How much "sugar-coating" is unethical?
How much "sugar-coating" is unethical?
Over half (55%) of physicians told a patient that his or her prognosis was more positive than the medical facts warranted within the previous year, according to a survey conducted in 2009 of almost 2,000 physicians in seven specialties.1
"Sugarcoating" or holding back information is "completely inappropriate" if it impairs the patient's ability to make informed medical decisions, according to Craig Bates, MD, MS, FACEP, clinical assistant professor of emergency medicine at Case School of Medicine and an attending emergency medicine physician at MetroHealth Medical Center, both in Cleveland, OH.
"The question of what is appropriate when discussing prognosis, when there is some 'gray zone,' depends on the situation," he says. "If the patient has to make choices that can alter their course of treatment, it is critical that physicians are as upfront as possible."
This is the only way that patients can give truly informed consent, emphasizes Bates. "In situations where leaning towards one side or the other will not alter the patient's choices or compromise their ability to give informed consent, I will try to choose the path that seems the best for the patient's needs at the time," he says.
Patients may need time
Many patients appreciate information being presented in a more optimistic manner than the facts warrant, says Barron H. Lerner, MD, associate professor of Medicine and Public Health at the Columbia University College of Physicians in New York City.
"The lie that gets told the most is when someone has metastatic cancer or end-stage disease. The doctor usually puts a more favorable spin on it at first than is warranted," he says.
This is to give patients a period of time to process the information. "With a new diagnosis of cancer, there are different ways to talk about it. You can harp on the bad or the good, or be ambiguous and talk about multiple possibilities," says Lerner.
The physician needs to be careful not to conceal information, however, cautions Lerner. "If patients get too unrealistic in their expectations, I will pull them back to earth a little bit," he says. "That is not a pleasant thing to do, but it's certainly in the job description."
Wait for right time
When a patient presents to an emergency department in cardiac arrest, health care providers know that the chance of meaningful recovery overall is very low, says Bates.
"The trick is that there are a small subset of reversible causes that can have a much better prognosis," he adds. Identifying those reversible causes will likely require the assistance of family present who can describe the events and any pertinent past medical history.
"If one of those relatives asks me what the probability of survival is during the time period that I am trying to identify reversible causes, I will generally not be forthcoming with specifics," he says. "I need that family member to focus on providing assistance."
At that point in time, says Bates, the physician really doesn't know the chance of survival until reversible causes are exhausted.
"I will make it clear that they have a very serious problem, but I won't quote statistics," he says. "As soon as we have determined enough information to figure out the true prognosis, I start informing the family so they know what to expect."
Reference
- Iezzoni LI, Rao SR, DesRoches CM, et al. Survey shows that at least some physicians are not always open or honest with patients. Health Affairs 2012; 31(2):383-391.
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