New approach to medical nondisclosure

Nov 2 2007

When family members ask physicians not to disclose bad news to ill loved ones, clinicians often struggle to balance their obligation to be truthful to the patient with the family's belief that the information would be harmful.

To help clinicians more successfully manage these conflicts, researchers at the University of Pittsburgh School of Medicine, in collaboration with colleagues at Stanford University, have developed an approach based on negotiation skills and described in the Nov. 1 issue of the Journal of Clinical Oncology.

“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,” said Robert M. Arnold, M.D., study co-author and professor of palliative care and medical ethics at the University of Pittsburgh School of Medicine. “We propose that by understanding the cultural factors that underlie divergent points of views and the use of skillful negotiation techniques, a balanced solution can be reached that satisfies all parties – the patient, family and physician.”

Although clinicians in the U.S. often view requests for nondisclosure as contrary to common medical ethics and norms of clinical practice, many families and patients, nonetheless, do not want bad news disclosed. “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," said Dr. Arnold.

Because a physician may feel as though he or she is being asked to do something unethical, it is common to overreact to a nondisclosure request, according to Dr. Arnold. A common mistake is to respond to a nondisclosure request with a categorical, “We can't do that,” he said. By over-reacting in this manner, however, a physician may lose the opportunity to learn why the family is asking and inadvertently heighten tensions. To avoid this, a physician should attempt to understand the family's viewpoint by starting a conversation with something like, “Tell me about your concerns,” and respond with empathy to the family's distress.

“Emotions are central to these disputes,” said Dr. Arnold. “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.”

Dr. Arnold also suggests that the physician talk to the family about what the patient would want, state his or her views in a non-confrontational manner and propose a negotiated approach in which the physician asks the patient how much he or she wants to know.

“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,” said Dr. Arnold.