August 30, 2007

On oops disclosures

Dr. Michael Wilkes's Second Opinion on KCRW on disclosure.

I've commented with my thoughts on disclosure of a cancer diagnosis to a Japanese patient before in "Shh! He doesn't know!" Culturally, it is acceptable for the family to request that this information be withheld from the patient -- something that I found ethically repugnant a year ago.

If a patient asks "why am I getting this treatment", is the family asking us to lie for them? How far is this betrayal of trust expected to go?

However, my recent visit to Japan made me reconsider this. There is a trend in Japan towards more Western values and practices in Medicine (among other things) and cancer disclosure is still a contentious topic there. I asked a few doctors (one was a cardiologist, the other, a resident training in GI) how they approach the subject.

The resident told me point blank that he followed the family's wishes and didn't tell the patient. He echoed the sentiment "a lot of patients cannot handle a diagnosis of cancer." I was surprised to hear this. Cancer isn't the death sentence that it used to be. The elder cardiologist agreed with me and told me that he tells his patients regardless of what the family wants. "It's their right to know," he said. Of course, he did have training in the U.S., so that might have affected his cultural judgement.

I'm not sure how I feel about the situation mentioned by Dr. Wilkes. If I were the surgeon, what would I do?

*deep inhalation*

I'd like to think that I could do the right thing and respect the family's wishes while still fulfilling my role as a doctor. Before the diagnosis is even made, I would like to approach the patient and tell him/her "now, one of the things we are testing for is cancer. If it turns out to be cancer, how would you like this to be handled?"

This gives the patient an opportunity to "opt-out" and puts patient decision-making in the hands of the family. I think this is culturally sensitive for both parties and it has the advantage of forewarning the patient of their potential diagnosis. If they are keen, they probably suspected cancer all along. Perhaps it's just reassuring for some patients to know that they are being taken care of as best as possible without having to worry about the prognosis.

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