Ethics Question

[bigloley]

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I had an ethics question posed to me and I wanted to know what other people think about it:

An elderly patient comes in and you diagnose her with an incurable terminal illness leaving her about 6 months to live. Her son is present and before you break the news to the elderly patient he asks you not to tell her the full extent of her condition.

What do you do? Does it change if the son is her proxy/guardian?

 

[LizzyM]

I had an ethics question posed to me and I wanted to know what other people think about it:

An elderly patient comes in and you diagnose her with an incurable terminal illness leaving her about 6 months to live. Her son is present and before you break the news to the elderly patient he asks you not to tell her the full extent of her condition.

What do you do? Does it change if the son is her proxy/guardian?

Who is your patient? To whom do you have an obligation? What are your obligations as a physician? (Why do people come to you?) Is there information that is so devastating that it should be withheld from a patient? Is telling an elderly person that they have an incurrable and terminal illness such a situation? What is the role of a guardian or health care proxy if the patient is capable of understanding a situation and making her own a health care decisions?

What would you say to the woman's son? What would you say to the patient?

 

[music2doc]

I had an ethics question posed to me and I wanted to know what other people think about it:

An elderly patient comes in and you diagnose her with an incurable terminal illness leaving her about 6 months to live. Her son is present and before you break the news to the elderly patient he asks you not to tell her the full extent of her condition.

What do you do? Does it change if the son is her proxy/guardian?

This sounds an awful lot like an MMI question.... You sure you're allowed to be posting this online?!

Regardless, LizzyM had some good questions to consider.

 

[mmmcdowe]

I had an ethics question posed to me and I wanted to know what other people think about it:

An elderly patient comes in and you diagnose her with an incurable terminal illness leaving her about 6 months to live. Her son is present and before you break the news to the elderly patient he asks you not to tell her the full extent of her condition.

What do you do? Does it change if the son is her proxy/guardian?

Well if the son isn't the proxy he has no business knwoing the diagnosis before telling the patient and has no right to request that you deny information to the patient. However, as a physician you do have what is known as therapuetic privilege, where under certain circumstances a physician withholds information. This, however, is not one of those cases as it is currently written. A patient can request that you not tell them things. The patient can also transfer all authority to the son, including access to information. In this case you wouldn't have to tell the patient unless the patient directly asks or revokes the tranfer of authority.

 

[phltz]

I had an ethics question posed to me and I wanted to know what other people think about it:

An elderly patient comes in and you diagnose her with an incurable terminal illness leaving her about 6 months to live. Her son is present and before you break the news to the elderly patient he asks you not to tell her the full extent of her condition.

What do you do? Does it change if the son is her proxy/guardian?

Personally, I think that if the patient is of sound mind, unless this patient has previously told you that she wouldn't want to hear this sort of news, you have to tell her. If she's mentally unstable, has dementia, or is otherwise incapacitated, and the son is making decisions for her, you'd tell him first, and he might choose not to let her know. The woman is your patient. To withhold important medical information from her is a big no no. Other people don't get to make decisions for an adult patient of sound mind without previously establishing power of attorney or the like.

 

[bigloley]

This was just a question from my ethics class last week.

My answer was that unless the elderly woman explicitly stated she did not want to hear the diagnoses then it was my responsibility to inform her of the complete diagnosis.

A lot of people argued the other way that in order to limit her suffering they would with withhold information. I thought that corresponded too much with the paternalistic view of medicine and argued against that.

Thanks for the replies!!

 

[thlaxer]

What if the patient's son asked you to delay giving the news for a day so they can emotionally prepare her for the bad news? He says that his mom will most likely over-react and be more stressed out if the news was given to her right away. What will/should you do in this situation? Ignore the son's request and drop the bombshell anyways? Just curious.

 

[WildEMDoc]

What if the patient's son asked you to delay giving the news for a day so they can emotionally prepare her for the bad news? He says that his mom will most likely over-react and be more stressed out if the news was given to her right away. What will/should you do in this situation? Ignore the son's request and drop the bombshell anyways? Just curious.

If the son did indeed tell me that, I would defer to him. He knows his mother best, if he is really sure she would over-react then I would rather let him break the news to her in a situation where she is most comfortable.

Now if the original situation, where he just didn't want me to tell her the full extent of her condition, was the case then I would be a bit more wary. Unless the son does plan on telling the mother I think it should be my job to break the news. The original scenario sounds more like he just wants her to be ignorant and continue leading her life as if nothing is wrong.

TL;DR: If the son plans on telling her and thinks she will overreact I might not tell her the full extent of the condition. If the son plans to keep her ignorant, then I have an obligation to tell her.

Man I hate that ethics questions never seem to have a right answer. 😕

 

[LizzyM]

I am not a physician but, to me, it seems irresponsible to leave a discussion of prognosis to the patient's son. Furthermore, a discussion of prognosis is not of much value without a discussion of care plans as well. What are the options for palliative care? This may include hospice care but might also include, for example, radiation or surgery that is not curative in nature but which may make the patient more comfortable by shrinking a tumor that is causing symptoms. Likewise, supplemental oxygen and medications may reduce other symptoms that cause discomfort in the face of other incurable illnesses.

Incurable doesn't mean "there is nothing we can do" or "you're on your own now".

Funny thing.... families don't want the patient to know but, in fact, the patient often does know and the real pain is the mutual knowing... how does a son relate to his mother when both know she is dying versus how can the son relate to his mother if he keeps secret the knowledge that she is dying?

In some cultures, the physician does not tell the patient but patients often say that they knew and maintained the charade for the comfort of everyone else.

 

[WildEMDoc]

I am not a physician but, to me, it seems irresponsible to leave a discussion of prognosis to the patient's son.

That was kind of what I was thinking as well in hindsight of my initial post, I don't really want to leave it up to the son to do something a doctor can much better explain. In hindsight the answer seems to be pretty clear, you need to tell the mother regardless of how the son feels.

 

[generator]

My gut instinct is that I wouldn't trust the son with that kind of power. As a physician, your obligation is toward to patient first - unless of course the patient wanted the son to make decisions or didn't want to know.

 

[thlaxer]

Sorry for the ambiguity. By 'emotionally prepare' I wasn't suggesting that the son should break the bad news instead of the physician. But if he wanted you to delay giving the bad news by a day so he can lift her spirit up first, would/should you honor this request?

On the one hand, I feel that the patient has the right to know the results as soon as possible. But on the other hand, as rcheech7 mentioned, the son does know the patient a lot better than you do. If he says that his mom is very stressed out and wouldn't be able to handle the stress of the bad news today, wouldn't it be arrogant for you to power ahead? Interesting thought about the patient already knowing the diagnosis though. That seems to be true for the people I know who've received bad news. Out of curiosity, in which cultures do the physicians not break the news to their patients?

Thanks for the thoughts everyone!

 

[generator]

Sorry for the ambiguity. By 'emotionally prepare' I wasn't suggesting that the son should break the bad news instead of the physician. But if he wanted you to delay giving the bad news by a day so he can lift her spirit up first, would/should you honor this request?

Thanks for the thoughts everyone!

Maybe I'm pessimistic, but I would suspect the son has some kind of ulterior motive. I'd definitely say no to him on this request.

Also, she's an elderly patient, so she couldn't possibly be all that surprised by this kind of news. Anyway, how much does someone have to "lift your spirits up" to prepare you? Its unnecessary and therefore, in my mind, suspicious.

 

[candav]

What if the patient's son asked you to delay giving the news for a day so they can emotionally prepare her for the bad news? He says that his mom will most likely over-react and be more stressed out if the news was given to her right away. What will/should you do in this situation? Ignore the son's request and drop the bombshell anyways? Just curious.

I don't really see a problem with this. Perhaps this is incorrect (I've never taken an ethics course in my life), but my gut tells me that the ethics of end-of-life care may be uniquely different in certain respects. I can only imagine that the experience of watching a loved one slowly dying is particularly harrowing on the family. In this situation, I don't see a need to cause the family undue distress, particularly when the son's request does not appear to harm or disempower the patient in the grand scheme of things.

I am interested, however, to know the legal consequences of informing the patient against the family's wishes, when the family holds legal conservatorship, yet the patient appears competent. Would this be illegal, or is it protected through the physician-patient relationship?

 

[music2doc]

I don't really see a problem with this. Perhaps this is incorrect (I've never taken an ethics course in my life), but my gut tells me that the ethics of end-of-life care may be uniquely different in certain respects. I can only imagine that the experience of watching a loved one slowly dying is particularly harrowing on the family. In this situation, I don't see a need to cause the family undue distress, particularly when the son's request does not appear to harm or disempower the patient in the grand scheme of things.

I am interested, however, to know the legal consequences of informing the patient against the family's wishes, when the family holds legal conservatorship, yet the patient appears competent. Would this be illegal, or is it protected through the physician-patient relationship?

My understanding would be that your responsibility is to the patient. Yes, keep their concerns in mind. Invite them to be a part of the conversation, but ultimately you need to ask the patient what s/he wants to know. After some greetings and small talk, you might say something like, "Sir, let's sit down. Do you feel ready to talk about your care?" "Yes, do we have the results back?" "Yes, we received them back this morning. The news may be difficult to hear. How much do you want to know?"

And then go from there. I suspect how you approach it would depend upon your relationship with the patient and how you "feel" the patient out. Some patients may not want to hear all of it (or any of it) but you need to at least offer them full disclosure.