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ss nucleus - autumn 1993,  Telling the Truth to Patients

Telling the Truth to Patients

The scientific basis of Western medicine demands strict adherence to truth, in learning, research, history taking, diagnosis, assessment of results of treatment and performance audit, but in conveying unpalatable truth to patients about their condition opinions differ and practice varies. Problems most readily arise in relation to inoperable malignant disease. In heart disease, smoking-related chest conditions or obesity, where a radical change in life-style promises improvement, the doctor's advice is usually frank and constructive; but where the limit of curative or palliative intervention has been reached and there seems nothing hopeful to say, the temptation to lie is the strongest. Tragically this is also the point of the patient's greatest need, when he most readily turns to the unqualified practitioner of alternative medicine with his whole-person approach, and often implicit if not explicit promise of improvement, without thought about the underlying philosophy, or indeed, the proven or unproven efficacy of his proffered treatment.

Do doctors want to tell?

We belong to a profession tending to secrecy though the patient's increasing desire for information and his demand, engendered by the media, for medical accountability are turning the pressure on. Statistically the majority of doctors do not favour divulging the facts to terminal patients, on compassionate grounds, being unwilling to deprive them of all hope - 'If this is all there is let it be good'.

The doctor may be urged to join a conspiracy of silence by relatives who do not understand that his first duty is to his patient. He may comply knowing that the concern they express will be about their own future ('what shall we do without you?') rather than about the patient and his needs.

Moreover the patient's stay in hospital gets shorter, with less opportunity to talk. Perhaps he will soon be sent home, or transferred elsewhere. With diminishing resources of personnel the clinician's time is at a premium. This type of conversation cannot be hurried and presupposes availability. Perhaps it is best avoided, maybe by exit from the ward another way leaving the situation to be coped with by others.

But perhaps more often the problem lies within the doctor, who fears the embarrassment that the interview may cause, not only to the patient, but to him. He may be loath to admit his failure to cure, or, not having faced the fact of death himself, realises that he has nothing to offer. The author well remembers the chiefs ward round when a patient drew the registrar to one side and said, 'That man hasn't got the guts to tell me I've got cancer!'

Do patients what to know?

They vary. Some don't, and ask not to be told, adopting an 'ostrich' position. Their basis of hope is wishful thinking. Those who hope for the best often live in fear of the worst. The Bible speaks of those 'who all their lives were held in slavery by their fear of death'.[1] Is ignorance really bliss? Or is it the folly it is designed to avoid? But have we any right to penetrate the self-made protective barrier that some have put around themselves? There is little virtue in forcing unwelcome news on unwilling ears. Some would like to ask but fear the answer. They only want to be told what they want to hear, either disbelieving unpalatable truth or denying that they have ever been told. Some are afraid to ask, suspecting that they will not be told the truth. Some do not ask out of deference to the doctor whom they do not want to embarrass with questions he would clearly prefer not to answer.

Figures from St Christopher's Hospice suggest that 75% of patients want to know.[2] The director of another hospice found that resistance to the truth was in herself rather than her patients. When she stopped praying that they would not question her and asked instead that they would, they did.

Is lying a valid option?  

Lying is unwise for the doctor and unkind to the patient; unwise because lie breeds lie and eventually the truth 'wins out'. The doctor loses everyone's respect and he is unable to help the patient further since without trust all he says is suspect. Moreover it is impossible to sympathize with ('suffer with') a patient who is unaware of his condition. If initially deceived the moment of truth causes such bitter disillusionment that to help him is almost impossible.

Lying is unkind

Over 50% of terminal patients know their diagnosis without being told[2], from their own observation of themselves and others; all too often confirmed by unconvincing assurances, evasions and denials by the staff, forcing them 'to live in isolation with the very truth from which others persuade themselves they are being protected'.[2] Lying builds tragic barriers between husband and wife just when they need each other most, each seeking to protect the other from the truth they both know. Facing the future together can be the most enriching and fulfilling time of their partnership. 'All life is lived in relationship to others. How dreadful it is if this be lost before death, for life without relationships has no meaning'.[3]

Perhaps our patients need to know more facts rather than less. By virtue of our training we have knowledge and insight not available to them. To whom does it rightly belong? We may feel responsible to tell a patient the facts affecting his earthly life, but not that he is soon to meet his Creator. We hold the truth in trust. Who are we to deny it to another with the right and desire to have it?

Uncertainty is hard to live with, and some patients are relieved to hear a definite diagnosis, though unfavourable. The news may be shattering at first, but once actively accepted patients are able to orientate to the crisis position and build their remaining life at a new level. Fear is often fuelled by ignorance. False assumptions must be dispelled. Patients need to know what the term 'Cancer' means, the wide range of conditions it covers, the variations in rate of spread and likely effects. In only about 20% of cases is there appreciable distress and not infrequently the inoperable patient dies of something quite different. Truth too, must be truth as the patient comprehends it. To say that a lipoma is not a growth is technically a lie, yet conveys the truth to the patient; conversely we can use such medical jargon in speaking the truth as to deceive him into believing a lie.

The question may not be whether to tell the truth, but when and how and how much. Straight questions demand straight answers but gratuitous information is not always necessary. Patients usually ask questions to which they are ready for the answer. The dawn of realization may be gradual, therefore it is wise to answer what is asked, when it is asked. Sometimes the query 'Am I getting better?' can be countered by another 'How do you feel yourself?' and a useful conversation ensues. Always a word of hope can soften unwelcome information; for truth is more than the absence of lying. It has positive value. It liberates.[4]

Does truth matter?

The answer is of vital consequence to doctor and patient alike. The problem of terminal illness is universal. Ours is a shared humanity. We all suffer from a fatal disease - mortality. The one certainty of life is death. Science can never answer the question, 'Is death the end?' Many may wish it, but the doubt remains. Suppose it is not?

'To die: to sleep;
No more; and, by a sleep to say we end
The heart-ache, and the thousand natural shocks
That flesh is heir to, 'tis a consummation
Devoutly to be wish'd. To die, to sleep;
To sleep perchance to dream: ay, there's the rub;
For in that sleep of death what dreams may come
When we have shuffled off this mortal coil
Must give us pause.'[5]

'Man's primary relationship is not with the material world around him or with his fellow human beings but with God himself.'[3] There is a disability from which we all suffer, our alienation from God through sin. What if that separation becomes eternal? And scientific medicine at best can only postpone death, sometimes succeeding only to prolong the process of dying.

If this is all that can be said the outlook for those nearing the end of their earthly life is indeed gloomy and a word of hope hard to find. But the Christian knows more: the book that tells the truth about death and God's judgment on sin also tells us of his love for us, his intervention on our behalf and his glorious offer of forgiveness and the free gift of eternal life through the atoning death of our cmcified and risen Lord Jesus Christ.[6] Contact with the dying can become not so much a situation to be feared as an opportunity to be grasped.[7] To the Christian, truth is not a cold sterile belief but a relationship with a living person who is himself 'the Truth', someone who has become real to him, whom he knows and trusts and to whom he has committed his life and loyalty.[8]

The Christian doctor does not stand on the touch-line telling his patients how to live and die. He is involved in the game himself. The Christian Gospel is not a department of medicine to which to refer patients saying, 'Believe in God if it helps you'. If it is indeed the truth the doctor must be wholly committed to it himself. He cannot give what he has not got, nor lead where he is not going, nor introduce others to someone he does not know. Cicely Saunders maintains that communicating truth to others is also a matter of relationship not expressed only in words, but a trust and confidence which is transmitted from one to another, an assurance that 'rubs off' and helps our patients to find the same faith for themselves.

The student situation

The student must address these issues during his student days. These are the formative years when the ground plan for decision making and clinical practice is laid down. But he is also in the hot seat now, and needs to know what to do now. He is in close contact with his patients who may well regard him as friend and confidant and will almost certainly ask him the direct and sometimes awkward questions they would prefer not to voice to those of whom they stand in awe.

As an onlooker he may feel that he can see most of the game. Aware of the damaging effects of lying he may be convinced that the truth should be told, and feel frustrated that he cannot share his own assurance in Christ. Convinced in his own mind what is right he not obey God rather than man? He must remember however that he is in a learning and observing situation. He is not in clinical charge but under authority, and in a real sense must represent to the patient the consultant under whom he is training. There is no necessity for him to lie, however. It is always wise to decline to make statements on any diagnosis or prognosis whether malignant or not, saying that as a student he is not in a position to give an authoritative answer and advising the questioner to ask someone who is. It may, however, be helpful to tell the medical staff or ward sister that the patient is seeking information.

It is sad that we tend to limit any mention of our faith to patients facing death. Jesus is a Saviour for living as well as for dying, for time as for eternity. The student must never impose his beliefs on others, but if the quality of his life is such that his patients ask questions about its source, there is no reason why he should not give an honest answer.[9] Often too there is the opportunity to encourage a frightened or anxious patient by pointing him to the one who is able to give strength, comfort and hope.

Student days are not only for gaining medical knowledge and expertise, but for learning the art of helping people, the art of patient listening, of wise and tactful counselling and expressing the love of Jesus in action as well as word.

References
  1. Hb 2:15
  2. The Management of Terminal Illness by Cicely Saunders (Hospital Medical Publications Ltd)
  3. Life at its Close by C G Scorer (CMF Publications)
  4. Jn 8:32
  5. Hamlet by Shakespeare Act 3 Scene I
  6. Rm 6:23; 1 Pet 2:24
  7. The Dying Patient by Robert Twycross (CMF Publication) a Jn 14:6
  8. 9 Co 14:5-6; 1 Pet 3:15
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