Should a doctor tell a patient they are terminally ill? That is the latest debate being thrashed out in this week's British Medical Journal (BMJ). Emily Collis and colleagues at the Central London Community Healthcare NHS trust believe that decision making can only be ethically sound with a fully-informed patient.
The group argues that accurate information allows the patient to make "informed, realistic choices and helps achieve patient preferences of care". Guidance from the General Medical Council (GMC) also suggests that information should only be kept from a patient in the event it will cause serious harm, which is defined as "more than becoming upset".
Under the GMC's recommendations, doctors that withhold information from a patient must justify their decision, document it and reconsider it again in the future. It can be a difficult issue for doctors to navigate as they have to determine how beneficial knowledge of the prognosis is for the patient, and whether or not it is ethically right to keep such significant information under wraps from the person it affects most.
In this latest report, the experts prioritise the importance of how the message of terminal illness is communicated to the patient, rather than concentrating on whether or not the person should be told their disease is incurable. Patients, they argue, "should be given the information they want or need in a way they can understand".
Rather than giving patients this information at the latest possible moment, however, the experts believe these conversations should form part of the ongoing treatment so that the individual is kept up to date with the pace of their illness, allowing them to come to terms with it "in their own time".
The study authors concluded: "Breaking bad news is challenging in any context, but the consequences of neglecting this duty may directly affect the trust between doctor and patient, the patient's autonomy, and ultimately his or her quality of life."
According to Leslie Blackhall, from the University of Virginia, terminal illness is not clearly defined and prognoses cannot be certain. She argues that patients in such situations should be informed of what medicine can continue to do for their disease, rather than given a timeframe for longevity.
"This is not an argument for deceiving patients, or for reverting to a paternalistic mode of care. On the contrary, it is an argument for honesty about the efficacy of various types of medical care throughout the spectrum of life limiting illness," she argued.
Dr Blackhall thinks the emphasis should be on the side effects of treatment and what the patient can expect as the disease progresses, but she believes that it is never true to say there is nothing the medical profession can do to prevent the person from facing a prognosis of terminal illness.
This is indeed a sensitive issue for doctors to approach, and while it is down to the discretion of the physician over what strategy they adopt, they might also find it useful to discuss the topic with their seniors for advice and guidance on delivering poor prognoses to patients.
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