Truth Disclosure at the End of Life: A Qualitative Study of Internal Medicine Residents in the United Arab Emirates

Background Respect for patient autonomy has become the guiding biomedical ethical tenet in the West; yet, moral values are contextual and culturally relevant. In the collectivist society of the Middle East, families and physicians have historically believed that concealing truth about a terminal illness is more ethical and compassionate. Recent studies reveal a trend toward truth disclosure. Objective To gain insight into resident experiences with, and barriers to, truth disclosure in terminally ill patients in the United Arab Emirates (UAE). Methods Focus group interviews were conducted with first through fourth year internal medicine residents and recent graduates at two large academic medical centers in the UAE. Qualitative thematic content analysis was used to identify themes related to communication and truth telling in end-of-life care. Results Residents revealed that non-disclosure of medical information in serious illness is a common practice in UAE hospitals. Barriers to truth telling include family objection, deficits in medical training, and inconsistently implemented institutional guidelines. Conclusion Educational and policy interventions are needed to improve physician-patient communication, decrease patient-family-physician tension, and alleviate trainee moral distress.

The experiences of health professionals, patients, and families with truth disclosure when breaking bad news in palliative care: A qualitative meta-synthesis

Objective Disclosing the truth when breaking bad news continues to be difficult for health professionals, yet it is essential for patients when making informed decisions about their treatment and end-of-life care. This literature review aimed to explore and examine how health professionals, patients, and families experience truth disclosure during the delivery of bad news in the inpatient/outpatient palliative care setting. Methods A systemized search for peer-reviewed, published papers between 2013 and 2020 was undertaken in September 2020 using the CINAHL, Medline, and PsycInfo databases. The keywords and MeSH terms (“truth disclosure”) AND (“palliative care or end-of-life care or terminal care or dying”) were used. The search was repeated using (“bad news”) AND (“palliative care or end-of-life care or terminal care or dying”) terms. A meta-synthesis was undertaken to synthesize the findings from the eight papers. Results Eight papers were included in the meta-synthesis and were represented by five Western countries. Following the synthesis process, two concepts were identified: “Enablers in breaking bad news” and “Truth avoidance/disclosure.” Several elements formed the concept of Enablers for breaking bad news, such as the therapeutic relationship, reading cues, acknowledgment, language/delivery, time/place, and qualities. A conceptual model was developed to illustrate the findings of the synthesis. Significance of results The conceptual model demonstrates a unique way to look at communication dynamics around truth disclosure and avoidance when breaking bad news. Informed decision-making requires an understanding of the whole truth, and therefore truth disclosure is an essential part of breaking bad news.

Attitudes of Physicians in Jordan Toward Non-Disclosure of Health Information

Objectives: Our aim was to investigate the attitudes of physicians in Jordan toward non-disclosure and the differential attitudes of physicians who are “always truthful” and those who are not. Methods: Our report is based on the second subset of data from a cross-sectional study of the truth disclosure practices and attitudes of physicians in Jordan, which was conducted between January and August 2016. We selected 240 physicians from four major hospitals by stratified random sampling, and we invited them to complete a self-administered questionnaire regarding truth disclosure attitudes. We compared the attitudes of physicians who were “always” truthful and those who were not. Results: In total, 164 physicians (68%) completed the questionnaire, of whom 17 (10%) were “always truthful”, while the remaining 144 (90%) were not. Physicians who were “always truthful” were more likely to indicate that non-disclosure is “unethical” (77% v. 39%; p=0.009). Moreover, physicians who were “always truthful” were more likely to disagree that non-disclosure is beneficial for the physical and psychological health of patients (82% v. 55%; p=0.03). The majority of physicians agreed that all patients have the right to know their diagnosis, most patients prefer to know their diagnosis, and the introduction of legislation to enforce disclosure would positively affect medical practice in Jordan. Conclusion: The differential attitudes of physicians who were “always truthful” and those who were “not always truthful” suggest a rationale behind independent non-disclosure, namely that non-disclosure is ethically justifiable and beneficial for the physical and psychological health of patients.Keywords: Truth Disclosure • Physicians • Attitude • Jordan • Middle East • Cross-Sectional Studies

The physician-nurse collaboration in truth disclosure: from nurses’ perspective

Background Collaboration between physicians and nurses is critical. However, a limited number of studies have provided insights into the status of physician–nurse collaboration in truth disclosure. Methods A cross-sectional survey was conducted using an electronic questionnaire among Chinese nurses who attended a provincial conference. The Nurse–Physician Collaboration Scale was administered to nurses to assess the collaboration in truth disclosure from their perspective. A multiple-choice question was asked to assess the perceived difficulties in truth disclosure. Descriptive statistics, univariate, and multiple stepwise regression analyses were performed to evaluate physician–nurse collaboration in truth disclosure. Results A total of 287 nurses completed the survey, and 279 of them reported that they had carried out truth disclosures among patients. The average score for physician–nurse collaboration in truth disclosure was 3.98 ± 0.72. The majority of nurses (73.1–81%) responded positively to different dimensions of collaboration in truth disclosure. The results of multiple stepwise regression analysis showed that seniority (B = − 0.111, 95% confidence interval [CI] = − 0.167−− 0.055, p < 0.001) and frequency of truth disclosure (B = 0.162, 95%CI = 0.076–0.249, p < 0.001) were the only two factors associated with collaboration in truth disclosure between physicians and nurses. The most common barrier perceived by nurses was fear of patients’ negative emotions or their suicide attempts after truth telling. Conclusions Most nurses responded positively to physician–nurse collaboration in truth disclosure. Various difficulties existed in the practice of truth-telling collaboration. Further studies are required to test the potential interventions to promote cooperation between nurses and physicians in truth disclosure.

Practice and Attitudes of Physicians Regarding Disclosure of Information to Patients With Serious Illness

BACKGROUND: Health Information disclosure is the cornerstone in respecting the patients&rsquo; autonomy and beneficence, particularly in the context of serious illness. Some Middle Eastern cultures prioritise beneficence over patient autonomy. This may be used as a justification when patient&rsquo;s family takes over the decision-making process. Although guidelines and protocols regarding information disclosure are fast evolving, there are no sufficient data regarding the application of these guidelines in the clinical context. The objective of this study is to explore the truth disclosure practices of physicians in Bahrain. METHOD: In this cross sectional study, a random sample of 234 physicians was obtained from the database of Salmaniya Medical Complex (the largest public hospital in Bahrain). We used self-administered 21-item questionnaire to assess the practices and attitudes of physicians regarding disclosure of information to patients with serious illnesses. RESULTS: A total of 200 physicians completed the questionnaire with a response rate of 69.6%. The question about the usual policy of disclosure revealed that 62.5% (125) of the doctors would always disclose the diagnosis to the patients, 26% (52) would often disclose the diagnosis and only 1% would never disclose the real diagnosis to a competent adult. Only 15% of the physicians would never make exceptions to their policy of &ldquo;telling the patient&rdquo; while all remaining physicians (85%) made exceptions to their policy either often, occasionally or rarely. The most common reason for not disclosing the diagnosis was family request (39.5%). About 64.5% of the physicians were not aware of any existing protocol or policy for diagnosis disclosure to patients. There was no statistically significant association between doctors&rsquo; policy of disclosure and other demographic variables. CONCLUSION: Most physicians opt to disclose the truth; however, the majority would make exceptions at some point particularly upon family request. Regional truth disclosure policies should take into consideration the interplay and balance between patient autonomy and the role played by the family in the decision-making process.

Death attitudes and truth disclosure: A survey of family caregivers of elders with terminal cancer in China

Background: Although family caregivers play an important role in end-of-life care decisions, few studies have examined the communication between family caregivers and patients at the end of life. Objective: The objective was to describe family caregivers’ attitudes toward death, hospice, and truth disclosure. Research design: A quantitative method was used, and a closed-ended survey of 140 family caregivers was conducted in China. The subjects included 140 primary family caregivers of elders with terminal cancer enrolled at a hospice center from April to August 2017. Participants: 140 primary family caregivers of elders with terminal cancer participated the study. Research Context: A high proportion of cancer patients continue to receive inadequate information about their illness. Family caregivers’ inhibitions about disclosing information to cancer patients have not yet been the objects of research in China. Ethical considerations: This study was reported to and approved by the Regional Ethics Committee in Shenzhen, China. Findings: A questionnaire survey collected information on family caregivers’ background information, emotional state, personal needs, death attitudes, and truth-disclosure opinions. The results revealed that family caregivers’ death attitudes and truth-disclosure opinions played an important role in the process of caring for elders with terminal cancer. Discussion: By adopting a quantitative method, the author revealed not only the general patterns of family caregivers’ attitudes toward cancer diagnosis disclosure but also the reasons for their actions and the practices of family disclosure. Conclusion: The findings suggested that ineffective communication concerning end-of-life issues resulted from family caregivers’ lack of discussion and difficulty in hearing the news. Future studies should examine strategies for optimal communication between family caregivers and patients, especially with regard to breaking the bad news. Professional training in breaking bad news is important and is associated with self-reported truth-disclosure practices among family caregivers.