HOPE 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.
·
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.
·
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.