Or: Just Give it to Me Straight, Doc

Any primary care physician from time to time has to give a patient bad news, sometimes terrible news.  These conversations can be extremely difficult for the patient and his loved ones, but also for the doctor.  When the patient is too sick to understand or participate in conversations about his prognosis and his treatment options, the terrible burden falls on his loved ones to have these conversations and make decisions on the patient’s behalf.  When the news is particularly bad, as when the patient is unlikely to survive the hospitalization, many physicians are reluctant to fully disclose the gravity of the prognosis.  Some doctors believe that to be fully honest would take away the family’s hope, or that the family is emotionally incapable of processing the bad news.

An important study in this issue of the Annals of Internal Medicine tested that belief.  The study found 179 critically ill patients in the intensive care units of the UCSF Medical Center who required a ventilator (breathing machine), could not participate in a discussion about their condition and had a high likelihood of dying during this hospitalization.  Structured interviews were conducted with the relatives or loved ones who identified themselves as the decision makers for the patient.

The interview sought to discover the families’ attitudes towards maintaining hope and receiving truthful prognostic information.  The interview started with the question “Some physicians are reluctant to discuss news of a poor prognosis with family members of a critically ill patient because they do not want to take away the families’ hope. Do you think physicians should avoid discussing prognosis in order to maintain hope?”

The results solidly refute the idea that families want to be protected from the truth.  93% said that avoiding discussions about prognosis was not an acceptable way of maintaining families’ hope.

The themes discovered in the study and the individual quotes are quite poignant.  Many relatives said that discussing the prognosis is part of what they expect doctors to do.  One said “Also, I think it’s a matter of respect and I wouldn’t want a doctor assuming that I couldn’t handle something or that I wouldn’t understand something.  That’s demeaning to me.”  And many relatives spoke of sources of hope outside of what is offered by physicians.  “My hope is not based on what doctors tell me; it’s based on how I feel as a person, my spiritual beliefs, how my family and I interact and hold each other up.”

We physicians should learn from this study that families want the truth; we owe it to them.  And we should admit to ourselves that the reason we are so desperate to sugar-coat the prognosis isn’t to maintain the family’s hope; it’s because giving bad news is so difficult.

Learn more:

Annals of Internal Medicine article: Hope, Truth, and Preparing for Death: Perspectives of Surrogate Decision Makers

Annals of Internal Medicine Summaries for Patients: Family Members’ Opinions about Sharing Bad News