Dilemma #1 According to the law, a physician must obtain informed consent prior to performing a procedure. Consent is obtained after telling the patient or the patient’s representative the following: * diagnosis * nature of proposed treatment * name of the procedure * description in layman's terms * risks associated with that treatment * alternatives and associated risks * risk of no treatment In the story, the problem the physician deals with is a family wishing to filter the information that the patient receives. The family may wish to do this because they do not feel that the patient will make wise choices or they may wish to avoid any stress or depression that may come as a result of negative information. The physician must determine if filtering is in the patients best interests or not. The physician must also determine if filtering is a choice even available to him.
To tell, or not to tell: that is the question. In this modern era of medicine, the physician, family, and patient create a team that together make decisions on the care of the patient. When a physician chooses of his own accord to withhold information from the team he is wrong. If the patient desires that information be kept from the family or vice versa, that is wrong as well. When the spouse in Dilemma 1 asks the physician to withhold negative information from the patient she is attempting to break up the “team.” The physician also feels that he will not be able to receive informed consent prior to the biopsy by withholding information. Finally, the physician does not wish to obtain any information (which the biopsy would create) that :
One, the family, and possibly the patient, does not want him to act on.
Two, by withholding it, he would be considered lying.
Informed Consent – individuals are entitled to know the indications, risk, and benefits hoped to be obtained Veracity – to be truthful Autonomy – to respect the freedom to make decisions for oneself Accountability – accepting responsibilities for one’s actions Ethical Principles at Risk
Pillars of Disclosure Pt. Self-Determination Pt. & Family Cooperation Hope & Closure
Since the early 1900’s there has been a growing belief in the patient’s right to know and the opportunity to make decisions related to their own care. The creation of “informed consent” was the result of the 1957 Salgovs Leland Stanford Jr Board of Trustees. In awarding judgment to Salgo, Judge Brady’s pronouncement were, “A physician violates his duty to his patient and subjects himself to liability if he with holds any facts which are necessary to form the basis of an intelligent consent by his patient to the proposed treatment... In discussing the element of risk a certain amount of discretion must be employed consistent with the full disclosure of facts necessary to an informed consent. Katz J. The Silent World of Doctor and Patient. New York: The Free Press; 1984. Pt. Self-Determination
When one member of a family has cancer, the whole family is affected and, in fact, psychologists consider these family members to be "secondary patients." Cancer affects an entire family, not only because there are genetic links to cancer and cancer risk, but because when one member of a family has cancer the whole family must deal with the illness. (American Psychological Association) Just as there is a healthcare team, the family and patient should be considered a team. A team can be compared to rope. An individual alone, or a strand of rope alone is not very strong. Take all the strands, or all of the family together, and the rope is very strong and do much more. Pt. & Family Cooperation
Improvements in quality of life and palliative care has seen the end of the phrase “there is nothing else I can do for you….” In the past the diagnosis of cancer was seen as a death sentence. Physicians and families were concerned that this may lead to depression or worse. Studies have shown:
There was no increase in perceived symptoms of anxiety, despair, sadness, depression, insomnia or fear in the group of informed patients compared to the uninformed patients.
Patients who were not informed of the diagnosis tended to be more anxious and at times, felt desperate.
Families of informed patients felt that they were in a better position to care for the patient.
Diagnosis disclosure in cancer is also correlated with improved symptom control and patient satisfaction with care.
Therapeutic decisions can be discussed with the patient and carried out with his or her full consent and knowledge.