Breaking bad news
Sanjay A Pai
As has been pointed out in the pages of this journal before by Roshni Chinoy (1), the ethical problems that most clinicians are affected by in daily practice do not arise in the routine of pathologists. We do not have to worry about DNR (Do not resuscitate ) orders, or about “pulling the plug “, to mention only two of a host of problems. However, this does not prevent us from discussing such problems with our colleagues. When we express our views on such things, some like to point out the irony of solutions being offered by those who do not have to do the real-life thing. It’s like teaching swimming while standing outside the pool.
Something that I have always been intrigued by is the breaking of bad news. It must be difficult, under any circumstances, to tell people (and their relatives) that they have an incurable disease. Quite apart from this, exists a different problem: not having to do so! It is not uncommon for relatives to beseech the doctor not to tell the patient the bad news “because s(he) will not be able to take the shock”, especially when the diagnosis concerns cancer or a terminal illness. Here, we enter into an area fraught with [ethical] danger: If the doctor gives in to such requests, is the doctor violating the patient’s rights by keeping him in the dark while informing the relatives? After all, doesn’t the doctor’s duty lie to his patient?
I was fortunate to discuss this subject with Dr Srinagesh Simha, a Bangalore-based surgeon who is also chairman of Karunashraya, a hospice in the city which has done tremendous service for the terminally ill.
Dr Simha responded with a recent example that he dealt with. A patient he had operated on was detected to have an inoperable pancreatic carcinoma. After the surgery, when he told the patient’s daughter, she responded with: “Please don’t tell him this. He will not be able to face such devastating news.” Sensing that something was amiss, Dr Simha probed further and learnt that the daughter and father had been estranged for some years now. She had married someone from outside the community and had been cast out of the family. Now, her marriage was on the rocks. She was not on talking terms with her brother. And her father was dying. What she wanted – more than anything else – was her father’s forgiveness.
Dr Simha explained to the distraught daughter that the pretence of acting as if all were well would be soon seen through by the father. He suggested that it would be appropriate to tell the father the truth. A man facing death is likely to forgive children’s worst discretions.
After much discussion, it was decided to gently break the news to the parent. A few weeks later, he died. A month later, Dr Simha happened to meet the daughter at a store. she told him “Doctor, the past few days were among my happiest of my life. Not only did my father forgive and forget but we were able to reminisce about our good old days. We cleared all our little misunderstandings and my father died a happy, relieved man.”
Dr Simha has attended courses on communication conducted by Dr Peter Maguire, Director of the Psychological Medicine group of the Cancer Research Campaign of the UK (Manchester) who is considered to be the Bradman of the subject. In fact, he (Dr Simha) will shortly be off to Cardiff, Wales, for a diploma in palliative medicine.
Have you heard of doctors suing patients? A physician I know has sued a patient because after consulting extensively with him over the phone, she dumped him because she preferred a lady doctor over a male doctor. Clearly, it took her considerable time to figure this out. My friend is not amused. He sees it a blatant violation of his human rights – and doubtless, as sexual discrimination, though with a variation from the usual! At first he wanted to sue the patient. I wonder what the readers of this journal have to say about this. (He changed his mind about suing her – but the question remains: does he have a case?)
A variant of this situation was referred to recently. A patient was referred by one specialist to another in a different hospital for specialised therapy. The treatment completed, the second physician referred the patient back to the initial hospital — but to a different doctor!
Perhaps the greatest fear about the proliferation of health-related web sites is the fact that they give an opportunity to quacks to display their wares to the uninitiated. Because there seem to be no laws to guard against this, as yet, it is heartening to note that a consortium has been formed by 20 companies to tackle this. Called Hi-ethics, the group expects to be fully compliant by November and lists 14 themes, among which are disclosure of conflict-of-interest. No Indian company is currently part of this group, a statement I fervently hope will be proved wrong, sooner, rather than later.
- Chinoy R F: Some ethical issues in histopathology Issues in Medical Ethics 2000 VIII (1): 22-23.