Posted: 11/30/2010.
"Honesty is the best policy" and "the patient always comes first."
As absolute and correct as those aphorisms may be, they can be hard for doctors to apply in the complex world of modern medicine.
A recent Medscape medical ethics survey of over 10,000 physicians found that when it comes to patient treatment, a significant number of physicians struggle when it comes to topics relating to honest, straight-forward communication, and even pain management. Physicians from a broad range of specialties answered 3 questions pertaining to patient treatment:
- Would you ever hide information from a patient about a terminal or preterminal diagnosis, because you believe that it will bolster their spirit or attitude?
- Would you ever prescribe a treatment that's a placebo, simply because the patient wanted treatment?
- Would you ever undertreat a patient's pain, because of a fear of repercussions or because you are concerned that a patient -- even a terminal patient -- might become addicted?
Open Communication Is Often Difficult
When it comes to delivering bad news, 59.8% of physicians indicate they "tell it exactly as I see it," while 14.6% indicate that they soften the news and "give hope even if there is little chance." Two percent indicate that unless a patient is going to die imminently, they don't tell him or her how bad the situation is and nearly one quarter (23.8%) say "it depends."
"The kind of compassion that brings people into medicine is the type of compassion that is needed for delivering bad news," says Kenneth Goodman, PhD, Director of the Bioethics Program at the University of Miami and author of Ethics and Evidence-Based Medicine: Fallibility and Responsibility in Clinical Medicine. But that compassion should never compromise the truth, he cautions.
Many of the physicians surveyed augmented their responses noting that, while they are honest, they try hard to deliver bad news in the most gentle, humane, and supportive way possible. That's exactly what patients should expect from their doctors, Goodman advises. But in "softening" the truth, he believes that doctors don't need to deviate from it.
"If there is something positive you can say, by all means say it. But only tell the truth: 'I will be there with you. I will help you manage your pain. I will see to it that you can arrange your affairs.' Those are truthful things," Goodman says.
When doctors withhold information, they make it more difficult for patients to chart their course and undermine their own credibility.
From the patient's point of view, "If I don't know my time is limited I can't put my affairs in order. I can't say, 'I'm sorry,'" he says. What's more, "it's not like patients are asking Dr. Kildare, 'What are my chances, Doc?' Patients are increasingly educated. If you don't tell them, they're going to be looking it up on the internet the next day, so you should probably be the source of the data, because you're a human and you care about them."
Goodman advises that the same rationale applies to the use of placebos. Nearly one quarter (23.5%) of respondents said they would prescribe a treatment that was essentially a placebo to a patient simply because he or she wanted treatment. Another 18.2% said, "It depends."
Physicians who were willing to provide "placebo" treatment generally fell into 2 camps. Some said they would do it to appease a patient but only after telling them it wouldn't do them any good. One doctor noted that he'd prescribe vitamins and supplements, "but I'd tell them I thought it was worthless"; while another would prescribe a cream for hemorrhoids, "but they are also forewarned" that the treatment wouldn't do any good.
Still another noted, "In this day and age, many patients will not accept that the best treatment is tincture of time and they have no hesitation about reporting you to the state board or hospital administrator. So, I figure out something that will do the least potential harm and try that."
Others say they'd be willing to prescribe a benign but ineffectual treatment in hopes of achieving a positive placebo effect. "Placebo works up to 50% of the time," said one. "Placebos ARE a form of treatment!" noted another and, "Placebo can be psychologically beneficial and I don't see that as placebo," wrote a third.
Physicians in the first group need to be able to stand their ground in the face of insistent patients, Goodman advises. After all, they are the medical experts.
"Doctors need to be able to say, 'I'm sorry, there is nothing I can do,' No physician is going to provide drugs for a recreational purpose. Why, if a patient asks for an antibiotic for a virus or a prescription that won't work, should he get it?" Goodman asks. As for those hoping to achieve a placebo effect he notes, if a patient finds out he or she has been prescribed a placebo, it will cause irrevocable damage to the physician-patient relationship.
Pain Management Quandaries
While the first 2 patient treatment questions in the survey pertained to communication, the last addressed pain management. While the overwhelming majority (84.1%) of physicians said they would never undertreat pain, a handful (5.6%) said they would, and about 1 in 10 (10.3%) said they would have to evaluate the situation before making a decision.
After filtering out responses from physicians – many of them emergency department doctors – noting that they routinely deny drug-seeking "frequent fliers" prescriptions for pharmaceuticals, the theme frequently voiced by doctors was that they would undertreat pain due to fear of lawsuits. A number of respondents augmented their answers with frustrated, emotional responses about state medical boards, government intrusion, and litigious patients.
Comments included: "I undertreat not due to concerns about addiction but concerns about Drug Enforcement." "We live in a real world. I would like to think I would answer 'no' if real tort reform took place." "I bet we all would in today's drug-abusing, litigious society." And "The state boards can wreck a doctor without appeal."
Despite those concerns, others remained steadfast. "I have only the patient to believe as to how much pain they are experiencing. I have been lied to at times over the years, but I would rather try to believe people than to deny everyone because of some bad actors," wrote one.
When Treatment Denial Causes Suffering
Another noted that physicians' fears of repercussions have "caused patients to suffer needless pain. If a physician does not feel competent or comfortable handling pain issues, (s)he should refer that patient to a reputable pain specialist. Pain is a legitimate medical condition, which we took an oath to alleviate when possible. If the treatment is appropriate and well documented with the current safeguards in place, there should be no fear."
Most respondents who elaborated on their answers, however, drew a sharp distinction between patients with chronic conditions and the terminally ill. Many noted that they do not prescribe narcotics to patients with chronic conditions, refer them to pain management specialists, and are vigilant when it comes to chronically ill patients who tend to "lose" prescriptions too often. When it comes to treating the terminally ill, however, respondents spoke in a single voice: treat their pain.
"Terminal patients should be able to get whatever they need whenever they need it," wrote one. "Terminal patients get whatever they need," said another. A third noted, "Terminal patients should never be allowed to suffer with pain because of inadequate treatment, especially fear of addiction: what difference does it make if they are going to die addicted to narcotics?"
Source:
http://www.medscape.com/viewarticle/732693?src=mp&spon=25
regards, taniafdi ^_^
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