There is an interesting article in the August 1 issue of the Journal of Clinical Oncology on why physicians and other health-care professionals don’t like to talk to their patients about “the bad news” when it comes to prognosis.
The bottom line, as expressed by Mack and Smith, is that (based on research carried out primary among cancer patients and their physicians) there are five common reasons why doctors are less than enthusiastic about discussing prognostically poor information — but these reasons are all based on misconceptions held by health care professionals:
- The misconception that negative prognostic information will make people depressed … But Mack and Smith report that: (a) in the Coping With Cancer study, patients who reported having end-of-life discussions had no higher rates of depression or worry and had lower rates of ventilation and resuscitation and more and earlier hospice enrollment, and that (b) more aggressive medical care at the end of life was associated with a higher risk of major depressive disorder in bereaved caregivers.
- The misconception that negative prognostic information will “take away hope” … But Mack and Smith argue in favor of evidence suggesting that hope is actually maintained even after truthful discussions that teach patients that there is little to no chance of any cure.
- The misconception that participation in hospice or palliative care reduces the probability of survival … But Mack and Smith accurately point out that multiple studies have shown that survival is equal or better with hospice or palliative care.
- The fact that we can really never know the prognosis accurately for an individual patient … In this case the perception is correct; the misperception, say Mack and Smith, is that a doctor can (let alone should) use uncertainty as an excuse for avoiding reality. Clinicians are (or at least should be) eminently capable of formulating a reasonable prognosis or range of possible outcomes that can help any patient’s understand something approaching the truth about his (or indeed her) personal situation.
- The misperception that discussions about prognosis are culturally appropriate (at least for patients of some ethnicities) … in this case, Mack and Smith note that it is certainly true that — in general — discussion of a terminal prognosis is less commonly accepted by people of some cultures than others. However, these conversations are not between a health professional and a culture; they are conversations between a health professional and an individual patient of a specific ethnic background who may or may not conform to his or her “cultural norm.” If the health professional is in any doubt about how the patient might react to such a conversation, he or she can and should simply ask the patient for his or her preference about whether to have this conversation.
At least as far as Mack and Smith are concerned, the real reason why health care professionals avoid conversations about “the bad news” is simple:
- These conversations are hard for health care professionals themselves, and they just don’t like to have to have them … So, just as we all tend to avoid the things we don’t really like to have to do, they avoid them whenever possible.
No patient or caregiver should be forced to listen to a one-way “conversation” about their poor prognosis if they don’t wish to have this. Equally, however, no doctor should be making the assumption that a patient with a severe case of prostate cancer doesn’t want to “hear the truth.” This is just one more place where the wishes of the patient should be paramount.
If I want to hear the doctor’s best guess about my life expectancy, my wishes should take precedence over my doctor’s discomfort about the subject matter and its implications. Equally, if my partner/spouse/caregiver doesn’t want to hear that conversation (or the implications) I and my doctor should make every reasonable attempt to avoid distressing her/him by forcing her/him hear it. What is more, particularly for health professionals like oncologists and oncology nursing staff, who are often faced with patients who will die of their cancers (prostate cancer or any other) becoming knowledgeable about how to have these conversations in an appropriate and honest manner should be a critical component of their training.