ethical question: revealing a terminal diagnosis

[DatInterviewDood]

As long as Mr. O is competent, would he deserve to be informed of the diagnosis? If he is not fully competent, would respecting his wife's wishes be appropriate?

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[ifnotnowwren]

View attachment 208848

As long as Mr. O is competent, would he deserve to be informed of the diagnosis? If he is not fully competent, would respecting his wife's wishes be appropriate?

Why don't you start this off with what you think? I have found that ethical reasoning is best cultivated by working through problems as opposed to reading answers.

 

[RogueBanana]

If Mr.O is fully competent, then yes, I would tell him without a doubt. For several reasons:
- You have a duty to provide care to your patient, and to keep them informed as to their condition.
- You have no obligation to his wife, unless he is incompetent and she is his designated caregiver.
- Patients come to us, trusting us to be honest and forthright with them. If we make exceptions, this trust is destroyed.
- While it may be the accepted custom in O's home country, we are not in his country, and he may not agree with the custom even if we were.
- Patient autonomy, Mr.O has the right to make his own informed medical decisions. He does not lose that right as soon as he is diagnosed with a terminal disease.

Assuming the unfortunate Mr.O is not competent, the Wife's wishes will hold more weight. However, depending on his competency level, I may still consider informing him of his diagnosis. (Is he incapable of understanding the diagnoses? Or simply incapable of making rational decisions with regards to said diagnosis?)

In general, I will lean towards informing my patient of his condition barring extreme incompetence or mental defect. My patients trust me to be honest with them, I will not compromise that trust.

*edit*
Also, I would find the MRI tech and give him a stern talking to for going over my head on this one.

 

[DokterMom]

You are being asked for your thoughts on the matter - what are they? There are reasonable arguments to be made for both sides of the issue as well as hospital policies, rules and laws to consider. As a pre-med, you will not be expected to know what all those laws, rules and policies are, but you should be able to see that there are reasons to tell and not tell Mr. O, to identify some of those reasons, and to explain your own personal feelings on the matter.

 

[Goro]

How about you tell us, and why you think that way.

That's what your interviewer will ask of you.

View attachment 208848

As long as Mr. O is competent, would he deserve to be informed of the diagnosis? If he is not fully competent, would respecting his wife's wishes be appropriate?

 

[Ismet]

If Mr.O is fully competent, then yes, I would tell him without a doubt. For several reasons:
- You have a duty to provide care to your patient, and to keep them informed as to their condition.
- You have no obligation to his wife, unless he is incompetent and she is his designated caregiver.
- Patients come to us, trusting us to be honest and forthright with them. If we make exceptions, this trust is destroyed.
- While it may be the accepted custom in O's home country, we are not in his country, and he may not agree with the custom even if we were.
- Patient autonomy, Mr.O has the right to make his own informed medical decisions. He does not lose that right as soon as he is diagnosed with a terminal disease.

Assuming the unfortunate Mr.O is not competent, the Wife's wishes will hold more weight. However, depending on his competency level, I may still consider informing him of his diagnosis. (Is he incapable of understanding the diagnoses? Or simply incapable of making rational decisions with regards to said diagnosis?)

In general, I will lean towards informing my patient of his condition barring extreme incompetence or mental defect. My patients trust me to be honest with them, I will not compromise that trust.

*edit*
Also, I would find the MRI tech and give him a stern talking to for going over my head on this one.

I'm holding off on my response to the scenario until OP shares their thoughts, but I'll say this: don't be so quick to disregard someone's cultural customs and norms just because they're living in America now. More on that later.

 

[JJRousseau]

I'm holding off on my response to the scenario until OP shares their thoughts, but I'll say this: don't be so quick to disregard someone's cultural customs and norms just because they're living in America now. More on that later.

I wholeheartedly agree with the fact that presence in America does not mean the patient's culture should be dismissed. But I'm curious to see your response, because I think the idea that the scenario presents his family's views of the necessary cultural customs and norms makes a steadfast respect of their culture and customs problematic.

I'm also curious if this could lead to litigation by the patient if the truth were to reach him that you failed to inform him of his diagnosis if he did have a strong rejection of his relative's interpretation of the home country's customs...

 

[DatInterviewDood]

Thank you everyone for the responses. I wasn't sure! Mainly just trying to learn and not looking for "free answers".

With that said, I initially thought about attempting to get more information about the patient to determine his level of competency and see if he would be in the mental state to understand the diagnosis. If I thought the patient was fully competent, I would feel obligated to fully disclose the diagnosis to him.

If the patient wasn't fully competent, I would reach out to the designated care provider. If this was his wife, I would help the wife understand the full situation and respect her desire to not disclose the situation to her husband if that is what she wanted. In both cases, my goal would be the maintain trust with the patient / parties involved and partner with the patient / care provider to make any decisions, but ultimately respect autonomy.

 

[RogueBanana]

I'm holding off on my response to the scenario until OP shares their thoughts, but I'll say this: don't be so quick to disregard someone's cultural customs and norms just because they're living in America now. More on that later.

I didn't mean to come off that way, my intentions were to show that just because he is from that area, doesn't mean he subscribes to their ideas on medicine. If he is presenting in an American hospital, he could very well be fully "Americanized" and not want his old customs upheld. I promise I'm not a "YOURE IN AMURICA, SPEAK AMURICAN" type of person.
In this case, there is much more harm (I believe) in not telling him, than if we were to be honest. My point is, Mr.O is my patient. His wife and family are not my patient. I will always try to accomodate local customs and beliefs, but I feel it is necessary to protect his right to autonomy. In addition, the possibility of litigation cannot be ignored. What If we withhold the information and he finds out? What if he wants to know? Yes it may be damaging to his affect to tell him he will die, but at least then he can make more informed decisions as far as palliative care / hospice. At the very least, we are giving him a better chance to plan his final days and get his affairs in order. I want to give the man a chance to get ready and die with dignity.

 

[MDProspect]

How about before telling him or withholding the cancer diagnosis, you first ask the patient what he wants? He could say that he does not want to know and that's fine. Maybe he suspects that the results are not good (i.e sudden gathering of family members or the wife's glum expressions could have tipped him off)

 

[PooshBag]

The illness is terminal, and there is not much that can be done to alter that. Telling Mr. O would not influence his health in any way. Not telling Mr. O would also not influence his health in any way. At this point, his terminal illness is also a family issue, and it would probably make him more comfortable if his family handled this the way they want to. I'm sure they could provide the support needed and help him through his remaining time. His family seems to be very supportive, given the "cordon".

On the other hand, there is the side that Mr. O is my patient, and he has a right to know all of the information regarding his own body. He has trusted me with being his doctor and providing him healthcare, so he deserves to know. It would be a betrayal of trust if I withheld this information from him, even if his family does not want me to tell him.

Ultimately, I'd still tell him. Even though he is terminally ill, I still have to act in his interest, not his family's, and I'm sure his best interest is to know what's going on with his body. It would be easier to not have to tell him and to let his family handle it from here on, but in my opinion, that would be the wrong thing to do.

**I'm new to MMI, and these ethical questions. Feel free to criticize or bash my response.

 

[tiedyeddog]

The ethical thing to do would be to ask him if he wants to know the diagnosis. I have had multiple families tell me they don't want a love one to know a terrible diagnosis. If the patient tells you they don't want to know and leave it to the family that is their right.

 

[Ismet]

This is all assuming the patient is competent to make his own medical decisions...

The patient has the right to informed consent and the right to autonomy, however they also have the right to not know their diagnosis if they so choose. I wouldn't go full force in telling the guy his diagnosis. First I'd ask him what he knows about what's going on. Maybe he knows his family is minimizing what's going on and he knows it's serious, but he doesn't want to let them know that he knows. Or maybe he has no idea what's going on with him and just thinks he has seizures. After that, I'd ask him if he wants to know the diagnosis and go from there. If he says no, that's what goes, and he has that right to refuse to know.

If you're lucky, there may be another member of the healthcare team who is of the same cultural background and can help you with the discussion, especially if there's a language/communication barrier, as you would not want a family member providing translation in this situation.

 

[MDProspect]

I can foretell that there would be a follow-up question during the interview, something like, "what if there was a treatment for his disease, but it only increases the person's longevity for a year or two, would you still have the same opinion as before?"

 

[NimbleNavigator]

Totally unethical because if you're a nurse practitioner you shouldn't be calling the shots

 

[Lost in Translation]

Did you really use a Twitch emote on here? Can someone ban this guy already PogChamp

 

[wizzed101]

@Ismet is asking a patient if they want to know a diagnosis-good or bad- every single time a standard practice?

If not, then the fact that you ask already tips them off. But the difference is that we can feel good about ourselves?

@MDProspect that question is super easy, if they ask that I will get the acceptance on the spot for sure coz I've read it on Reader's Digest It was touching. I will actually retell it lol

 

[NimbleNavigator]

Did you really use a Twitch emote on here? Can someone ban this guy already PogChamp

 

[colinolin]

This is all assuming the patient is competent to make his own medical decisions...

The patient has the right to informed consent and the right to autonomy, however they also have the right to not know their diagnosis if they so choose. I wouldn't go full force in telling the guy his diagnosis. First I'd ask him what he knows about what's going on. Maybe he knows his family is minimizing what's going on and he knows it's serious, but he doesn't want to let them know that he knows. Or maybe he has no idea what's going on with him and just thinks he has seizures. After that, I'd ask him if he wants to know the diagnosis and go from there. If he says no, that's what goes, and he has that right to refuse to know.

If you're lucky, there may be another member of the healthcare team who is of the same cultural background and can help you with the discussion, especially if there's a language/communication barrier, as you would not want a family member providing translation in this situation.

I agree!

 

[Matthew9Thirtyfive]

@Ismet is asking a patient if they want to know a diagnosis-good or bad- every single time a standard practice?

If not, then the fact that you ask already tips them off. But the difference is that we can feel good about ourselves?

@MDProspect that question is super easy, if they ask that I will get the acceptance on the spot for sure coz I've read it on Reader's Digest It was touching. I will actually retell it lol

You're asking because the cultural practices of the patient and family appear to be such that they wouldn't reveal a terrible dx in their home country (the wife is a doctor there). We are in America and generally don't do that, but you still want to respect cultural norms, so by asking you are leaving it up to him. If he chooses to follow that, then you don't tell him. He will likely suspect it is really bad, but he probably assumes that already given the sudden appearance of family.

 

[Ismet]

@Ismet is asking a patient if they want to know a diagnosis-good or bad- every single time a standard practice?

If not, then the fact that you ask already tips them off. But the difference is that we can feel good about ourselves?

You're asking because the cultural practices of the patient and family appear to be such that they wouldn't reveal a terrible dx in their home country (the wife is a doctor there). We are in America and generally don't do that, but you still want to respect cultural norms, so by asking you are leaving it up to him. If he chooses to follow that, then you don't tell him. He will likely suspect it is really bad, but he probably assumes that already given the sudden appearance of family.

It's actually pretty standard if you're delivering bad news to get an idea of what the patient knows and what they want to know, if they want family present or not, etc. Not just when there's a cultural difference. Sometimes they just want the next steps, sometimes they prefer you tell their family and not them, once in my experience they just didn't want to know at that moment (they did later). Delivering bad news is a continuous discussion, you don't just drop the info and leave, you give them whatever information they want to handle at that time, and then you revisit once they have time to process and discuss more. You can also give a "test blow," something like "I'm afraid I have some bad news..." to prepare them.

 

[Matthew9Thirtyfive]

It's actually pretty standard if you're delivering bad news to get an idea of what the patient knows and what they want to know, if they want family present or not, etc. Not just when there's a cultural difference. Sometimes they just want the next steps, sometimes they prefer you tell their family and not them, once in my experience they just didn't want to know at that moment (they did later). Delivering bad news is a continuous discussion, you don't just drop the info and leave, you give them whatever information they want to handle at that time, and then you revisit once they have time to process and discuss more. You can also give a "test blow," something like "I'm afraid I have some bad news..." to prepare them.

Great point. I was talking specifically about the case at hand, but yeah. Definitely applies broadly.

 

[LizzyM]

More important than the diagnosis is the prognosis. Research has shown that many times when the family does not believe that a terminally ill patient is aware of the prognosis, the patient does in fact know but plays dumb in front of the family to spare them! Everyone knows but pretends that the other doesn't know to avoid the awkward conversations....

That said, many (most) patients want to be able to get affairs in order, deal with unfinished business, and so forth.

If the patient still has decision making capacity, the provider really needs to have a conversation with the patient about end of life decisions. If the patient doesn't have a durable attorney for health care and would want to have someone other than whomever is the default decision maker in accordance with state law, that needs to be worked out asap.

It is curious that this scenario is written putting the interviewee in the nurse practitioner's role. Why do you think that is?

 

[Promethean]

The patient's life is his own, not his family's. He is the guy who is going to die. Maybe he wouldn't want to know that. But maybe he would. Maybe he has his own idea of what he'd like to do with his last days on Earth. Maybe he doesn't want to go home. Maybe he has always wanted to go on a wild week of debauchery in Vegas with the girl who got away, that he has pined for all these years. Whatevs. His life. He needs to at least have the opportunity to make some decisions based on good information.

Now, his wife maybe does know his mind on the matter as well as he does, and it really would be his will to avoid receiving a terminal diagnosis if there is nothing to be done. If you just blurt it out to him, you've done him as great a disservice as if you went along with the suggestion not to tell him.

You need to have a private conversation with your patient, without the confounding factor of a large family all with their own interests in the situation. There isn't an easy algorithm for this. You have to be a person and be able to gauge what kind of person your patient is, and what he seems to want. You can ask how much he'd want to know without telling him his current situation. You can talk about it in terms of an advanced directive... "What would you want to have done if such and such ever happened?" You have to gather data before you can make a plan. How you proceed depends on what the patient himself tells you that he wants.

And find out who exactly violated their duty to the patient and to you by telling the family. You should almost certainly fire them.

 

[Promethean]

It is curious that this scenario is written putting the interviewee in the nurse practitioner's role. Why do you think that is?

I imagine that it is a scenario being pitched to a nurse or nurse practitioner student. Or that it is drawn from a text being aimed at an interdisciplinary audience of students.

My answer assumes that I'm in the role that I'm training for, not the one posited by the scenario.

 

[Ehwic]

This might be a silly question, but as a nurse practitioner, are you allowed to disclose the diagnosis or is the consultation part done by the physician?

 

[LizzyM]

This might be a silly question, but as a nurse practitioner, are you allowed to disclose the diagnosis or is the consultation part done by the physician?

I personally know a nurse practitioner in an outpatient clinic for low-income patients who says that most of her job is delivering bad news.

 

[Moko]

I would ask the patient about their understanding of their illness, and how much information he would like to know. My duty is to both the patient and their family, but when these are at odds, the former takes precedence.

Alternatively, a stat ethics consult could always be ordered

 

[Ismet]

Alternatively, a stat ethics consult could always be ordered

You know if this was USMLE that would not be the answer!

 

[NimbleNavigator]

I personally know a nurse practitioner in an outpatient clinic for low-income patients who says that most of her job is delivering bad news.

Pretty sad that poor people in our country get substandard care

 

[tiedyeddog]

I personally know a nurse practitioner in an outpatient clinic for low-income patients who says that most of her job is delivering bad news.

Eh there is bad news as in " your hypertension is still out of control" and then there is bad news in "your previously healthy three year old is now clinically brain dead after suffering a previously undiagnosed arteriovenous malformation". The latter takes a bit more tact than the former and what constitutes bad news is a perspective thing.


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[LizzyM]

Eh there is bad news as in " your hypertension is still out of control" and then there is bad news in "your previously healthy three year old is now clinically brain dead after suffering a previously undiagnosed arteriovenous malformation". The latter takes a bit more tact than the former and what constitutes bad news is a perspective thing.


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Bad news of the kinds that are delivered in a primary care clinic such as pregnancy, pregnancy complications, newly diagnosed diabetes, need for referral for work-up of an abnormal mammogram or screening colonoscopy.

Bad news is relative but it is a daily event in clinical care.

 

[Promethean]

This might be a silly question, but as a nurse practitioner, are you allowed to disclose the diagnosis or is the consultation part done by the physician?

In some states, NPs can practice independently of physician oversight. Let's not turn this into a discussion regarding whether that should or shouldn't be the case. It is a thing, in some jurisdictions. In those places, NPs could well be the provider with the responsibility of delivering grim diagnoses/prognoses in a sole provider clinical setting.

This seems to be describing a situation in a facility where there is a team of healthcare providers. Presumably, that would be headed up by a physician, an attending oncologist, who I would expect would be the person who gave the news. It should be the person with the most authority and responsibility who carries news like this to the patient. It should not be done by someone down the chain of command unless there is some compelling reason. Like I said, I answered for the role that I am training for, that of attending physician. I didn't bother to consider how I would handle it as the NP, since I decided when I enrolled in medical school that I would not be satisfied with the NP role and so I don't spend a lot of time trying to think like one.

 

[RogueBanana]

Did you really use a Twitch emote on here? Can someone ban this guy already PogChamp

That moment when I return to this thread to find nimblenavigator has been banned moments after Lost in Translation requested it. How did you get these powers?
Teach me your ways, and we will rule SDN with my > 9000 potassium levels

 

[ATPsynthase123]

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As long as Mr. O is competent, would he deserve to be informed of the diagnosis? If he is not fully competent, would respecting his wife's wishes be appropriate?

With all due respect they have no right to know the diagnosis before the patient himself. Regardless of how medicine is practiced in the wife's country, in America we respect the patient's autonomy above all else, and to withhold the information would be a severe breach of that autonomy.

So that being said I would inform Mr. O as truthfully and gently as I could and offer advice/sympathy to the best of my ability. Also, I would probably report the radiology suite to HR for a HIPPA violation. Anyone who thinks they are able to do this or feel that they are above HIPPA laws does not belong in the medical field.


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[ATPsynthase123]

I'm holding off on my response to the scenario until OP shares their thoughts, but I'll say this: don't be so quick to disregard someone's cultural customs and norms just because they're living in America now. More on that later.

If the family is requesting you to disregard the patients autonomy and rights to know about their own body, and you agree to it, then that is a huge ethical breach. No one makes decisions about the patient except for the patient himself unless he is incapacitated or mentally unable to do so.

I would also be very concerned about the HIPAA violation that happened in the radiology suite. That should be reported to HR or whoever handles that asap.


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[Ismet]

If the family is requesting you to disregard the patients autonomy and rights to know about their own body, and you agree to it, then that is a huge ethical breach. No one makes decisions about the patient except for the patient himself unless he is incapacitated or mentally unable to do so.

I would also be very concerned about the HIPPA violation that happened in the radiology suite. That should be reported to HR or whoever handles that asap.


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Perhaps you should read what I posted after the OP shared their thoughts. I'm very well aware of medical ethics and patient rights, thanks.

And it's HIPAA, not HIPPA.

 

[Lucca]

The ethical thing to do would be to ask him if he wants to know the diagnosis. I have had multiple families tell me they don't want a love one to know a terrible diagnosis. If the patient tells you they don't want to know and leave it to the family that is their right.

Precisely this scenario came up multiple times while at a major cancer center. Typically, the physician respected the family and patient's wishes in this regard and I agree with their decision to do so.

 

[Mad Jack]

The appropriate response would be to ask the family why they feel that way, and then ask the patient if he would like to defer knowledge of his condition per his family's wishes. Or at least that's what my Step 1 memories are telling me.

 

[DingoPingo]

Recently had this question in an interview. I stalled for the entire duration of the session by asking the person why they do not want to reveal the diagnosis (balancing pros/cons) and at the end said I would have to consult with another family member to make a final decision.

 

[MSTPlease]

Also, I would find the MRI tech and give him a stern talking to for going over my head on this one.

That's not just "going over my head" that's a HIPAA violation aka breaking the law.