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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
  • More About:

  • Hospice Care
  • Clergy and Faith Communities
  • Additional Links
    Site Index
    Back to Module 13: Cultural Issues
    Tools for Diagnosing and Mediating Cultural Misunderstandings

    Touch and Gender
    Medical Subculture
    Traditional Medicine
    Body Language
    Bad News Fatalism
    Meaning of Illness
    Alternative Medicine
    Imminent Death

    Communicating Bad News

    Issues and Values to Consider in Communicating Bad News

    • Communicating bad news is a burden and an art about which much has been written in the medical literature lately
    • It is intimately associated with issues of truth telling and patient autonomy
    • It is important to remember that truth telling and patient autonomy are highly time- and culture-bound values that are not necessarily shared by your patients



    • As recently as the 1960’s physicians in this country were routinely taught to withhold disclosure of terminal diagnoses out of kindness
    • This is still the common, ethical practice in many countries (such as Italy and Japan)
    • You do not need a list of cultures…. The same basic set respectful questions asked of all patients would obtain the information you need to proceed. This has been called “Talking in pieces”


    Patient Autonomy

    • The concept of patient autonomy is an outgrowth of ideas floating around Western Europe and English-speaking North America since the Reformation on the one hand and the French Revolution on the other
    • However, it is a foreign and even abhorrent idea in many cultures. Permitting patients to choose among treatments may be perceived as avoiding responsibility on the part of the health care practitioner. It may be interpreted as lack of professional knowledge and skill. In any case, a rigid or abrupt approach to decision-making may put the patient in an untenable position, especially if family or group decision-making is the norm



    • ASK the patient what they know about their illness, the name of it, how does it affect their life, what do they expect to happen over the next few weeks or months
    • You can start, if you are not the treating physician, by asking, “What did your doctor tell you about your sickness?”
    • Invite the patient to ask questions. If the patient wants to know, or wants to know from you, the patient will ask you questions, volunteer information and engage you. This is also a good way to ascertain what the patient heard and compare it to what the doctor said
    • Alternatively, volunteer information a little bit at a time like the layers of an onion
        For Example
        "We have found an abnormal growth in your… The mass is rather large…The tumor is in a difficult place for surgeons to reach…There is some tumor in your liver as well… I am afraid that the tumor is probably malignant, that means it could spread even more…. There are several kinds of treatment we can offer you…”
    • The patient will signal when you should stop unwrapping the bad news. S/he will change the subject, ask for a negative confirmation or tell you to stop until a family member comes
    • If the patient is aware of the prognosis and expecting a visit from the palliative team, it is still a good idea to verify their understanding and clarify the nature of the care you will provide
        For Example
        “I am from the palliative care service. Dr. Blank asked us to consult with him about your care. We are the doctors and nurses who specialize in comfort care for patients with serious illnesses such as yours. Has Dr. Blank explained to you about your illness and what can done for you?"


    Family Disclosure

    Determining Whether, Who, and When to Tell

    • Who should you talk to? Generally, whoever asks to talk to you, provided you have the patient's permission
    • An assertive patient may tell you in advance, “Don’t tell my family anything until we talk”
    • Families may approach you in advance asking you to talk to them before you talk to the patient or insisting that you not tell the patient
    • Whatever the case, it is important that you anticipate
    • If the terminal diagnosis has been made you may ask the patient, “Would you like me to talk about it with you alone or would you prefer that I talk to your family first or would you like to talk about it all together?”
    • If the family is chosen, ask whom in the family the patient designates. You may confirm this by asking the family who should be contacted for medical matters, and who is “head of the family” for decisions
    • Learn the authority hierarchy of the family. Then ASK how to proceed. “We will have to make a lot decisions about treatment for your (wife) as things go along. Who should we call first? Who second? Would you like to have regular meetings?”


    Family Decision-Making

    • Family decision-making is more the norm than the exception
    • Once the “command system” is agreed upon, you can begin to explore the specific care needs and beliefs of the patient
    • It may be that you will “lie” to the patient if the difference is between total disclosure and negotiated discretion
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