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Fast Fact and Concept #21: Hope and Truth Telling

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Title: Fast Fact and Concept #21: Hope and Truth Telling

Author(s): Warm, E.; Weissman, D.

This Fast Fact and Concept discusses the difficult balance between maintaining hope and truth telling, especially as it applies to giving bad news. It is appropriate for use during ward rounds, morning report or a communication skills workshop.


Educational Objective(s)
Understand the physician's role in balancing hope and truth telling. Review strategies for eliciting patient hopes.
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.

Teaching Tips

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.

References

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.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Disclaimer Concerning Medical Information
Health care providers should exercise their own independent clinical judgment. Accordingly, official prescribing information should be consulted before any product is used.

Contact: David E. Weissman, MD, FACP Editor, Journal of Palliative Medicine Palliative Care Program Director Medical College of Wisconsin (P) 414-805-4607(F) 414-805-4608

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman, D. Fast Fact and Concepts #21: Hope and Truth Telling. September, 2000. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 8/2000

Format: Handouts

Purpose: Instructional Aid

Audience(s)
Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Clergy/Chaplains, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers

ACGME Competencies: Interpersonal and Communication Skills, Medical Knowledge, Patient Care

Keyword(s): Communications skills, Death pronouncement, Discussing hospice care, Family conference, Giving bad news, Hope, Negotiating treatment goals, Personal reflection, Prognosis


The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).