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Disclosing Bad News

January 2008 - Research from the University of Pittsburgh School of Medicine, in collaboration with colleagues at Stanford University and published in the Journal of Clinical Oncology, uses an approach based on negotiation skills to help clinicians handle requests from family members not to reveal bad news to a patient.

Co-author Robert M. Arnold, professor of palliative care and medical ethics said:

"While the topic of patient nondisclosure raises many ethical questions, these situations are too often thought of as dilemmas in which one party must win and the other must lose. We propose that by understanding the cultural factors that underlie divergent points of views and the use of skilful negotiation techniques, a balanced solution can be reached that satisfies all parties - the patient, family and physician."

Researchers explain that American physicians tend to view requests for nondisclosure as contrary to medical ethics and norms of clinical practice. However many families do not want their loved one to be informed of bad news. In such circumstances physicians face conflict between their duty to be truthful to the patient and the family's belief that such information would be harmful.

Robert Arnold commented:

"Family members, who may have the patient's best interests at heart, may believe that the patient would give up hope if given the news. These requests put physicians in difficult situations in which they feel as though the patient has a right to know, yet the family is adamant that the patient not be told."

Researchers suggest that it is common to overreact to requests that are perceived as potentially unethical. A common mistake is to respond with a categorical "we can't do that". However, this is likely to exacerbate the situation, missing an opportunity to learn why the family is making the request. To avoid this, physicians should adopt a more open approach such as "tell me about your concerns" and respond with empathy to the family's distress.

Robert Arnold added:

"Emotions are central to these disputes. Given that it is a topic that both parties care about deeply, it is not surprising that issues of pride, respect and self-esteem often surface."

Researchers also suggest that efforts are made to elicit the family's views about the patient's likely wishes, that physicians state their own position in a non-confrontational way and that a negotiated approach is proposed in which physicians ask patients how much they want to know.

Robert Arnold concluded:

"By using empathy and understanding and applying communication and negotiation skills to these conversations, nondisclosure requests from families can be successfully resolved in the vast majority of cases."

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