Canadian Neighbor Pharmacy: Discussion of Advance Directives for Truth Disclosure

metastatic malignancyThis study confirms the results of previous studies on truth disclosure in a more realistic clinical setting. The patients in the current study did not have a previous diagnosis of cancer and were facing the real uncertainties of hospital admission and investigation; they were aware that their preferences would be recorded and acted on if necessary. The vast majority of patients in this study wanted to be told of a serious diagnosis and most wanted full details of their condition. Somewhat surprisingly, a clear majority of patients preferred to be alone rather than with their family when told of bad news. This is contrary to the findings of other workers. Subsequently, doctors were able to comply with patients’ wishes in almost all cases.

Individual people have specific informational needs that can only be identified by asking the individual. Respecting patient autonomy means that we should attempt to identify those who would prefer less information rather than adopting a policy of full automatic disclosure. This is consistent with the wishes expressed by patients in other studies. However, it is important that the desire to protect such patients should not lead to a lack of candor with the majority of patients who do want to know about their diagnosis. This study confirms that seeking preferences regarding truth disclosure at the outset of hospitalization is helpful and feasible in everyday practice and that the results can be used by clinicians to improve communication with patients and families in accordance with patients’ own wishes. Discussions about treatment options may mandate the disclosure of the diagnosis in some cases, and it could be argued that it is inappropriate to offer such patients the option of not receiving information, However, most of the patients who would prefer not to know of a serious condition would accept being told if that were required to provide effective treatment.

effective treatmentRelatives often ask that a serious diagnosis be withheld from older people, and physicians sometimes collude with them in maintaining secrecy. However, several reports have shown that agreement between the preferences of relatives and those of patients regarding truth disclosure was not significantly greater than that expected by chance alone. For example, we have found that three quarters of relatives who asked that a patient not be told of their diagnosis were in conflict with the patient’s wishes. Moreover, advance consultation with the relatives of competent patients violates the patient’s rights to confidentiality. This study shows that well-intentioned but ageist attitudes to truth disclosure are indefensible, since older people were no less likely than younger patients to ask to know of bad news. If you like to read more about medicine you may check out the website of Canadian Neighbor Pharmacy on facebook.

The major disadvantage of our approach was that it led to anxiety in a minority of patients, many of whom were inevitably at low risk for receiving bad news. However, major distress was rare, and informal feedback from patients and staff was overwhelmingly positive. Hence, we believe the advantages of disclosure outweigh any drawbacks. Targeting patients who are at higher risk for receiving bad news for discussions regarding disclosure preferences could be considered, although unexpected diagnoses of cancer are not uncommon in hospital practice.

This study was conducted in a relatively monocul-tural society. Cultural factors strongly influence attitudes toward truth telling For example, ethnicity was the main factor related to attitudes toward truth telling and decision making in a survey of elderly patients in North America. Korean Americans and Mexican Americans were significantly less likely than European Americans and black Americans to believe that patients should be told of a diagnosis of metastatic malignancy. The advance directive approach to truth disclosure warrants further assessment in other settings.

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