Exploring the Role of Health Professionals in Truth Telling: A Nursing Perspective
Issue 7, August 2002
Truth telling (veracity) is a key factor in the relationship between patients, their families and health professionals. The Oxford dictionary defines truth as: a quality or state of being true, genuine, loyal, faithful; in accordance with fact or reality, exact, accurate.
Yet, for the health professional, there is more to telling the truth than simply being accurate and exact, factual and literal. Relationships with human beings are far more complex, as is the way we speak the truth. There are many aspects to communicating the truth to patients and families. Adopting a blanket "they must know at all costs" approach, or even having policies and protocols that provide a fixed framework for patient health professional dialogue, does not adequately deal with the complexity of truth telling. What is called for is a mix of skill, knowledge, wisdom, intuition and insight. Further variables to be considered in an understanding of truth telling include the context, rapport, professional relationships and institutional culture. This article will briefly explore some of the issues around truth telling from a nursing perspective.
Principles and Truth Telling
It is not unusual for nurses to have a number of discussions each day around the issues relating to a particular case. The well known principles of autonomy, beneficence and non-maleficence are used by nurses as guides to assist them in the 'to tell or not to tell' debate. Helpful as they are, however, the reality is that these principles often conflict with each other and require balancing in our efforts to communicate with patients and their families.
Lichter (1989) believes it is vital to tell the truth to a patient because they have a right to know. He therefore advocates overriding the principles of non-maleficence (whether the "full" truth may in some ways be detrimental to a patient) and beneficence (whether it is to the patients advantage not to know the full truth) in favour of autonomy (the right to choose who we wish to be, to make our own decisions and to be in control of what is being done to us). Kendall (1995) argues that "an action can be harmful at the same time as being beneficial" and draws an analogy between truth telling and chemotherapy treatment. While chemotherapy introduces toxins that can cause extreme harm, the outcome of this treatment may well be beneficial for the patient. Likewise, telling the painful truth can be beneficial by allowing patients and families to facilitate planning and decision-making in regard to their lives and future care.
The views of Lichter and Kendall are representative of many others and lead us to conclude that the debate about truth telling in the area of healthcare is no longer around 'to tell' or 'not to tell', but rather about who should tell, when to tell and how to tell.
Nurses and Truth Telling
A review of the relevant literature reveals that many health professionals will only tell the truth to patients if asked outright. Recent studies analysing this fact suggest that the culture of the institution in which nurses work has a significant influence on nursing practice when it comes to discussing diagnosis or prognosis with their patients. (Kendall, 1995, Dunniece et al, 2000, Costello 2000)
Of particular interest is the research that shows how nurses tend to distance themselves from their patients for fear of reprimand from medical staff for disclosing information asked of them by the patient. When a nurse is unsure of the response from medical staff she/he may avoid the patient in order not to be asked a question outright, rather than lie. (Kendall, 1995)
In recognition of this unsatisfactory state of affairs, codes of nursing ethics and nursing practice have been changed, providing nurses with the opportunity to challenge the traditional premise that doctors alone are responsible for disclosing information, and enabling nurses to be truthful in their responses to patients' questions rather than avoiding them. (See Beauchamp and Childress, 1989) For example, whereas earlier versions of the International Council of Nurses "Code for Nurses" highlight the "nurse's obligation to carry out the physicians orders, intelligently and loyally" the revised code of 1973 states that "the nurse's primary responsibility is to those people who require nursing care." (New Zealand Nurses Organisation, cited Johnstone p.465)
This shift in emphasis is also evident in the New Zealand code of nursing ethics, revised in 1993, which states the importance of nurses "communicating with the client in an open, honest and truthful manner" (New Zealand Nurses Organization, Code of Ethics 1993). Further understanding of the impediments that nurses experience in communicating truthfully is essential if changes in their role are to be effected.
A Framework for Truth Telling
There are a number of key elements that help to provide a framework that enhances truthful communication. Firstly, there is the need to develop open and honest communication from the very beginning of the patient-health professional relationship. Secondly, the health professional needs to use patient preference as a "gauge" by asking them what they wish to know, how much they wish to know, and determining what they already know. In other words, it is a responsibility of the health professional to get a 'feel' for the situation, including the patients' perception of the situation.
It is not only the giving of the truth that as health professionals we are responsible for, but also the way in which the truth is delivered and received. Therefore, as a corollary of truth telling it is vital that the health professional is available to assist the patient and family/whanau in understanding what has been said, as well to support them in situations where there may be distress. Many commentators note that the way in which bad news is delivered, and the available support at the time, has a bearing on how people cope with their illnesses and prognosis (Bok, 1978, Centeno-Cortes, 1994, McCabe, 2001).
Nurses in particular have a key role to play in supporting patients and families/whanau when bad news is given, as they are most frequently the health professionals at the forefront of patient care and treatment. The nurse is the health professional that spends most time at the 'bed-side' and this presents a unique opportunity for the establishment of trust. (Bok 1978, Johnstone 1999, Kendall 1995). The provision of intimate personal care that can lead to the development of close relationships can in turn provide nurses with privileged insights. Nevertheless, nurses are not always present at outpatient appointments or at the bedside when a patient is given information that might be distressing. Consequently, when nurses are asked for information by a patient and they are not sure what medical staff have already discussed with the patient, nurses report increased anxiety among themselves. (Bok, 1978)
For communication between nurses and medical staff to improve, and in order for it to become common practice for nurses to be present at times of important disclosure, healthcare institutions need to adopt a strong multidisciplinary approach toward patient care. A feature of palliative care is the way it champions the concept of multidisciplinary teams. This concept acknowledges the unique skill and expertise that the different disciplines bring to the team. Team members work together and along side the patient and family/whanau to ensure that the care provided is appropriate and timely. In circumstances where frank discussion is required or when truthful disclosure is called for, team members can discuss strategies in advance. Decisions can then be made as to who might be the most appropriate person to communicate the news to the patient. Because everyone knows what is going to be discussed, the team's ability to provide the necessary support to the patient and family is enhanced. In addition, such an approach also allows the team to offer support to each other.
Truthful communication is multifaceted and multidisciplinary. The health professional must be committed to giving the truth and then be prepared to support the patient when the truth has been delivered. Presenting the truth needs to be done in a sensitive and timely manner.
It appears that in some settings health professionals find it difficult to tell the truth to patients and families and it is reasonable to suggest that institutional culture has some bearing on this. Relationships between health professionals and patients can be jeopardised if truthfulness is not part of their every day communication. Truthfulness is one element that engenders trust without which there can be no real partnership between the health professional and patient. However, truthfulness involves more than being 'accurate and exact'. Truth telling is best understood as a process that calls for skilled communication and respect for the person and their perception of their circumstances, including their desire for information and how much they wish to know. Intuition, wisdom and knowledge are integral to the process.
Nurses are the health professionals at the forefront of patient care in hospitals and hospices and, because of their position, can provide vital support that facilitates patient choice and understanding in an environment of truthfulness.
Lichter, I. (1989). The Right to Bad News. B.A. Stoll (Ed.), Ethical Dilemmas in Cancer Care. London: Macmillan Press, pp.7-16.
Beauchamp, T. L., Childress, J. F. (1989). Rules of Fidelity. Principles of Bio-medical Ethics. 3rd Edition. New York: Oxford University Press, pp.341-349.
Bok, S. (1978). Lies to the Sick and Dying. Lying: Moral Choice in Public and Private Life. Brighton: Harvester Press, pp.220-241 and 309-311.
Centeno-Cortes, C., Nunez-Olarte, J. M. (1994). Questioning Diagnosis Disclosure in Terminal Cancer Patients: A Prospective Study Evaluating Patients' Responses. Palliative Medicine 8, pp.39-44.
Costello, J. (2000). Truth telling and the dying patient: A Conspiracy of Silence? International Journal of Palliative Nursing 6:8, pp.398-405.
Dunniece, U. Slevin, E. (2000). Nurses' Experience of Being Present With a Patient Receiving a Diagnosis of Cancer. Journal of Advanced Nursing 32, pp.611-618.
Johnstone, M. (1999). Ethics, Bioethics and Nursing Ethics: Some Working Definitions. Bioethics: A Nursing Perspective. Australia: Southwood Press Ltd, pp.57 –64, 465.
Kendall , M. (1995). Truth-telling and Collusion: The Ethical Dilemmas of Palliative Nursing. International Journal of Palliative Nursing 1:3, pp.160-164.
McCabe, M. (2001). Striking a Balance in Truth Telling, The Nathaniel Report, Issue 4.
Debbie Wise is a palliative care specialist Nurse employed by the Mary Potter Hospice, Wellington.