I have a personal bias towards telling…..telling the patient of the truth about his diagnosis. This is what I was taught in school.
Initially, I went around in circles when talking to patients that they sometimes perhaps wondered what I was really saying. But practice makes perfect. I learned the skill. Got rid of my own discomfort and became quite confident and proud that I can swing it.
Oops! Wrong Mistake!
However, I also noticed that telling the truth is not as simple as I thought it would be. What I have read in the books about the relationship being strictly between patient and doctor were only half as true.
When faced with an actual patient, I never dealt with a single person but almost always an entire community or entire family at the very least. I realized that if I insist on what I learned in school, I will be met with resistance in many different points. This resistance will swell-up and eventually explode into a war not between the doctor and the cancer but between the doctor and the family. The patient will never win in this kind of war. The doctor will never be therapeutic but a constant source of irritation and anger for the family. The doctor will only add to the already tense and anxious situation pervading the patient and family.
The Lesson: Respecting Variability is Key
I have learned that there are patients who want and patients who don’t want to know.
I have learned that there are families who are amenable to open discussion with the patient and there are families who must first be made to realize and convinced of its importance and there are families that who will insist on their wishes.
I have learned that I need to convince the relatives that we are allies, that we are on the same boat and that we have the same goals.
I have learned that the approach will never be one size fits all but must be customized for each patient.
Strategy: How To Tell Or Not To Tell
So, when faced with a patient, I often do not go directly to the patient. I discuss with relatives first and win them over to allow me to evaluate the readiness of the patient to discuss. The relatives also need to be assured that the amount of news to be delivered is only up to how much the patient wants, needs and can tolerate. I remind them that I am a friend and as such I will not impose harm on the patient. When I already have their go signal, I proceed to the next stage.
The next stage involves meeting the patient. When we are face to face, I determine first what the patient already knows. I listen intently and be sensitive for cues. In this way, I avoid the shock of delivering a bomb. Making the patient talk first somehow softens the impact because events are brought up to her consciousness at her own pace.
It is never easy to say when the right time has come. Given the weight of the news, there is never truly a right time. Often, we need to warm up to the patient. It might take a number of encounters before I can deliver. What is certain, however, is that when the patients asks for the truth, even when I have promised the relatives not to tell, it is a very clear sign that the promise has to be broken and the patient needs to know. There is no question about that.