & comply with the treatment plan they have to be able to trust that the doctor has been honest all the way along.
I am a patient and also a medical student, so I often see this debate. Knowing that my doctor may be withholding information from me in order to protect my feelings does nothing but cause paranoia that there is something going on with my disease that I am not aware of. There were many important components of my pathology report that were not at all addressed despite my constant questioning about it. I find this ridiculously unprofessional. Yes, doctors must be aware of the emotional and mental state of a patient, but this should be used to deliver information on their health condition in a way that is clear and understandable by the patient and their family, not to determine whether or not they should withhold it.
I think the most important is to know the "supportable true" . Each person have different possibilities to resist and copy the fact to have cancer.
As a patient, I definitely think the total truth, including prgnosis, how-ever bad, should be discussed. Not be pessimistic, but rather frank, allows one to adjust to various possibilities (with the help of a professional counsillor if needed) and get to a place where, after the shock, you want to fight the fight with everthing possible, as well as come to terms with one's life aspects to sort through. I think it is totally unprofessional and blatant disregard of a patient, not to tell them the whole truth. I feel the onus lies with the patient what to do with the information - and the doctor should give them resources and names of professional support they are able to seek.
I think the most important is to know the "supportable true" . Each person have different possibilities to resist and copy the fact to have cancer.
I am a counsellor and cannot agree with you more. I am currently conducting research with a long-term "patient" of the mental health service, writing her biography. Despite complete awareness of all treatments she has received and putting in a formal request under the Freedom of Information Act for access to her medical records; her request has been sidelined and ignored by her psychiatrist; instead platitudes have been offered. This has definitely created deeper anxiety about what might have been written historically and also frustrated the research process. If people have the capacity and will to ask; professionals surely have a duty to grant access to all the available information. It does, after all, belong to the patient ultimately. I am so heartened to hear your view as a medical student who will ultimately join this profession and be party to the power relations that occur in such academic discourse. I wish you every success in your career.
Not telling the truth as the MD sees it to protect the patient, out of concern that the patient can't handle the truth, may be hurt by the truth, offended, etc., is patronizing and assumes the MD "knows best"...especailly given the very limited true knowledge an MD has of his or her patients, no doctor can truly know what's best. Telling the truth, tactfully but completely, respects the patient and avoids miscomprehensions and many of the concerns mentioned in the above posts.
I am an oncolocgy patient and have experienced on several occassions the consequences of my oncologist, my contact nurses and my surgeon deciding to tell different slices of the truth. All with good intentions I am sure however I "need" to know the whole truth, it is exhausting trying to piece it all together and know with bitter expereince that it can lead to leaping to the wrong conclusions that either over or under estimate the impact of the disease/procedure/treatment/drug etc. Doctors remember.....I have a brain and it is my body!
As an oncology patient too, I could not agree more!!!!!!
Many decades ago, when I was in med school, patients' family and friends would be visiting to help the patient, especially providing social and emotional support and sometimes assisting with tasks like eating. Now these visitors are needed to protect the patient from the hospital conditions and staff, including doctors, and may also be important so that a witness for the patient is present during any discussions. Medicine sure has come a long way! Hopefully you will be able to influence others to be aware of the perspective and experiences of patients. I pray you have the health and strength for meeting that challenge.
My mother-in-law died of metastatic breast cancer a year or so ago. She never complained about having the disease, or the treatments or the pain. So with all this on board, what wast he thing that bothered her the most (and that she mentioned at every opportunity)? The fact that she felt she couldn't tell her oncologist "anything" and he "wouldn't give her the full story". So the communication with her doctor weighed more heavily on her mind than dealing with her disease!
Do you have the gift of certitude, together with complete confidence in your clinical judgement? If your answer is yes, you will probably have little by way of sensitivity to your patient's needs, which include careful consideration of the way in which information is communicated. Information to be imparted is opinion, rather than fact, and must be qualified as such. In so doing, information should not include anything that you, in your professional capacity, do not believe to be true.
An interesting and layered comment - if I understand you correctly you point out the fact that humility is a real virtue for good doctors and that arrogance and deceipt are (of course) to be avoided.There is still a grey zone about just how much needs to be said and how much interpretation the doctor ought to give. While raw data or facts are not synonymous with 'truth', the doctor can help patients understand the information and thus co-creates the truth.
I find it hard to believe there is any need to debate the issue. A doctor is in a position of trust. Trust is only maintained by truth. A patient has a right to believe they are being told the truth about their health by their doctor- not given an edited version because it is uncomfortable for the doctor to say 'It is likely you will die from this disease in so many months/years' How can 'informed' consent can be given by a patient if they have not been fully informed?
Your comments are invited