Sonntag, 2. Oktober 2011

Truth telling in clinical practice

The English novelist George Eliot wrote “falsehood is so easy, truth so difficult”. Truth-telling can be very challenging in clinical practice, especially when it relates to adverse outcomes. In The Lancet today, Ranjana Srivastava gives a moving account of her professional relationship with a young mother with terminal cancer. Srivastava laments the brave young woman's endurance of multiple rounds of chemotherapy that, clinically, were doomed to failure, yet that she and her family believed would eventually lead to a cure. When the end finally comes, “after 5 years of preparation…nobody had a chance to say goodbye”. According to Srivastava, patients who have a chance to discuss their wishes for the end of life often undergo fewer futile interventions and spend more quality time with their relatives than do patients who are denied this option.
In the past, when paternalism characterised the doctor—patient relationship, some doctors withheld the truth when they perceived that discretion might benefit a patient. With increased patient autonomy and empowerment, as well as developments in treatment, there have been substantial changes in truth-telling attitudes, practices, and policies worldwide. Legal and professional codes have evolved to include requirements for disclosure and informed consent in many countries. For example, New York's Palliative Care Information Act, which took effect on Feb 9, 2011, clearly says that “If a patient is diagnosed with a terminal illness or condition, the patient's attending health care practitioner shall offer to provide the patient with information and counselling regarding palliative care and end-of-life options appropriate to the patient, including but not limited to: the range of options appropriate to the patient; the prognosis, risks and benefits of the various options; and the patient's legal rights to comprehensive pain and symptom management.” Furthermore, patients are increasingly involved in the decision-making processes of diagnosis and treatment. In the Breast Cancer Prevention Trial Participant Advisory Board model, women participate in the design of the trial, outreach efforts to recruit individuals from under-represented populations, and identification of research priorities. While advances in palliative care have allowed clinicians to shift their goals from cure, when no longer possible, to palliation, and have created a pressing need for clinicians to discuss this transition openly and effectively with patients.

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