18. CASE: When the “Truth” is Painful

Mrs. Sally Parrot, a 73-year old widow, has mild dementia of a presumed neurovascular type. She resides in her own small apartment in Serenity, a private continuing care community in Bedford, where she receives some assistance with housekeeping, meal preparation and organization of her medications. Sally is actively engaged in Serenity’s structured activities and, in particular, enjoys participating in the music program and walking group. One of her two children, Lorna, resides in Halifax and visits her once weekly.

Sally was recently diagnosed with slowly progressive, metastatic bowel cancer. After talking it over with Lorna and her son Fred, Sally decides to go ahead with a series of recommended palliative treatments: a short course of chemotherapy, de-bulking bowel surgery and low dosage radiotherapy.

After the chemotherapy, which she has tolerated well, Sally is admitted to hospital for her surgery, which involves removal of a section of large bowel that contains the primary tumour. Unfortunately, she develops post-operative delirium, which has been slow to clear over the past few weeks in hospital. At the present time, she is reasonably clear-headed in the morning, but her cognition deteriorates in a ‘sun-down’ fashion as the day progresses.

Seeing how her mother has reacted to surgery, Lorna begins to wonder if the planned third phase of treatment, i.e., palliative radiotherapy, is the still the way to go. She decides to wait until her brother arrives later that week from Australia to sort this out. In the meantime, during the late afternoons and evenings, Sally has begun to ask her health care providers about why she is in the hospital. They tell her that she is in hospital for surgical treatment of her bowel cancer. However, Sally does not retain information for more than ten minutes late in the day due to her delirium-related confusion, so each time the direct care nurses inform her that she has cancer in response to her question, she responds in the same way – with surprise and significant emotional distress.

The nurses consider truth-telling in the disclosure of health information to be an important professional value and practice. However, they begin to wonder whether they are doing more harm than good in responding to Sally’s repeated questions in an honest and forthright way.

A group of nurses who are experiencing moral distress in these challenging circumstances get together and, with the knowledge of their health services manager, contact the clinical ethics service to make a formal request for ethics support.

  • What are the ethics issues in this case?
  • How would you work through the issues with the health care team?
  • Is withholding the truth from a patient ever the right decision?
  • Should alleviating the distress of the patient and/or the health care team be more of a priority than upholding the value of truth-telling?

Some Values and Ethics Issues to Consider

  • Honesty, trust and truth-telling
  • Capacity
  • Substitute decision-making
  • Respect for patient autonomy
  • Moral distress among health care providers
  • Patient-family relationships
  • Respect for human dignity
  • Patient-centered care
  • Respect for professional integrity
  • Beneficence and non-maleficence

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