AETCOM (Attitude, Ethics
and Communication module)
Dr. Karun Kumar Assistant Professor Dept. of Pharmacology

Principle
• Changing a person's attitude can change his or her
behaviour

Foundations of communication
• Communication is a fundamental prerequisite of
the medical profession
• Bedside skills is crucial in ensuring professional
success for doctors
• During professional year II, the emphasis is on
1. Active listening
2. Data gathering

Foundations of bioethics
• Cardinal pillars of ethics
1. Autonomy
2. Beneficence
3. Non-maleficence
4. Justice

Autonomy
1. Respect the decisions of adults who have
decision-making capacity
2. Always seek the consent or informed agreement
of the patient before any investigation or
treatment takes place
3. Respect the privacy of others
4. Protect confidential information

Beneficence
• To act for the benefit of others by providing
benefits and balancing benefits and risks/harms
1. Protect and defend the rights of others
2. Prevent harm from occurring to others
3. Remove conditions that will cause harm
4. Help persons with disabilities
5. Rescue persons in danger

Nonmaleficence
• Not to inflict harm on others
1. Do not kill
2. Do not cause pain or suffering
3. Do not incapacitate
4. Do not cause offense

Justice
• Individuals should be treated the same
1. To each person an equal share
2. To each person according to need
3. To each person according to effort
4. To each person according to contribution
5. To each person according to merit

Case introduction
• Evaluate Mrs. Lakshmi Srinivasan who is a 48 year
old woman presenting with lymphadenopathy
• She had been complaining of mild fever and weight
loss for the past 4 -5 months
• Examination of the neck shows large rubbery lymph
nodes that are present also in the axilla and the
groin
• There is a palpable spleen
• She is accompanied by her caring husband

• Lakshmi undergoes a lymph node biopsy and the
pathologist calls you and tells you that she has a
lymphoma
• That evening Mr. Srinivasan comes in first into your
office and leaves the report on your table
• As you read the description you realise that the
final diagnosis has been altered to Tuberculosis by
whitening out the pathologist’s report

• When you look up he tells you –“Sir, I googled
lymphoma - it is almost like a cancer. My wife can’t
handle that diagnosis. She has always been a
worried frightened person. I want you to tell my
wife that she had TB. She is waiting outside, doctor.
I thought I will call her in after I had a chat about
this with you”

Points for discussion:
1. Does the patient have a right to know their
diagnosis?
2. What should the patient be told about their
diagnosis, therapy and prognosis?
3. How much should be told to a patient about their
illness?
4. Are there exceptions to full disclosure? Can
family members request withholding of
information from patient?

• In Western countries, the concept of patient
autonomy dictates that a physician must offer
every patient the information regarding their
diagnosis and the treatment options available to
them
• This allows the patient to make informed treatment
decisions
• South and Southeast Asian countries, including
China and India, practise collective autonomy:
where the patient’s family plays a vital role in
treatment decisions

• The stage of the disease is also something that
plays an important part in disclosing the cancer to
the patient
• If the cancer is in early stage and has a good chance
of cure, the patient and family will take it better
compared to an advanced stage cancer
• In early stage, compliance to treatment is very
important to have good results in cancer
• An informed patient is more likely to be compliant

• Education and a strong support system also have a
greater impact in cancer management
• An educated person is more likely to understand
the diagnosis and outcomes
• This is not because he is emotionally different than
the one who is not educated but because he has
the ability to acquire and understand information
about his disease

• To a certain extent, the family is right in requesting
to hide the diagnosis from a family member with
terminal cancer
• But eventually all patients come to know what they
are suffering from
• Slowly but surely they are losing weight, losing
energy, confined to bed, need more and more
assistance, more and more medications to keep the
pain away

• All these are signs of an incurable disease
• Frequent trips to chemotherapy centers, hush-hush
discussion among family members repeatedly
remind them of their disease
• There was a time when the diagnosis of a cancer
was almost like a death sentence
• Nowadays cancer care has made tremendous
progress and many cancers that were considered
terminal a few decades ago, now have high cure
rates with latest cancer treatments

• The doctor has an obligation to disclose the
diagnosis to the patient
• He is bound by professional oath and he can’t
withhold the truth if the patient asks him directly
• Though the family has the best interest of the
patient in mind, it is ultimately the patient who has
to consent for the all the tests and treatment

• Every major test and invasive procedure and
treatment needs a written informed consent from
the patient (guardian in case of minor)
• It is practically impossible to proceed with the
treatment without informing the patient what he is
suffering from and taking a consent to proceed
further

• Regardless of the family’s wishes the patient may
have a different opinion and view point about his
disease
• He/she may not wish to pursue treatment at all
• Such views and decisions can be discussed only
when all the information is shared with the patient
• It is the patient’s right to “refuse or accept
treatment”
• The diagnosis of cancer is a deeply personal issue

• Beyond the diagnosis, one must understand that
the patient also has to undergo physically
challenging treatments, bear health impairment
and disability, pain and loss of income
• There may be varying degree of permanent change
in his health and body

• Family members often feel that it is their duty to
protect the patient from a sense of hopelessness
• However, withholding the truth may have opposite
effects
• Lack of information can give rise to more anxiety
and distress

• To keep the severity of the diagnosis hidden there
is a risk of opting for less intensive treatment
regimens than more effective ones
• The patient may come to know about the diagnosis
from a third party or an unreliable source which
can cause total loss of trust between patient and
the family

Advantages of disclosing the
diagnosis
1. After disclosure most of the decisions regarding
treatment become transparent
2. There is no fear among the family and caregivers
that some third party will spill the beans
3. Though the diagnosis has a profound
psychological effect on the patient, it gives them
a chance to make important decisions of their
life- like one may want to make formal will, one
may want to complete a bucket list, one may
want to meet close friends etc.

4. Preserves the dignity of the patient by taking their
opinions on the matter
5. Cancer treatments are long. The patient and family
have to have a trusted relationship with the doctor.
And trust can only be built by truthfulness and
honesty.

• Hiding the diagnosis alienates the patient
• Someone with cancer experiences immense
amount of psychological stress
• If there was no open discussion about the disease,
the patient will never be in a position to discuss the
problems he is facing openly
• He may even think that his family and friends are
more distressed than him

• Many who were kept in the dark were also able to
guess on their own – in a process that they have
described as painful and demoralising
• Patients who don’t know their diagnoses have a
tougher time
• They expect to feel better with treatment and
become disappointed when they don’t
• Then they slowly lose trust in the treatment team
and the process

• If indeed they have a poor life expectancy, they
spend the last few days of their lives trying to figure
out what is happening rather than seeking the sort
of care and support that could help them
• Knowing the diagnosis and the disease outcome
also gives patients an opportunity to plan what
they will do with their days: meet people, tie up
loose ends, ask for (or give) forgiveness – all leading
to a peaceful and dignified death

• Each patient is different and has different response
to such sad news
• There is no clear path that can be taken every time
• A skillful doctor will understand every situation and
adjust his responses accordingly
• The treating doctor can consider discussing the
diagnosis and treatment in a graded manner
• He can talk to the relatives and patient, first to
gauge their understanding and wishes
• Based on this understanding he can decide how to
break the news

• Even if the family has expressed its wish to keep the
diagnosis from the patient, as long as the patient is
present in the consulting room the doctor must
address the patient directly and at least reassure
that all the possible steps are being taken to help
him/her regain his health
• While discussing the diagnosis and treatment in
such scenario it is better to avoid words like cancer,
stage 4, chemotherapy, etc.

• If the patient expresses desire to understand the
diagnosis (mostly a head of the family or a sole
breadwinner of the family in Indian context etc. )
the doctor can start by Asking how much the
patient wants to know
• It is surprising how different each patient is
• While some want to know every detail of the
treatment, some wish to know only the broader
aspects

• If the family and the patient are not really sure how
to go about it then the doctor must decide the
steps of action
• To build trust with the patient and family :-
1. Give information in small chunks
2. Avoid medical terms
3. Start at patient’s vocabulary and comprehension
4. Summarizing in the end

Take home message
1. Revealing the diagnosis to patients doesn’t
negatively impact patient’s quality of life, and
may even be associated with better disease
outcomes
2. Breaking bad news is not easy. Physicians use
techniques such as SPIKES (short for ‘Setting,
Perception, Invitation, Knowledge, Empathy, and
Summary’) to share bad news with their patients.

3. Patients often prefer knowing the diagnosis along
with their family members, not after the family has
already been told
4. They also expect to be offered some form of hope
and to have all the treatment options explained to
them
5. Doctors (based on their assessment of the patient)
should reveal the diagnosis in an empathetic manner
and involve patients in decision-making to the
maximum possible extent