Truth Telling to Terminally Ill Patients: To Tell or not to Tell

Cancer is a life threatening disease, which for many years and in many cultures was supposed as incurable. Previously, cancer meant death, and therefore was likely to hide the diagnosis from the patient. This situation has changed and presently health care professionals usually favour to inform patients about their disease and its prognosis. However, deception is still sometimes used by health care professionals while treating terminally ill patients [1]. It may be intentional or unintentional and, apart from lies, it can involve half-truths and controlled provision of information to patients. Although, disclosing the diagnosis of terminal illness like cancer is devastating for patients. Health care professionals are the ones who have responsibility to break bad news by giving information about diseases and their prognosis to patients. This duty becomes more difficult when family asks to conceal the diagnosis from patients. This paper aims to discuss the ethical dilemma in the light of the four principles of Beauchamp and Childress [2]. Moreover, truth telling from different perspectives and challenges that nurses has to face when making an ethical decision will be discussed.


Introduction
Cancer is a life threatening disease, which for many years and in many cultures was supposed as incurable. Previously, cancer meant death, and therefore was likely to hide the diagnosis from the patient. This situation has changed and presently health care professionals usually favour to inform patients about their disease and its prognosis. However, deception is still sometimes used by health care professionals while treating terminally ill patients [1]. It may be intentional or unintentional and, apart from lies, it can involve half-truths and controlled provision of information to patients. Although, disclosing the diagnosis of terminal illness like cancer is devastating for patients. Health care professionals are the ones who have responsibility to break bad news by giving information about diseases and their prognosis to patients. This duty becomes more difficult when family asks to conceal the diagnosis from patients. This paper aims to discuss the ethical dilemma in the light of the four principles of Beauchamp and Childress [2]. Moreover, truth telling from different perspectives and challenges that nurses has to face when making an ethical decision will be discussed.

Case Scenario
Merry was a 40-year-old mother of two with a history of tumor and hospital visits; however, her last doctor's visit in October left her and her family with shattering news. Doctors diagnosed Merry with metastatic inoperable tumor. Since Merry last visit, her conditions worsened due to malignancy and she became a victim of nausea, vomiting, intestinal obstruction and slothfulness. When Merry came to know of her medical conditions, she became stubborn and denied treatments the hospital offered her: exploratory laparotomy, insertion of a urinary catheter, and insertion of nasogastric tube.
The matter of refusal of treatment between the medical staff and Merry put her family in a hard situation. They encouraged Merry to agree to take the hospital's treatments; on the other hand, they also wanted to respect and honour her autonomous wishes. In due course, the medical team established a terminal diagnosis for Merry and informed this to her family. Afterwards, the family asked the consultant to keep this information from Merry. The consultant agreed and Merry sustained her stay in the hospital with the trust that she was suffering from tumor which can be cured.
A week later, the holidays approached Merry and her family conversed plans for Christmas as well as her discharge from the hospital. Though Merry's family and doctors were well aware of her prognosis, both groups willingly concealed the truth and let Merry believe her health condition was not terminal. This created an uncomfortable situation for the involved health care professionals involved in this tough conflict of interest. Eventually, Merry's disease took control of her life and she unknowingly passed away one week before her expected Christmas holiday.
Truth telling to terminally ill patients is a common ethical dilemma in health care ethics: to inform or not to inform, is the main question. Nurses work closely with patients and thus are the ones put in this difficulty between their patient and their patient's family. Who should they listen to? Should they leave their patient in the dark by not telling them truth?

The Ethical Dilemma
This case scenario presents a dilemma when the nurse has to select between the mutually exclusive events [3]. The definite issue is whether a nurse by respecting the family's wish should keep the truth from her terminally ill patient, or by abiding the Code of Ethics for Nurses, should disclose the truth to the patient. The Nurses Code of Ethics articulates the ethics and values of the nursing profession by affirming that "nursing care is directed toward meeting the comprehensive needs of patients and their families across the continuum of care, " in addition, "promoting, advocating for, and striving to protect the health, safety, and the rights of the patient" [4]. Although the restriction of keeping truth from patient was posed by family, but nurses the primary person who deals with such dilemmas. However, nurse's responsibility is to be professional, stay true to the lawfulness of their practice, and follow the Nursing Code of Ethics as well as hospital's policy in truth telling [5].

Respect for Autonomy
Principle of autonomy entails respect for patient's wish [1]. It is significant to note that principle of biomedical ethics begin with the dialogue of autonomy. According to Beauchamp and Childress (2001) [1] "…our order of presentation does not imply that this principle has priority over all other principles. A misguided criticism of our account is that the principle of respect for autonomy overrides all other moral considerations. This we firmly deny. "Autonomy is to make a choice for the self, without of the control of others and a patient can make meaningful decision having adequate level of understanding [6]. In this case scenario Merry has full rights to be informed about her diagnosis and prognosis regardless of the family decision. Besides, if the nurse would reveal the prognosis Merry could made independent choices about her treatment plan. Moreover, Merry is not incompetent nor has any mental incapacity and could have taken decision of her treatment on her own.

Beneficence
Ethical principle relating to this dilemma involves the well-being of the patient. The principle of beneficence states that the nurse should promote good and prevent harm [7]. This means that patient's autonomy should be respected. In Merry's case, beneficence is not considered by her nurse and she conceals her poor prognosis of malignant inoperable tumor from Merry. Informing about patient's diagnosis and prognosis may let Merry to complete her unfinished task of her life and spending quality time with her two children and family members. Moreover, it may help in gaining peace of mind and lessen her worries; therefore, knowing her poor condition could have benefited her in many ways. Thus, diagnosis and prognosis should not be with held as per family's wish.

Non-malefience
Non-maleficence, do no harm is the negative side of the beneficence like the two sides of the same coin. The notion of not telling truth in this case scenario relates to the principle of non-maleficence. Telling about poor prognosis to the patient may cause psychological harm to her. Therefore, in this situation action of nurse by withholding truth about her diagnosis may enhance patient care and prevent harm.
On the contrary, the principle of veracity focuses on telling truth and providing full and accurate information to patient. Therefore, if nurse abiding by this principle advocates truth telling, can may disregards patient's and family's feelings. However, if the anticipated harm to Merry in this situation is greater like psychological trauma because of young age and her two children than harm should be avoided. This entails nurse to be skillful enough in weighing the net benefits versus net harm that is being provided to patient. Hence, nurse must reflect and do in-depth situational analysis before reaching to decision.

Analyzing context
To understand the decision making process in this case, nurse should consider all the principles ofBeauchamp and Childress (2001) [1] before taking any decision namely autonomy, beneficence, nonmaleficence, and justice. According to Gardiner (2003) [8] all the ethical principles should influence one's choice. In this case, family of Merry has suspected that after knowing the prognosis she might experience psychological distress and keep the prognosis from her.
After analysing these four principles, it is concluded that a lot of value conflicts exist. Owing to their emotional relationship with the patient, nurses frequently struggle in truth telling situations where they might have to turn their back on the patient to keep the truth a secret. Professionally, nurse should always stand by the hospital's policies and permit their patient to have access to all the medical information comprising their prognosis, treatment options, and its outcome, irrespective if it is bad [9]. In this case the Merry's nurse could have made a decision from the code of ethics by honoring patient's autonomy. The American Nurses Association, code of ethics outlines "The nurse provides services with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes or the nature of the health problem" (ANA, 2001, p.1) [10].To respect Merry's choice and dignity, correct information should be delivered to the patient in an effort to justify her rights, while valuing her wishes at the same time.

Conclusion
Truth telling about disease and it prognosis to terminally ill patients is a big ethical dilemma that nurses have to deal with on regular basis. Nurses are always at forefront in hospitals for patient care, therefore they must be committed to provide truthful information to patients and support them and their families when the truth has been delivered. Telling the truth needs to be done in a timely and sensitive manner. Relationship between nurse, patient and family can be jeopardized if truthfulness is not part of the everyday communication.
In this case of Merry, if she knew she was about to die, she could have said goodbye to her two children and rest of the family members. Unfortunately, due to family pressure, Merry's nurse chose not to disclose the truth and therefore further options were out of her knowledge that could have lengthen the time that Merry could have had on earth.