Truth-telling to the seriously ill child - Nurses' experiences, attitudes, and beliefs

BACKGROUND

Nurses play an integral role in the care of children hospitalised with a serious illness. Although information about diagnostics, treatments, and prognosis are generally conveyed to parents and caregivers of seriously ill children by physicians, nurses spend a significant amount of time at the child's bedside and have an acknowledged role in helping patients and families understand the information that they have been given by a doctor. Hence, the ethical role of the nurse in truth disclosure to children is worth exploring.

METHODS

A systematic academic database and grey literature search strategy was conducted using CINAHL, Medline Psych Info, and Google Scholar. Keywords used included truth, children, nurse, disclosure, serious illness, and communication. A total of 17 publications of varying types were included in the final data set.

ETHICAL CONSIDERATIONS

As this was a review of the literature, there were no direct human participants. Empirical studies included in the review had received ethics approval.

RESULTS

Of the 17 articles included in the review, only one directly reported on the experiences of nurses asked to withhold the truth from patients. Empirical studies were limited to HIV-positive children and children diagnosed with cancer and the dying child.

CONCLUSION

A paucity of literature exploring the experiences, attitudes, and beliefs of nurses with regard to truth-telling to seriously ill children is evident. Little consideration has been given to the role nurses play in communicating medical information to children in a hospital setting. The 17 articles included in the review focused on cancer, and HIV, diagnosis, and end-of-life care. Further research should be undertaken to explore the experiences and attitudes of nurses to clinical information sharing to children hospitalised with a wide range of serious illnesses and in diverse clinical scenarios.

Truth-telling and doctor-assisted death as perceived by Israeli physicians

Background

Medicine has undergone substantial changes in the way medical dilemmas are being dealt with. Here we explore the attitude of Israeli physicians to two debatable dilemmas: disclosing the full truth to patients about a poor medical prognosis, and assisting terminally ill patients in ending their lives.

Methods

Attitudes towards medico-ethical dilemmas were examined through a nationwide online survey conducted among members of the Israeli Medical Association, yielding 2926 responses.

Results

Close to 60% of the respondents supported doctor-assisted death, while one third rejected it. Half of the respondents opposed disclosure of the full truth about a poor medical prognosis, and the others supported it. Support for truth-telling was higher among younger physicians, and support for doctor-assisted death was higher among females and among physicians practicing in hospitals. One quarter of respondents supported both truth-telling and assisted death, thereby exhibiting respect for patients’ autonomy. This approach characterizes younger doctors and is less frequent among general practitioners. Another quarter of the respondents rejected truth-telling, yet supported assisted death, thereby manifesting compassionate pragmatism. This was associated with medical education, being more frequent among doctors educated in Israel, than those educated abroad. All this suggests that both personal attributes and professional experience affect attitudes of physicians to ethical questions.

Conclusions

Examination of attitudes to two debatable medical dilemmas allowed portrayal of the multi-faceted medico-ethical scene in Israel. Moreover, this study, demonstrates that one can probe the ethical atmosphere of a given medical community, at various time points by using a few carefully selected questions.

Electronic supplementary material

The online version of this article (10.1186/s12910-019-0350-5) contains supplementary material, which is available to authorized users.

The use of behavioural theories in end-of-life care research: A systematic review

Background:

It is necessary to understand behaviours that contribute to improvement in the quality of end-of-life care; use of behavioural theories allows identification of factors underlying end-of-life care behaviour, but little is known about the extent to which, and in what manner, these theories are used in an end-of-life care research context.

Aim:

To assess the number of end-of-life care studies that have used behavioural theories, which theories were used, to what extent main constructs were explored/measured and which behavioural outcomes were examined.

Design:

We conducted a systematic review. The protocol was registered on PROSPERO (CRD42016036009).

Data sources:

The MEDLINE (PubMed), PsycINFO, EMBASE, Web of Science and CINAHL databases were searched from inception to June 2017. We included studies aimed at understanding or changing end-of-life care behaviours and that explicitly referred to individual behavioural theories.

Results:

We screened 2231 records by title and abstract, retrieved 43 full-text articles and included 31 studies – 27 quantitative (of which four (quasi-)randomised controlled trials) and four qualitative – for data extraction. More than half used the Theory of Planned Behaviour (9), the Theory of Reasoned Action (4) or the Transtheoretical Model (8). In 9 of 31 studies, the theory was fully used, and 16 of the 31 studies focussed on behaviours in advance care planning.

Conclusion:

In end-of-life care research, the use of behavioural theories is limited. As many behaviours can determine the quality of care, their more extensive use may be warranted if we want to better understand and influence behaviours and improve end-of-life care.

Truth Telling in the Setting of Cultural Differences and Incurable Pediatric Illness: A Review

IMPORTANCE

Navigating requests from parents or family caregivers not to disclose poor prognosis to seriously ill children can be challenging, especially when the requests seem culturally mediated. Pediatric clinicians must balance obligations to respect individual patient autonomy, professional truth telling, and tolerance of multicultural values.

OBSERVATIONS

To provide suggestions for respectful and ethically appropriate responses to nondisclosure requests, we used a hypothetical case example of a Middle Eastern adolescent patient with incurable cancer and conducted an ethical analysis incorporating (1) evidence from both Western and Middle Eastern medical literature and (2) theories of cultural relativism and justice. While Western medical literature tends to prioritize patient autonomy and corresponding truth telling, the weight of evidence from the Middle East suggests high variability between and within individual countries, patient-physician relationships, and families regarding truth-telling practices and preferences. A common reason for nondisclosure in both populations is protecting the child from distressing information. Cultural relativism fosters tolerance of diverse beliefs and behaviors by forbidding judgment on foreign societal codes of conduct. It does not justify assumptions that all individuals within a single culture share the same values, nor does it demand that clinicians sacrifice their own codes of conduct out of cultural respect. We suggest some phrases that may help clinicians explore motivations behind nondisclosure requests and gently confront conflict in order to serve the patient's best interest.

CONCLUSIONS AND RELEVANCE

It is sometimes ethically permissible to defer to family values regarding nondisclosure, but such deferral is not unique to cultural differences. Early setting of expectations and boundaries, as well as ongoing exploration of family and health care professional concerns, may mitigate conflict.

Nurses' Perceptions of Diagnosis and Prognosis-Related Communication: An Integrative Review

BACKGROUND

Disclosure of diagnostic and prognostic information has become the standard in the United States and increasingly around the world. Disclosure is generally identified as the responsibility of the physician. However, nurses are active participants in the process both intentionally and inadvertently. If not included in initial discussions regarding diagnosis and prognosis, the nurse may find it challenging to openly support the patient and family.

OBJECTIVE

The aim of this study is to synthesize published literature regarding nurses' perceptions and experiences with diagnosis and prognosis-related communication.

METHODS

The Whittemore and Knafl method guided the integrative review process. Electronic databases including Cumulative Index to Nursing and Allied Health Literature, Health Sciences in ProQuest, PubMed, and Web of Science were used to review the literature from 2000 to 2015. Constant comparison methods were used to analyze the data and develop themes.

RESULTS

Thirty articles met all of the inclusion criteria and were included in this review. Several themes emerged from the data, including the nurse's role in the process of diagnosis and prognosis-related communication, barriers and difficulties related to communication, and positive and negative outcomes.

CONCLUSIONS

Nurses play an integral role in the process of diagnostic and prognostic disclosure. Further exploration of both physician and patient perceptions of the nurse's role are needed. Interprofessional training regarding diagnosis and prognosis-related communication is essential to promote collaboration and better empower nurses in this process.

IMPLICATIONS FOR PRACTICE

Nurses should aim to purposefully partner with physician colleagues to plan and participate in diagnostic and prognostic discussions. Nurses should identify opportunities to improve their knowledge, understanding, and comfort with challenging conversations.

Older people and decision-making following acute stroke in China: ‘hiding’ as a barrier to active involvement

Decision-making among older patients with stroke, their families and professionals has been extensively studied in a Western context, but there has been little prior work in China. The study reported here explored how decision-making took place between older people with stroke, their family carers and professionals in an acute care context in mainland China using a constructivist grounded theory approach. Data were collected through semi-structured interviews, participant observation and documentary analysis. Constant comparative analysis of the data was carried out. This paper focuses on the key social process of ‘hiding’ and its dynamic relationship with the core category ‘keeping the peace’. In order to meet the traditional Chinese cultural value of ‘maintaining harmony’, both family carers and professionals hid essential information from older stroke survivors who, as a consequence, were effectively precluded from playing an active role in major decisions. In understanding ‘hiding’, the paper draws upon both Chinese cultural values and ‘awareness context theory’ and in so doing questions the relevance to the Chinese context of key Western notions such as involvement in health-care decision-making. A better understanding of the experiences of decision-making processes between older people with stroke, their family carers and professionals in China will help professionals to provide the best possible support and care whilst promoting informed decision-making amongst all concerned.

Attitudes, beliefs and perceptions regarding truth disclosure of cancer-related information in the Middle East: a review

The aim of this review is to evaluate the current status concerning attitudes, beliefs and/or practices of patients, family members, health professionals and/or caregivers regarding truth disclosure about a cancer diagnosis in the Greater Middle East countries. A search was done via MedLine for all publications related to this review objective. 55 publications were included emanating from Egypt, Iran, Israel, Jordan, Kuwait, Lebanon, Palestine Pakistan, Saudi Arabia, Turkey, and United Arab Emirates. In the Greater Middle East region, a diagnosis of cancer is still mixed with social stigma and misperceptions related to incurability. Physicians conserve a truth disclosure policy in which from one side they respect some of the historical and cultural misperceptions about cancer and accordingly, tell the truth about cancer to one of the family members and from another side acknowledge the patients' right to know the truth and tend to disclose it for him(or her) when possible. Family members and caregivers' attitudes, perceptions and beliefs about telling the truth to the patient seem to be in favor of concealment. Discrepant results concerning physicians' and patients' evaluation of the quality of truth disclosure exist in the literature. Education programs in breaking bad news are lacking in many countries. Finally, the most important and common problem affecting truth disclosure to a patient suffering from cancer is the lack of codes and legislations concerning the patients' rights in an informed consent. Studies, legislations and training programs are needed in this domain in Middle Eastern societies.