Would you lie to a patient interview question?

[apumic]

Well said


... and I'd like to add, justifying lying to patients will likely blow your interview.

Lying? Yes. Showing social sensitivity and ability to neatly package the truth and/or decide upon the best time to announce unpleasant news? I highly doubt it. Truthfully, though, you should have stories not "I would...s" to answer these kinds of questions. You want to show what you have done not tell "what you would do." Showing how your approach to unpleasant conversations has (NOT "will") benefitted pts in the past is what you want (or, if not pts, other people).

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[WholeLottaGame7]

I see what you mean now. I took this "optimistic phrasing" to be a form of lying but if done properly it isn't. I've seen many people in a non-medical setting to "optimistically phrase" something and having it turn out to be a complete lie. Obviously good doctors wouldn't make that kind of mistake though...

I gotcha now

Fo' sho'. Of course, some of it is semantics. Just because this is a good movie scenario, pretend you are a medical student in the trauma bay and someone comes in who's been shot eleventy billion times and is bleeding out before your very eyes. The team is trying their best to resuscitate them but you're pretty sure it's a lost cause. The family is nearby and you feel the awkward silence filling the room and you blurt out "everything will be OK."

Not the smoothest move and probably not the most appropriate/accurate thing to say, but you meant well and were trying to be encouraging. Did you lie? They're probably going to die, which is usually associated with "not OK," whereas alive = OK. Now this starts to venture into personal opinion, but once you've been in an ICU, you quickly realize that there are worse things than death, and there are plenty of times where "everything will be OK" would actually end with a peaceful death.

So, personally, "everything will be OK" is more of a philosophy and not a lie (and not the worst thing to say in that scenario), but you have to be cognizant and respectful of the fact that other people may not feel that way.

 

[getdown]

But I'll use a real-world example that is as close as I can think of. Say you have a patient in the ICU who has been intubated for a month. Say you also have a paper stating that patients >age X who have been intubated for >2 weeks have a 100% mortality at 1 year (there is a paper similar to this that I'm not going to bother looking up right now). The conversation with the patient and/or family would probably go something like this, "unfortunately, studies have shown that patients in situations similar to Y's are all deceased within a year. Now, studies don't tell what WILL happen in the future, only what will LIKELY happen based on what has happened in the past. It is always best to hope for the best and expect the worst, and it is important that you understand what the worst is in this situation."

Since we're going with ethics. A similar scenario actually came up during our ethics class. Elderly man with end stage multisystem organ failure and docs have decided to take him off life support but the wife is hysterical and refuses to hear reason and only wants the doctors to save his life because "she can't live without him". Many of my classmates felt that we should try to save him at all costs and apparently DC futility laws agrees with them. However, I've always taken a utilitarianist view on these things. Sure we can keep him "alive" on machines for several weeks to months and even years but he's never going to get better and we're only delaying the inevitable. On the flip side, we're taking a much needed ICU bed from someone who could actually benefit from ICU care and that's wholly irresponsible. I'm curious if any of the residents have input from personal experience on such a case.

 

[CoolWhipp]

Fo' sho'. Of course, some of it is semantics. Just because this is a good movie scenario, pretend you are a medical student in the trauma bay and someone comes in who's been shot eleventy billion times and is bleeding out before your very eyes. The team is trying their best to resuscitate them but you're pretty sure it's a lost cause. The family is nearby and you feel the awkward silence filling the room and you blurt out "everything will be OK."

Not the smoothest move and probably not the most appropriate/accurate thing to say, but you meant well and were trying to be encouraging. Did you lie? They're probably going to die, which is usually associated with "not OK," whereas alive = OK. Now this starts to venture into personal opinion, but once you've been in an ICU, you quickly realize that there are worse things than death, and there are plenty of times where "everything will be OK" would actually end with a peaceful death.

So, personally, "everything will be OK" is more of a philosophy and not a lie (and not the worst thing to say in that scenario), but you have to be cognizant and respectful of the fact that other people may not feel that way.

I found this very insightful, thanks.

 

[WholeLottaGame7]

Since we're going with ethics. A similar scenario actually came up during our ethics class. Elderly man with end stage multisystem organ failure and docs have decided to take him off life support but the wife is hysterical and refuses to hear reason and only wants the doctors to save his life because "she can't live without him". Many of my classmates felt that we should try to save him at all costs and apparently DC futility laws agrees with them. However, I've always taken a utilitarianist view on these things. Sure we can keep him "alive" on machines for several weeks to months and even years but he's never going to get better and we're only delaying the inevitable. On the flip side, we're taking a much needed ICU bed from someone who could actually benefit from ICU care and that's wholly irresponsible. I'm curious if any of the residents have input from personal experience on such a case.

Granted, I'm only an intern, but in my ICU experience so far, the overwhelming majority of people are reasonable human beings. Some people just need longer to come to terms with reality than others, and as physicians we should respect that. It may be frustrating to have to round/write orders/notes/"waste" resources on a patient for an extra week or two past when it became a lost cause, but that extra week may be exactly what the family needs to cope (emotionally/financially/etc).

For those rare other cases, the best I can say is that there has been plenty written on the ethics of long-term care/resource utilization, and obviously there isn't a lot of consensus (otherwise there wouldn't be so much written). It really comes down to your personal philosophy.

 

[WholeLottaGame7]

I found this very insightful, thanks.

No problem. It's an interesting discussion and one worth having. Hopefully this helps someone come interview time.

 

[rHinO1]

Lying? Yes. Showing social sensitivity and ability to neatly package the truth and/or decide upon the best time to announce unpleasant news? I highly doubt it. Truthfully, though, you should have stories not "I would...s" to answer these kinds of questions. You want to show what you have done not tell "what you would do." Showing how your approach to unpleasant conversations has (NOT "will") benefitted pts in the past is what you want (or, if not pts, other people).

It's just advice, take it or leave it. I suspect most of these types of interview questions are designed to judge peoples maturity, integrity, and moral compass. Not their ability to concoct scenarios that justify lying. Very simple purpose, but disguised in a more elaborate interview question.

I worked in human resources interviewing people for jobs for a couple years before going into healthcare, which I entered 5+ years ago. Like I said, I took this approach in my mmi ethics interviews, and it gained me an acceptance. However, if it will make you happy I'll wrap things in a more palatable package for you apumic.

 

[mishaS]

IRT to Rhino and every other person who would never lie, under any circumstances, here's a classic scenario: You are in the ER and two ambulances rush in carrying a husband and wife who've been in a car accident. The wife is dead on arrival while the husband is conscious but in critical condition. He keeps asking how his wife is doing, do you tell him she is dead?

You might have the knee jerk response to say "yes, he has a right to know," but you have to ask yourself how much harm you're doing vs. good. In a life or death moment you don't need to burden him with his wife's death, something he'll find out anyway. He might even go as far as saying he wants to die, and becoming hostile to treatments, which you'll force on him regardless because he's obviously not competent to make a decision of such gravity in his current condition. You cause no real good with your cavalier honesty, only stroking your own black/white integrity.

That's obviously an extreme example, but while paternalism is becoming less favorable in our independent society, there are still situations where lying could be made justifiable when you know your patient, and you know that the truth will inevitably cause much greater harm than good.

 

[Ursa]

If I know the patient is a sort of Rita Skeeter and will spin any personal information I tell them as if I sleep around with a lot of men I've never even seen in my life, I'll spin the question around with an open question to the patient or stating the least amount of information possible, just enough to curb their interest.

I usually got questions from patients stating I was an American because of my looks (guess white skin and green eyes stands out in Mexico) but while I told them I was indeed born in the US, I tell them many people in Mexico City look white and my university has a lot of Ashkenazi jew students.

And when a patient would be persistent if I was dating a guy from the village, I'd spin the question around that I doubt a lot of macho men from the region would be okay with dating a woman with a university degree in a region where most people don't even finish junior high, is a mediocre cook and most likely would be the breadwinner. That usually shuts them up.

If it's something like suspected cancer, my job as a PCP was to always refer patients to the next level of care for an evaluation to discard the disease, not to freak them out for nothing. Cancer is a rare disease in the region I worked in this past year but I have had to tell bad news to a few patients when I had results at hand for a random array of diseases. I'm usually pretty through with pregnant patients with high risk pregnancies stating the likelihood that their pregnancy will end up in a c-section for x reason or they need to be referred for another reason. I've referred about 3 patients for probable appendicitis but telling them the disease has to be confirmed with lab tests and proper x-rays which I don't have in my clinic.

I love the Harry Potter reference.

 

[WholeLottaGame7]

IRT to Rhino and every other person who would never lie, under any circumstances, here's a classic scenario: You are in the ER and two ambulances rush in carrying a husband and wife who've been in a car accident. The wife is dead on arrival while the husband is conscious but in critical condition. He keeps asking how his wife is doing, do you tell him she is dead?

You might have the knee jerk response to say "yes, he has a right to know," but you have to ask yourself how much harm you're doing vs. good. In a life or death moment you don't need to burden him with his wife's death, something he'll find out anyway. He might even go as far as saying he wants to die, and becoming hostile to treatments, which you'll force on him regardless because he's obviously not competent to make a decision of such gravity in his current condition. You cause no real good with your cavalier honesty, only stroking your own black/white integrity.

That's obviously an extreme example, but while paternalism is becoming less favorable in our independent society, there are still situations where lying could be made justifiable when you know your patient, and you know that the truth will inevitably cause much greater harm than good.

That's exactly right. You do have to ask yourself that. But how do you know what is going to cause this man more harm than good? The news is going to be tragic regardless of when you break it. You make a good point about the timing of breaking bad news being important, but you also make a lot of assumptions about what will happen when you tell him (wanting to die, refusing treatment, etc). (As an aside, emotional distress =/= incompetence, and you cannot "force" a treatment upon anyone who is competent.

I don't think basing the decision on whether to lie or not should be dependent on hypothetical future actions by a competent adult. You could very well wait a month to tell him and he'd still go out and commit suicide. All you can do is try to create as supportive an environment as possible and do your best to help him through it. I agree that oftentimes in the ED is not the ideal place, but if he is with it enough to ask the question, he has kind of forced your hand and you do the best you can. You can try deflecting, "why don't we get you taken care of first and then we can worry about your wife," or "unfortunately we have bad news, it might be better if we do this with family and friends around," but if I were in the patient's situation, I doubt that would cut it and I would want to know. And if I found out you had lied to me, I would be pretty peeved.

The take-home point is, it is dangerous to assume that you know what is best for a patient emotionally, especially as young doctors (and soon-to-be-doctors) with mostly limited life experience.

 

[apumic]

That's exactly right. You do have to ask yourself that. But how do you know what is going to cause this man more harm than good? The news is going to be tragic regardless of when you break it. You make a good point about the timing of breaking bad news being important, but you also make a lot of assumptions about what will happen when you tell him (wanting to die, refusing treatment, etc). (As an aside, emotional distress =/= incompetence, and you cannot "force" a treatment upon anyone who is competent.

I don't think basing the decision on whether to lie or not should be dependent on hypothetical future actions by a competent adult. You could very well wait a month to tell him and he'd still go out and commit suicide. All you can do is try to create as supportive an environment as possible and do your best to help him through it. I agree that oftentimes in the ED is not the ideal place, but if he is with it enough to ask the question, he has kind of forced your hand and you do the best you can. You can try deflecting, "why don't we get you taken care of first and then we can worry about your wife," or "unfortunately we have bad news, it might be better if we do this with family and friends around," but if I were in the patient's situation, I doubt that would cut it and I would want to know. And if I found out you had lied to me, I would be pretty peeved.

The take-home point is, it is dangerous to assume that you know what is best for a patient emotionally, especially as young doctors (and soon-to-be-doctors) with mostly limited life experience.

IMO, one person should not be making the decision what to withhold from such a pt. However, this is why we have a treatment team. In cases like this, my hospital has behavioral health crisis mgmt teams based in the ED available to help assess the best plan of action (in the ED or on one of the floors). If a pt is in critical condition, the added stress of knowing a family member died or is also in critical condition may reduce his/her likelihood of survival. There is a social aspect to health that has been repeatedly demonstrated to be quite powerful. This is especially true if we have two pts in critical condition, say a husband and wife. Perhaps the medical prognosis is poor for both but we remain very positive toward each person about his/her spouse's chances. In addition, we bring in family, etc., it is possible that the couple could pull through because of that hope. (There are numerous documented stories of people staying alive up until a landmark in a child or grandchild's life and dying the next day. In addition, there have been studies such as the research on the Korean War American POWs showing the power of a lack of hope to kill with absolutely no medical reason."

Nevertheless, lying to a pt is inexcusable. Withholding of information under good counsel might clinically useful but outright lying to your pts should not be practiced.

 

[WhizoMD]

what would you guys do when dealing with peds. patients? I had one doctor when I was younger that would never lie, no matter what question I asked; looking back, I don't view him as a man of great principle, I see him as a person who completely lacked any sort of social tact. Some of the stuff he told me slipped me into depression for weeks, when it was stuff I really didn't need to know.

 

[rHinO1]

IRT to Rhino and every other person who would never lie, under any circumstances, here's a classic scenario: You are in the ER and two ambulances rush in carrying a husband and wife who've been in a car accident. The wife is dead on arrival while the husband is conscious but in critical condition. He keeps asking how his wife is doing, do you tell him she is dead?

You might have the knee jerk response to say "yes, he has a right to know," but you have to ask yourself how much harm you're doing vs. good. In a life or death moment you don't need to burden him with his wife's death, something he'll find out anyway. He might even go as far as saying he wants to die, and becoming hostile to treatments, which you'll force on him regardless because he's obviously not competent to make a decision of such gravity in his current condition. You cause no real good with your cavalier honesty, only stroking your own black/white integrity.

That's obviously an extreme example, but while paternalism is becoming less favorable in our independent society, there are still situations where lying could be made justifiable when you know your patient, and you know that the truth will inevitably cause much greater harm than good.

Wholelottagame's post above was an excellent response to your scenario, IMO. I agree that timing is certainly important. My response would depend on how critical the husband was in the ED. As was pointed out, if he is coherent enough to ask about his wife, then it is entirely plausible he could handle hearing the bad news. Before I considered deflecting the question, I would have to ask myself if I was deflecting the question because it was in the patient's best interest, or if it was simply to avoid dealing with the patient's response at this point in time.

I believe you posed the scenario as if the husband was critical, and therefore, I assume you are also implying that upsetting the husband will aggrovate his current condition (which is unstable). In that situation, I might respond to his question by saying "the staff here are doing everything they can for you, and your wife, right now we need to worry about you" or "we will have more information about your wife later, but right now we need to stabilize you."

I also agree with wholelottagame that we cannot predict what a patient's emotional response will be. Nor is it my job to determine what they can or cannot handle. I think sometimes we need to step back, and realize that this is not our emergency/difficult situation, it belongs to the patient. However, as doctors/healthcare workers, we are there to help. But in order to help, sometimes we need to let people have their own response to things, and simply be supportive.

 

[45408]

Ok...

Someone who tells a lie to save someone's life or protect someone's life has a valid reason to tell a lie. There are times in which lying is necessary. An extreme example would be telling a terminally ill patient that they're probably going to die. I would instead try to encourage hope while still trying to be straightforward. Lying for the sake of the patient and saying that it is possible to survive despite all medical proof is something I would be willing to do.

That's how I'd respond to that question.

You plan to be the kind of doctor that drives me up the freaking wall. Day in and day out in the ICU, I hear doctors tell patients and families that there's hope, when everyone knows there isn't. This puts people through a brutal emotional roller coaster that is unnecessary. It involves spending tens and hundreds of thousands of additional dollars to keep someone alive when all of us (doctors) know better. This isn't even infrequent. The last time I saw this play out was on Wednesday.

Furthermore, when you lie to the patient like that, you set yourself up for a lawsuit. Lawsuits typically happen because patients and families had a different expectation of what would happen than what actually happened. Nobody sues the doctor for getting what they wanted/expected. When you tell the family that their loved one might live, and they end up dying, the family might sue you because they think you committed malpractice. Honesty won't always keep you safe from lawsuits, but before you perform a dangerous operation on a patient, if you tell them (and document) that they are at a very high risk of death, then the family is more prepared for that potential outcome.

 

[45408]

I don't think basing the decision on whether to lie or not should be dependent on hypothetical future actions by a competent adult. You could very well wait a month to tell him and he'd still go out and commit suicide. All you can do is try to create as supportive an environment as possible and do your best to help him through it. I agree that oftentimes in the ED is not the ideal place, but if he is with it enough to ask the question, he has kind of forced your hand and you do the best you can. You can try deflecting, "why don't we get you taken care of first and then we can worry about your wife," or "unfortunately we have bad news, it might be better if we do this with family and friends around," but if I were in the patient's situation, I doubt that would cut it and I would want to know. And if I found out you had lied to me, I would be pretty peeved.

That's what I would do first. If I were going to lie about it, I would just lie that I didn't know rather than saying she was okay. Tough situation all around.

 

[apumic]

You plan to be the kind of doctor that drives me up the freaking wall. Day in and day out in the ICU, I hear doctors tell patients and families that there's hope, when everyone knows there isn't. This puts people through a brutal emotional roller coaster that is unnecessary. It involves spending tens and hundreds of thousands of additional dollars to keep someone alive when all of us (doctors) know better. This isn't even infrequent. The last time I saw this play out was on Wednesday.

Furthermore, when you lie to the patient like that, you set yourself up for a lawsuit. Lawsuits typically happen because patients and families had a different expectation of what would happen than what actually happened. Nobody sues the doctor for getting what they wanted/expected. When you tell the family that their loved one might live, and they end up dying, the family might sue you because they think you committed malpractice. Honesty won't always keep you safe from lawsuits, but before you perform a dangerous operation on a patient, if you tell them (and document) that they are at a very high risk of death, then the family is more prepared for that potential outcome.

Yikes...futile care. I wonder how much research has been done on what futile care actually costs. I'd expect it probably makes up a pretty good fraction of the money spent on healthcare in this country. One of the medical directors I know regularly has to take people off ventilators, etc. in the ICU because some scared/inexperiened doc/PA/NP ordered unnecessary treatment for someone who had essentially a 0 chance of survival. I do think in the case of a very low chance of survival that it is crucial that that be explained to the family and to the pt -- in a tactful manner at an appropriate time.