Talking with Patients

from "Textbook of Healthcare Ethics" p.192-195 by Erich H. Loewy, M.D., Plenium Press, New York, 1996. Reproduced here with the permission of the author.

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Physicians and their colleagues in other health professions find talking to patients whose prognosis is poor or for whom no further therapeutic intervention is possible very difficult. Not rarely such persons, at times consciously but more often unconsciously, avoid the dying patients and, when they must be with them, avoid the issue by resorting to idle chatter or pointless jocularity (a thing quite distinct from humor). Likewise, the body language often sends a clear message of distancing to the patient. At the very time that patients need communication most, communication is cut off. This is not a problem unique to health professionals. It is a problem that involves the family, who, likewise, are loathe to address the problem head-on and who “to be kind” hide behind optimistic platitudes, half truths, self delusion or outright lies. And yet studies have shown time and again that patients generally want to be involved, want to share, and want, above all, to communicate.

Health care professionals often do not involve patients in critical matters: Often they fail to tell them the truth about their prognosis, and they frequently fail to involve patients in critical life-and-death decisions. When this happens, the professional- patient relationship becomes a game of charades. Often such a failure to communicate demoralizes all members of the health-care team. Nurses, asked by patients who find communication with their doctors cut off, find themselves in the terrible quandary: They can tell the patient the truth, knowing that this may bring about the physician’s wrath as well as perhaps otherwise "get them into trouble"; they can join in the game of charades; or they can simply obfuscate and, in truth, lie to the patient. Physicians, as the acknowledged heads of the health-care team, owe an obligation not only to the patient but likewise to the other members of the team. Open communication among all members of the team is of utmost importance.

On the other hand, while patients, because of the respect humans one to another, ought not to be lied to, telling the truth comes in many shades and gradations. As one paper has put it so aptly, these conversations are an elaborate pas des deux in which both the two parties feel each other out. Patients can only be told what patients are ready to hear; they will turn a deaf ear and literally deny being told if told at a time when they are not receptive. I well remember a lady who was told about her diagnosis of cancer at least four times by her physician, and each day would ask again and simply deny having been told. Sick people are not, as Eric Cassel put it so beautifully, simply well people caring "the knapsack of disease. " They are people in whom a whole host of changes and adaptations are and have been taking place. Simply assaulting patients with the truth is hardly the proper thing to do.

Patients must be gently led to receive bad news. The manner in which this is done varies with the personality of each patient, each health care professional and his or her role, each situation, and the peculiarities of the specific relationship. It depends on the assessment of the situation (an assessment that can receive in valuable help from the other members of the health-care team as well as from a family) and defies a stereotypic approach. Human understanding, rather than technical knowledge, is what is needed, and humor, as always, has its place. Physicians have to be sensitive to the patient's implied wishes as they are to the "letter of the [moral or legal] law." Shoving the facts down the throat of a helpless patient who may derive some lasting comfort from deception is "moral" in no more than a very aseptic sense. The physician has to "size up the patient" (a comment made by Eric Cassel to Professor Jonas some time ago) and deliver judgment as to the patient's desire and capacity for truth. Talking to patients who must be given the news that they are hopelessly ill truly requires compassionate rationality: compassion, so as to be able and willing to share humanity with one another, and rationality, so that sentimentality does not swamp the situation.

Under most circumstances, most patients must eventually, if they desire to hear it, be told the full truth. Just as patients have any "right" to be informed, they also have a "right" to choose not to be informed. Patients, in other words, must have the right to choose and have their choice respected. Respect for persons demands as much. In some cultures patients are traditionally not generally told bad news, a tradition that, however, seems to be rapidly changing. But even here the physician with the active help of other health care professionals must try to ascertain the patient's wishes and act accordingly.

When the truth has to be told, however, it has to be gently given. Physicians and other health-care professionals involved must allow ample time to share what they perceive to be the truth, as well as what they know to be their ignorance and uncertainty, with the patient. A hurried approach to patients under these circumstances violates the duty of respect as much as it does not telling the truth at all. Patients who are willing to hear must be told truth, but they must not necessarily be informed the moment the "facts" become known. Physicians are well advised to defer such conversation to a time when there are not pressed for time, not "due at the office in five minutes," and not physically harassed by conflicting demands. Likewise other health care professionals need to choose their time to speak with patients, if necessary telling them that they will return when they have more time and then returning and spending what time is needed. Sitting at the patient's bedside, perhaps sharing a cup of coffee, perhaps touching a shoulder, or an arm, are all appropriate maneuvers that can convert the process from one of mutual pain to one of sharing of mutual mortality. It is here that a start can be made at orchestrating the rest of the patient's life so that it is as full as possible.

Patients may asked not to be told. This does not occur frequently but it does occur. If it occurs, and if it seems to be a truly autonomous decision, the request must be respected. An ample opportunity for patients to change their minds must be given, but the patient who in effect "leaves everything up to the doctor" and does so knowingly has made a deliberate choice. Physicians who cannot live with such a choice (and some may not be able to) are well advised to communicate this with their patients and to reach with them with a shared agreement of how to proceed: It may be that the patient delegates a family member; it may be that the physician may have to obtain consultation or turn the case entirely over to another.

On the other hand, relatives may beseech physicians not to tell the truth to their patients. A wife may "forbid " the physician to tell her husband of his metastatic cancer or even threatened suit (the fact the patient's threaten suit does not mean that they will sue, that they, in fact, can find cause to sue, or that, ultimately, they can hope to prevail in such a suit.” They may plead that they know their husband well and that he "couldn't stand to know.” In general, physicians are ill advised to follow such counsel. First of all and in most circumstances, who will and who will not be told should be explicitly and tacitly at least agreed upon long before the need arises. Secondly, when circumstances have made this impossible the physician's first obligation is to the patient: unless physicians know in individual cases that something about a specific patient makes the administration of truth ill advised or that the patient has specifically stated that they do not wish to be informed, they are obligated to tell it. Streptococcal disease is treated with penicillin except in the very unusual case when penicillin this contraindicated because of some special condition (allergy, for example) peculiar to the particular patient. Truth telling, in the moral sphere, has a somewhat similar standing: Unless overwhelming reasons to the contrary can be given, the truth must be told. In general, it is not if but how the truth should be told that is the issue. Physicians must open "size up their patients" (guided, perhaps, by their family but certainly not dictated to by them) and reach a decision about how much and above all how to share the bad news.

Most of the time, when they are speaking with patients health care professionals do not have to deal with such vexing and emotionally disturbing matters. Is in the daily conversation with patients that patients and professionals caring for them can feel each other out and get to know each other. And it is these daily conversations in this mutual understanding that forms the basis of later, far more difficult conversations. When health care professionals and their patients have come to know each other over time, such difficult conversations become far easier: patients and health-care providers have tacitly or explicitly come to know, understand, and hopefully respect each other's world view. But that is the ideal. Often health care professionals and their patients do not know each other well when illness strikes. Even here, however, the less emotionally wrenching parts of the conversation proceed and it is here, even if the time is brief, the mutual understanding and trust can be achieved.

Critical to all of this is not so much open " talking to the patients" as listening to them and to them as they interact with their families and other health-care professionals. The good listener not only must listen but also as gently try to steer the conversation so that their real conversation rather than (as my father used to put it) "A mere exchange of meterologic data " results: They must learn what the patient and their loved ones know, fear, or hope about their illness and about its course and consequences. In other words, they must try to understand what the disease or illness means in the context in totality of the patient's life. The good listener (not the bored or the uninvolved listener who open "simply listens" and fails to engage himself or herself) is the one who will be able to accomplish the most for their patient when it comes to dealing with ethical issues or confronting emotionally trying problems.




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