Aga Khan University School of Nursing and Midwifery, Karachi, Sindh, Pakistan
Received date: December 14, 2015; Accepted date: February 22, 2016; Published date: February 25, 2016
Citation: Badruddin S (2016) Ethics of Breaking Sad News to Patient by Health Care Professionals: Pakistan Perspective. J Clin Res Bioeth 7:261. doi: 10.4172/2155-9627.1000261
Copyright: © 2016, Badruddin S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Visit for more related articles at Journal of Clinical Research & Bioethics
Sad news is defined as a situation where there is feeling of no hope, a threat to person’s mental or physical wellbeing, or where a message is given which may result in fewer choices to individuals’ lives. This issue creates ethical controversies among health care professional that who should decide and to whom health personnel will disclose this sad news. The aim of this paper is to explain and analyze this concept in the light of ethical principles. The paper will discuss the role of health care professionals in the disclosure of sad news integrating an explicit ethical decision making process.
Health care; Decision making; Ethics; Prognosis; Gastroectomy
In Pakistani culture, families are given ultimate authority and are responsible to take decision on behalf of patient. This situation creates conflict for health personnel whether to break sad news to patient or not. The most difficult part for the health team to face is how to break the sad news. There are many reasons for that, why health personnel are facing difficulty while dealing such controversial issue. A universal concern for the multidisciplinary team is that how sad news will have an effect on the patient, whether to informed the patient or not. This is the dilemma which most of the health personnel face while breaking sad news.
The same scenario came across in surgical ward. Sixty years old female was admitted with stomach cancer and underwent total gastrectomy. During the post-operative period, patient was asking about her disease and prognosis. Family does not wanted health care professional to share the diagnosis with patient. Upon asking, health care professionals were giving false statement about her condition and disease process.
After analyzing the scenario, several questions come up to mind. Why health personnel give false reassurance to patient when we know that patient is terminally ill? Does hope has more power than truth telling? Sad news is defined as pertaining to situation where there is feeling of no hope, a threat to person’s mental or physical well-being, a risk of upsetting an established lifestyle, or where a message is given which conveys to an individual fewer choices in his or her life . This is the main issue that who should decide and to whom health personnel will share this sad news. American Medical Association’s first code of medical ethics stated that life of a sick person can be shortened not only by acts, but also by the words or manners of a physician. It is therefore a sacred duty to guard him carefully in this respect and to avoid all things which have tendency to discourage the patient and to depress his spirits .
Massage the dilemma
In order to resolve this conflicting issue, Patricia Crisham model was integrated to make decision. There are three persons involved in this scenario. One is patient, one is family and other is health professional. Family and patient may be considered as one unit or separate.
There are two positions involved in this scenario.
One stand is family should decide whether health team member share this sad news to patient or not.
The other stand is health personnel should directly share this sad news to patient and patient should make the decision to whom health team will break this sad news.
In the next few lines, we will discuss the proponent and opponent view on the basis of ethical theories or principles and at what level health personnel should disclose information to patient and how to make decision to whether disclose sad news or not.
Breaking Sad News: Proponent and Opponent Views in Light of Ethical Theories/Principles
Review criteria and resolve: Truth telling vs. Hope:
Truth telling is foremost our duty and should not be neglected even when we are not aware about the consequences. According to Kant, individuals must always reveal the truth irrespective of consequences (Hodkinson, et al.). Experience and study suggest that most patients, family members or other decision makers want to hear the reality of their situation . On contrary it is argued that telling truth will decrease patient’s hope. It is common to hear clinicians arguing that most patients do not wish to hear the truth as they will lose hope, become overwhelmed with an immobilizing depression and not enjoy their remaining time . Hence, some health personnel prefer hope rather than truth telling. After hearing the diagnosis of cancer, future living is negatively altered by the threat of impending death. Truth telling is important because it will prepare the patient for advance directives and spiritual upliftment. In contrast, when patient is denying and doesn’t want to hear about the diagnosis, then we wouldn’t disclose this information to patient. As a health professional, it is our responsibility to assess the patient perception about disease, level of education and decision making capacity. However, if the patient favors this decision to family, then it is the responsibility of health care professional to share this sad news to family.
Autonomy vs. Nonmaleficence
Patient should tell the truth and family should be convince to give knowledge to patient about diagnosis and treatment because this is patient’s right and we can’t ignore patients autonomy. Autonomy has acquired meaning as self-governance, liberty rights, privacy, individual choice, freedom of the will, causing one’s own behavior and being one’s own person . Health care team claims that decision not to tell is based on non-maleficence. The principle of non-maleficence asserts an obligation not to inflict harm on others . The principle of nonmaleficence also guides not to hurt the patient. Patient with prolong suffering may have depression and they may lose their hope. Hence it is justified that we are not censoring information to patient in an attempt to protect patient from hurtful sad news. It is rightly to say that autonomous choice is a right, not a duty of patient . Even autonomous persons with self-governing capacities sometimes fail to govern themselves in particular choices because of a temporary constraints caused by illness or depression, or because of ignorance, coercion, or other conditions that restrict their options . However, if the patient doesn’t want to know the truth or she is denying by crying then we don’t have to pressurize her to receive this sad news. She is giving this authority to her family members. In addition, respecting an autonomous agent is, to acknowledge that person’s right to hold views, to make choices and to take actions based on personal values and beliefs .
Ethics of care
Ethics of care believes in providing care and saving life. Ethics of care will question how one can give trauma to person or destroy her hope. Caring in these accounts refers to care for, emotional commitment to and willingness to act on behalf of persons with whom one has a significant relationship . Ethics of care would approach by focusing on relationships involving care, responsibility, trust, fidelity, and sensitivity. Ethics of care supports family involvement and families are more capable to decide for patient because they are very much closer and nearer to patient. They can take decision on behalf of patient. The nursing codes of ethics (International Council of Nurses (ICN), American Nurses Association (ANA) shared nurses should refrain from making decisions that do not respect the preferences, values and beliefs of patients, together with their autonomy and privacy, as well as requiring them to be consistent in making decisions that promote patients’ well-being and integrity [6-9].
Affirm position and act
On the basis of literature review for breaking sad news and hope, its analysis with ethical theories and principles, the final position is that we would not disclose diagnosis to patient when patient does not want to know or transfer this power to family members. We need to properly assess the patient education level, fear and decision making capacity [10-12]. We also need to integrate Kubler Ross stages of grief such as denial, anger, bargaining, depression and acceptance while dealing with such sensitive issues. In this way, we will be able to reach to final decision.
If the same scenario occurs in future, i will use the proper communication with patient and properly assess the patient level of understanding. Asking the patient is our priority in order to protect patient’s autonomy. As a health care professional, I will ask the patient, build the rapport and discuss to whom I can share this information. I will advocate and take initiative for my patient and take this issue to the Ethics committee in the hospital. Moreover, I will use the same steps to make the decision as I have incorporated Patricia Crisham model in this paper [13-15]. I will analyze the scenario from different point of view on the basis of ethical theories or principles. If the patient doesn’t want to know or recommends family then we will directly break this news to family and respect patient wishes.
In conclusion, health care professionals encounter such situation in their day to day practices. The disclosure of sad news is an ethical dilemma that requires deliberative thinking and reflection by the health care providers. It is suggested that disclosure of sad news should be encouraged keeping in view the principle of beneficence, nonmaleficence, patient’s autonomy and Kant’s theory. This disclosure will lead to better satisfaction from the patients and health care providers. This will give autonomy to patient and will give the chance to patient to prepare their advance directives. This case also raises the concept of making Advance directives awareness in the country legal system. In recommendation, I would advocate that we should create awareness regarding the concept of advance directives at the media and community level.