COLLUSION IN PALLIATIVE CARE
Khoo Siew Beng FRACGP
Penang Medical College.
Address for correspondence: Dr Khoo Siew Beng, Department of Family Medicine, Penang Medical College, No 4, Sepoy Lines Road, Penang 10450, Malaysia. Tel: 604-2263451, Fax: 604-2284285, E-mail: email@example.com
Collusion is generally an act of love and protection for a close relative from knowing the bad news with regard to diagnosis and prognosis of his/her illness. Evidence from research studies showed that although truth hurts, deceit may well hurt more. Filial duties and obligations form the basis for non disclosure in some cultures while principles of informed consent and patient autonomy are ethical and legal obligations to provide patients with as much information as possible in some countries. Collusion serves to isolate the patient, cause family disruption, incurs tremendous psychosocial stress on patient and relatives and leads to poor standard of healthcare. It is vital to assess for presence of collusion from the outset and to avoid this distressing dilemma. This case report is an example of the great cost of collusion on the carer’s part.
Keywords: Collusion, anxiety depression, guilt, ethical issues, cultural acceptance, truth telling.
Khoo SB. Collusion in palliative care. Malaysian Family Physician. 2006;1(2&3):62-64
Miss A, a 22-year old teacher, suffered from severe palpitation, tremor and intense feeling of fear whenever she went to work. Her symptoms had become progressively worse over a period of 10 months. She was diagnosed with anxiety depression with suicidal tendency and was under the care of a hospital psychiatrist for 2 months when I met her. She was treated with alprazolam for panic attacks and a course of sertraline for her depression. She attributed her illness to stress at the new working place.
Casual conversation with Miss A and her aunt revealed that Miss A’s father was diagnosed with gastric carcinoma a year earlier. Partial gastrectomy was done for him followed by oral chemotherapy. Lately it was discovered that he had metastases to the surrounding lymph nodes and had to undergo another surgical intervention.
The patient himself was told that he had some “toxic” tumour in the stomach that had been removed and that he would be fine. Miss A, being the eldest in the family, and her aunt who is a nurse were told of the diagnosis. All the other family members including Miss A’s mother, brothers and sisters did not know about the malignancy. Miss A was adamant that her father must not be told of the truth for he would not be able to take it.Miss A used to have an optimistic, cheerful demeanour, without any past history of anxiety depression. Her symptoms started soon after diagnosis of her father’s cancer was revealed to her. At about the same time she was transferred to work in a new school. On assessment we could not identify any specific factors associated with her anxiety depression and panic attacks whenever she
went to school. I realized that Miss A’s anxiety depression was more likely due to the cost of collusion rather than stress at the working place.
Disadvantages of collusion were explained to both Miss A and her aunt. Miss A’s aunt decided to reveal the truth to the whole family in spite of protest from Miss A. The patient was quite depressed the first few days. Given time and support from the family, he came to terms with the fact that he was dying. He discussed his plans with the family with regard to his will and other legal matters and his funeral arrangement. He prepared the family emotionally for his final departure. He had a good peaceful death in the end.
Miss A’s symptoms improved soon after the truth of malignancy was disclosed to the patient and other family members. She realized that her father was able to cope better than she anticipated. There was better communication among all family members, everyone was free to express their emotions and had the opportunity to provide support for her father. After witnessing the favourable outcome from the disclosure of the truths, she expressed her gratitude and described her feeling as “a heavy burden taken off my shoulder.” Miss A was eventually called off her psychiatric medication. She is still teaching at the same school and is now pursuing an off campus degree course in Science.
DISCUSSIONDo cancer patients want to know the truth?
“The news would kill him – you must not say anything”. This is a commonly expressed belief that what people do not know does not harm them. ‘No news is not good news, it is an invitation to fear’ Evidence from research studies showed that although truth hurts, deceit may well hurt more.1
In a recently published paper examining the information preferences of a heterogeneous sample of 2331 patients with cancer in UK 2027 (78%) wanted all possible information, be it good or bad news.2 The evidence for substantial cultural differences regarding information needs among cancer patients is rather thin or inconclusive. For example Fielding and Hung challenged the notion that Asian patients with cancer and their families want less information than their western counterparts in a series of well conducted studies.3 In some Chinese culture filial duties and obligations form the basis for non-disclosure.4 In Japan it is a common practice for physicians to explain about the patient’s condition to family members first and that the patients are informed only when their families agree. This is due to the Japanese culture that the group’s wishes are more respected than those of the individual that indicates that the sense of belonging to the family is very strong.5 In North America, principles of informed consent, patient autonomy, and case law have created clear ethical and legal obligations to provide patients with as much information as they desire about their illness and its treatment.6
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