Thursday, March 29, 2012

Should Physicians Always Tell the Truth?

Everyone is in favor of telling the truth. No one is going to suggest that physicians should lie to their patients.

In a recent column Dr. Danielle Ofri recalls her agony about whether or not she should tell a woman that she, the patient, was going to die.

She adds some reflections about her agony about having made a treatment error that might have been fatal. Should she have told the truth about her mistake and apologized?

It may have seemed convenient to lump these two forms of truth-telling together, but they do not really have very much in common.

Predicting a future outcome is not the same as acknowledging a past error.

Offering a scientific opinion about a prognosis is not the same as taking personal responsibility for a mistake.

Throwing them all in the basket of truth-telling is misleading and potentially confusing.

Of course, Ofri’s larger and more important question concerns doctor/patient communication.

Considering how badly many physicians communicate with their patients, it would be a good topic indeed.

Unfortunately, her article asserts, trivially and narcissistically, that doctors have feelings.

Most cases of bad doctor/patient communication have nothing to do with the physician’s feelings. They have to do with the physician's communication skills and his respect for his patient's feelings.

How often have we heard of physicians casually dropping worst-case diagnoses, with no regard for the fact that words like leukemia and lymphoma are likely to panic the patient and injure his health?

It might be true they are among the possibilities, but no physician should feel compelled to list options that might cause unnecessary psychological harm.

Such is not Ofri’s topic. It might have been, but it isn’t.

She is more concerned with the moment when a physician is obliged to communicate a very negative prognosis. That is, when she feels compelled to announce that her patient is going to die.

At such moments, the doctor’s feelings are not the problem. A physician whose primary concern is with his own emotional state is missing the point, rather seriously.

What about my feelings?... is not the question that she should be asking.

What matters are the patient’s feelings. The physician should try to appraise how the patient will receive the bad news. And she should also be trying to measure the best, most tactful and compassionate way to communicate a poor prognosis.

If the physician states it coldly and heartlessly, or is pessimistic and dismissive, the patient will feel demoralized.

Regardless of how much state of mind contributes to treatment outcomes, no physician should counsel despair. At the least, he should be concerned with the patient’s quality of life during his last days.

If a physician implies that there is some hope, even if he thinks that there is none, is he being untruthful. If he wishes to help the patient to feel slightly better and to have a better quality of life in his remaining days, is he being dishonest or untruthful?

When it comes to bad news, most physicians, I would venture, tend to hedge their bets. They offer probabilities and percentages. They are not in the business of pronouncing death sentences, and often prefer to leave open the possibility for a miraculous recovery.

No physician wants to deprive his patient of the slimmest chance by blurting out, in the most tactless and insensitive way: You are going to die.

There are many ways to communicate unpleasant truths and every physician should be aware that he or she has many more options beyond: You are going to die.

Would you not assume that a patient can understand what it means when his physician says that the prognosis is not good? Does the patient need to hear words that amount to a death sentence?

You will say that it’s all a traffic in euphemism, but euphemism has a purpose. It soothes emotion, harmonizes relationships, and helps people maintain hope and optimism.

If a physician’s words sound like a death sentence, he is not really functioning as a physician. He is acting like a trial judge or an executioner.

Most physicians do not want to take on a role that contradicts their own moral responsibility. They are right not to do so.

For reasons that escape me Ofri’s article collapses the question of communicating a bad diagnosis with the question of whether or not a physician should admit to having made a mistake.

Telling someone that he will never recover is not the same thing as telling him that your error made him sicker than need be.

Ofri admits that the risk of malpractice litigation has a decisive and negative effect on what physicians communicate to their patients, and perhaps even on how they communicate.

For some physicians, fear of lawsuits inhibits open and honest communication, especially when the physician has made a mistake.

And yet, when it comes to physicians admitting error, the University of Michigan has done a study showing that when physicians apologize for their errors they are, in fact, much less likely to be sued for malpractice.

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