COMMENTARY

Did This Doctor Do Wrong by Delaying Bad News to a Patient?

Arthur L. Caplan, PhD

Disclosures

July 18, 2017

Hi. I'm Art Caplan at the Division of Medical Ethics at the NYU School of Medicine.

One of the toughest things doctors face is giving bad news. The medical profession is notorious for holding off [on telling a patient about] a diagnosis that's grim, particularly when there may not be a treatment available. Many patients complain that they don't get the prognosis that, let's say, their child is dying of an incurable brain tumor until well into the care of their child, and they didn't realize that they were going to fail in getting a cure.

A story that brings this home in a very direct way is that of an Australian woman who went to the doctor with a very persistent cough. The doctor was very competent, understood what this cough might mean, tested her, and determined that she had very advanced lung cancer and, in his opinion, it was something that couldn't be treated. He also knew from talking with her that she was about to go on a cruise for a week to have a good time.

The question that [the doctor] faced was, should he tell her that she had incurable lung cancer? He thought about it and tried to do the right thing, the compassionate thing, and decided this can wait—let her go on the cruise without this bad news, without worrying about this at all, and he would tell her the following week or within 2 weeks of her return.

Remember, there was nothing that could be done for her. In his view, the cancer was too far advanced, so there was no reason to leave her very worried rather than to let her enjoy the cruise.

She goes away on the cruise, and after a few days, she comes down with pneumonia. They have to take her from the cruise ship to an emergency department. She wants to go back to Australia, where she's from. There are no beds in the hospital in Sydney. The intensive care unit (ICU) is full, and she winds up getting care for quite awhile outside of Australia before she can finally get back in.

Then [the patient] dies. The events leading to her death leave her family very upset. They're angry and feel that the doctor wasn't compassionate, but rather paternalistic.

What do we say ethically? The desire to sometimes spare patients bad news is commendable. There are times when a patient may not be ready to hear it. There are times when the context is very poor. There are even times when you don't have enough time to fully go into the details of why the news is bad and what's going to happen, and you may decide, I'm going to put that off a little bit.

At the same time, I don't think the doctor made the right choice. I understand what he was thinking, but I don't think it was the correct choice, because when you're facing an incurable fatal disease—something that could actually strike you down within a very short period of time—the patient may decide, I don't want to go on that cruise. I'm going to spend my final days with my grandchildren, or I'm going to spend my final days making arrangements, getting my affairs in order. I'm going to ask my family to come in from far away so they can be with me. Or they may still say, I'm taking that cruise and I'll deal with this when I get back, not realizing that they might even die during the cruise.

It's the patient's choice, how to manage extremely bad news and a situation where there's nothing much medicine has to offer. It's pretty clear that if something is life-threatening, different people are going to react in different ways.

The diagnosis should have been given. It could've been given compassionately, in the sense in which the doctor could say, "I don't see any reason why you can't go on your cruise. I think you can enjoy your time there, and then we can wrestle with this when you get back, although there may be a danger that you could become ill while on your cruise, and here's what you need to know if that happens." By withholding the information, at the end of the day, the patient and the patient's family didn't get a chance to plan or make the choices that they felt would be best.

While the desire to be compassionate was good and I would admit that it isn't always correct to immediately tell a patient bad news in every situation, in this case probably withholding it when the patient was going away was not a good choice.

I'm Art Caplan, from the Division of Medical Ethics at the NYU School of Medicine. Thanks for watching.

Talking Points: Did This Doctor Do Wrong by Delaying Bad News to a Patient?

Issues to consider:

  • A Baylor University Medical Center survey conducted among 54 participants in the Department of Surgery (17 women and 37 men) found that 93% of respondents felt that delivering bad news is a very important skill, but only 43% felt that they had the training to effectively give bad news.[1]

  • In the survey cited above, 85% of participants felt they needed additional training to be effective when telling patients bad news. Of these respondents, 59% were residents and 26% were attendings.[1]

  • Participants with more experience in the profession believe that they are better prepared to deliver bad news than participants who have less work experience.[1]

  • Many healthcare professionals worry that patients have to cope with a range of emotions when they receive bad news.

  • Years ago, it was expected that physicians could be "paternalistic" toward patients and make decisions that they thought would be best for patients. Today's focus on collaborative patient relations no longer supports that attitude. Some physicians feel the paternalistic attitude is still acceptable and helpful to the patient.

  • Some physicians feel that hiding information from patients prevents them from choosing the most effective course of therapy, which could endanger the patient's health, increase costs, and lead to a patient's increased hopelessness and anxiety.

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