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When a family
member asks you not to tell (Collusion) |
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Although information belongs to the patient, there are still times
when a family member is told the diagnosis before the patient. Typically,
in order to protect the patient from pain and worry, the family will
ask you not to disclose diagnosis and prognosis. Legally, the family
has no right to make such a request, but they will argue that they
know the patient better than we and give a number of, very cogent,
reasons why they know best. The aim of breaking collusion, maintaining
honesty with the patient and of not alienating the family, involves
three steps:
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Try to establish, with the family member, why it is important
to them to collude. Ask if there are reasons why honesty might
be preferable and respect their knowledge of the patient. Negotiate
access to the patient, to establish their awareness and promise
that you will only disclose the diagnosis if the patient asks
for it.
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Talk to the patient to discover what they know or suspect.
Typically, they will be aware of reality but are also colluding
to protect the family. Confirm their suspicions, if appropriate,
and arrange to see both patient and relative together.
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Confirm, to both patient and family member, that each has
been protecting the other in an attempt to save them from distress.
This should be enough to open a dialogue between them so that
you can then slip away, leaving them to discuss the situation
and how they plan to manage it.
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When collusion involves a child, whether that child be a relative
or a patient, there seems to be even more motivation to collude, parents
arguing that the child is too young to understand and should be kept
happy for as long as possible. In fact, children are well able to
adjust to a situation and respond well to being informed. They may
become very angry if they feel that they are excluded from a situation,
especially if it involves their own health. For parents of a sick
child, they should be encouraged to include the child in all discussions
about diagnosis, treatment and prognosis. Similarly if a close relative
is ill, the child will, almost always, wish to be involved and feel
that they are helping in some way.
It could be argued that, if both patient and family seem happy with collusion, there is no need to attempt to break it. If one partner subsequently dies while collusion is intact, there will be the possibility of "unfinished business" between them that could complicate the grieving process.
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Denial
