blank StationeryHOPE AND TRUTH-TELLING





The miserable have no other medicine; But only hope.

                --William Shakespeare (1564-1616) Claudio, in Measure for
Measure act3, sc.1.



One of the most difficult things physicians do is give bad news.  In
particular, medical students and residents are often afraid that by telling
someone the truth about his/her diagnosis, they will be responsible for
taking away hope.  And yet, are physicians really that powerful?  Isn’t it
possible that our fear of causing the loss of hope is just another way we
can avoid the harsh reality of impending death?   This conflict, between
truth-telling and fear of destroying hope, is commonly noted by patients and
families who feel that “the doctor is not really telling me everything”, a
feeling that is highly corrosive to the doctor-patient relationship.



Brody writes, “Hope means different things to different people, and
different things to the same person as he/she moves through stages of
illness’ (1). The physician can play a valuable role in helping the
individual patient define their hopes and fears.  When close to death, hope
often becomes refocused away from long-term goals and towards short-term or
spiritual goals.  Hope may mean a pain free day, a sense of security, love
and non-abandonment, or a wedding to attend in the near future.  “When we
talk to patients and find out what is really worrying them, we can almost
always give them realistic assurances”(1).  Factors that often increase hope
in the terminally ill include feeling valued, meaningful relationships,
reminiscence, humor, realistic goals, and pain and symptom relief.  Factors
that often decrease hope include feeling devalued, abandoned or isolated
(“there is nothing more that can be done”), lack of direction and goals, and
unrelieved pain and discomfort.   Some strategies for beginning a dialogue
about hope and goals include (2):

1.        Ask the patient, “Do you have long term hopes and dreams that have
been threatened by this illness?”  Support the patient in recognizing and
grieving the possible loss of these hopes.

2.        Ask the person if there are particular upcoming events they wish
to participate in--a wedding, birth, trip, etc.

3.        Ask “What are your hopes for the future?” and “Do you have
specific concerns or fears?”

4.        Encourage the patient to make short, medium and long range goals
with an understanding that the course of terminal illness is always
unpredictable.



Teaching Tips
·         Use the Brody article for discussion article during Morning report
or ward rounds.

·         When faced with the need to give bad news, ask trainees how they
feel before they give the news; are they worried about causing a loss of
hope?  Ask them to reflect further—do they feel hopeless because of the
situation? Whose feelings are they trying to protect, their own or the
patient?

·         Ask trainees to make a list of risks and benefits of truth
telling—use a starting point for group discussion of the hope—truth telling
conflict.


References
·          Brody H., Hope. JAMA 1981;246:1411-1412

·          Ambuel, B.  Spirituality, in D Weissman, B Ambuel & J Hallenbeck
(eds.) Improving End of Life Care: A Resource Guide for Physician Education
(3rd Edition). Medical College of Wisconsin.

·          Twycross R, Lichter I, The terminal phase. Oxford Textbook of
Palliative Medicine, 2nd ed. Doyle D., et al., editor. Oxford University
Press, 1998, pp. 977-78.

·         Remen RN, Kitchen Table Wisdom: Stories That Heal. Riverhead
Books, 1997.





by Eric J. Warm, MD







Edward E. Rylander,M.D.
Diplomat of the American Board of Family Practice
Diplomat of the American Board of Palliative Medicine