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When is it ethically acceptable to lie to your patient?


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This article appeared a few days ago on MDLinx. I thought it was worthwhile to read and was surprised at the findings. I think that this is a good question for discussion on Physician Assistant Forum.
 

When is it ethically acceptable to lie to your patient?

Naveed Saleh, MD, MS, for MDLinx | May 29, 2019

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Interesting read, but honestly I found it weird.  Approximately halfway through, Dr. Smith states, "But if you actually believe what you’re saying to the patient, then even if it ends up being wrong, I don’t think that’s anything we can avoid."  That isn't lying...that is just being wrong.  Now, to conceal the "being wrong" has the stark potential to stray into lying.  But, the fact of being wrong is not lying.  It also mentions cultural differences where a patient decides not to know a diagnosis, while the "husband or head male family members make all medical decisions for women"...again, that is not lying.  That is a decision made by the family, whether by force or otherwise.  But apart from counseling the patient, it is not our place to go against an individual's culture.  Lastly, it mentions not disclosing "near misses."  What about that is lying?  If it was a near miss, the by definition no harm was done...what use is it to disclose something that didn't happen so the patient has less confidence in their medical care and begins questioning literally EVERYTHING?

 

So, overall, I do agree that this topic is a good exercise in philosophy, ethics, etc., but personally feel this article was goofy in how the topic was approached.

 

Personally, I do not believe in lying to patients for any reason.  If they ask to NOT be told a diagnosis then that is their decision, not lying.  Giving them a better prognosis than the truth can be extremely harmful as they may not prepare financially or emotionally for what is coming.  I have also learned in my few years of medical practice that patients appreciate honesty and appreciate when their provider is open and talks to them as a human rather than a medical chart.

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Never.

I had a nursing home patient who was 2 years SP CVA ask me when he was going to be able to walk again after being bed bound total care that entire time. I had to tell him never. his wife was furious with me because I "took away his hope." My answer was simple and polite. He has to know when I tell him something it is the truth. Otherwise he can't trust anything I do.

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Same as DizzyJ, extremely seldom, but do recall 1 time only - told a patient he was getting something other that Geodon when he was getting that, just to avoid another physical altercation.  Patient had already broken a window with a chair trying to attack me.  He was being medicated for everyone's safety, including his.

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SAS,  Sometimes how something is said is as important as what is said.  I don't think "never" is a good answer.  Maybe in a few sentences saying that most likely not, etc.  One thing I have found in medicine is there is no such thing as "never".  Only my opinion.

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I work with an anxious population. While I never outright lie, I often omit part of the differential because it will just cause them undue stress. They will worry, Google, worry some more, email me with questions and all sorts of test requests I have to say no to.  

If I'm fairly certain, I will give them the straight dope. Saw a young guy last year with a firm testicular nodule. I didnt tell him he had cancer, but I said in all likelihood this is testicular cancer. He was of course devastated and went to the ER later in a panic. Turns out he had a benign calcification on the testis---something I didnt even know existed. But I acted in good faith. 

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Good reply and I personally would not tell a patient all of the differential diagnosis of presenting symptoms lest they decide on using a razor to their wrist. We can talk about questionable diagnosis with the need for more clinical correlation. As far as the patient with a possible testicular cancer; I remember when my SP told a patient that they had melanoma when he had not performed a biopsy. This became a malpractice case for creating severe psychological damage. I forget the outcome but an insurance company does look at the number of cases presented against you.

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on the CANCER topic

 

I try to NEVER lean forward and say the C word - till there is a tissue Dx - every single patient has that in their mind as a fear.  I see no reason in pouring gas on the fire of fear.  I just say there is a bunch of things it could be (and I have seen some things I was POSITIVE was CA come back as benign......)   and leave it at that.  only if they really really push do I start to give a Ddx listing.... and then usually all the benign stuff first.....

 

I wold not call this a lie - but instead the art of medicine and patient care.

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21 hours ago, ohiovolffemtp said:

Same as DizzyJ, extremely seldom, but do recall 1 time only - told a patient he was getting something other that Geodon when he was getting that, just to avoid another physical altercation.  Patient had already broken a window with a chair trying to attack me.  He was being medicated for everyone's safety, including his.

At the point where a patient poses an actual, imminent danger of death or serious bodily injury to self or others, then using the least amount of force necessary to neutralize the threat. If that force can be a falsehood instead of a taser, baton, or firearm, I am ethically OK with that. 

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7 hours ago, rev ronin said:

At the point where a patient poses an actual, imminent danger of death or serious bodily injury to self or others, then using the least amount of force necessary to neutralize the threat. If that force can be a falsehood instead of a taser, baton, or firearm, I am ethically OK with that. 

but what about the down stream harm of the patient realizing they were lied to?  They loose faith in medical providers, and boom you have hurt them in the future.... nope not gonna outright lie.....

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On 6/4/2019 at 6:08 AM, TWR said:

SAS,  Sometimes how something is said is as important as what is said.  I don't think "never" is a good answer.  Maybe in a few sentences saying that most likely not, etc.  One thing I have found in medicine is there is no such thing as "never".  Only my opinion.

Tom I was pretty comfortable telling a full on quad that was in his 90's and near death he wasn't going to walk. I take your point though.

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3 hours ago, ventana said:

but what about the down stream harm of the patient realizing they were lied to?  They loose faith in medical providers, and boom you have hurt them in the future.... nope not gonna outright lie.....

Balance of harms, my friend.  They will eventually understand that I had the right to do more harm, possibly even killing them to protect other people, and instead chose to lie, and at that point they can either forgive me or not.  If they end up getting shot and dying... well, they're never going to forgive me for that. For those of you not familiar with it, "... an actual, imminent danger of death or serious bodily injury to self or others" is just a rephrasing of when homicide is justifiable in defense of self or others.  It's not a light consideration, even if it can be a split-second evaluation.

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On 6/4/2019 at 1:46 PM, surgblumm said:

Good reply and I personally would not tell a patient all of the differential diagnosis of presenting symptoms lest they decide on using a razor to their wrist. We can talk about questionable diagnosis with the need for more clinical correlation. As far as the patient with a possible testicular cancer; I remember when my SP told a patient that they had melanoma when he had not performed a biopsy. This became a malpractice case for creating severe psychological damage. I forget the outcome but an insurance company does look at the number of cases presented against you.

With the testicular guy, In retrospect I would not have used that word unless he asked me outright. 

I saw another guy for 'congestion' who had lost 40 lbs in 6 months and had a huge pharyngeal mass. I knew it was cancer instantly. I did not say the word. He was admitted that day, turns out he had unknown HIV as well as lymphoma. Crazy case. 

Edited by BruceBanner
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Those are the ones that stay with you forever. Some 15 years ago I had a older woman come to the ER for nausea and vomiting.  It seemed like AGE on presentation. Found a large liver mass and she was dead within a month. She was surrounded by kids and grandkids in the ER. 

I still didn't say cancer even though I was 99.9% sure and her prognosis was grave.

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This topic kind of brings you back to a historic question asked by a Roman Governor; "What is truth?" Like Scott, I do not feel that we need to give everyone a dire diagnosis or an absolute prognosis because there is no absolute prognosis. I have seen pancreatic cancer patients expire in a month and I have seen them comfortable and able to have a normal life for three to four years. We are not the Judge and Jury but we are the witness. We share what we know to be clinically correct and offer hope.  Rather than play the Grim Reaper, we have the ability to "be a rainbow in someone's cloud." Maya Angelou  Just a thought not a hardline expectation.

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On 6/4/2019 at 6:36 PM, ventana said:

I try to NEVER lean forward and say the C word - till there is a tissue Dx - every single patient has that in their mind as a fear.  I see no reason in pouring gas on the fire of fear. 

I don't diagnose CA in the ED, but I frequently tell patients that "this is suspicious for cancer, so you need to follow up asap."

 

On 6/5/2019 at 6:19 AM, ventana said:

but what about the down stream harm of the patient realizing they were lied to?  They loose faith in medical providers, and boom you have hurt them in the future.... nope not gonna outright lie.

Rev is referring to a self defense/defense of other situation.  The only rule there is getting yourself and others out alive.  At that point I don't care if the bad guy/crazy makes it out alive or not, let alone whether he has trust in the medical establishment.

The hippocratic oath goes out the door as well.  If it's self defense, I'll definitely do bad guy/crazy great bodily harm.

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On 6/5/2019 at 5:19 AM, ventana said:

but what about the down stream harm of the patient realizing they were lied to?  They loose faith in medical providers, and boom you have hurt them in the future.... nope not gonna outright lie.....

I agree.  I listened to a podcast a few years ago(EMRAP, maybe) that discussed creating a trusting partnership with these mental health patients.  "I have a medication that I'd like to give you that I think will help you feel calmer.  Would you be willing to try it?"  I've had good success with that approach, especially when offering PO meds...i.e. oral vs IM haldol.  Even agitated elderly delerious/demented patients will usually give it a shot.

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I agree,  starting with verbal de-escalation, PO meds, or even IM with pt's agreement.  I've got a pretty good line of schmoozing that's often effective.  However, there are some patients, often with a combination of mental illness, substance abuse, and alcohol abuse, who are actively violent and who are either an immediate danger to themselves or others, e.g. staff, or with whom de-escalation efforts have failed where deception and/or force is required.  When this occurs, rapid implementation with sufficient numbers of personnel and appropriate meds, sometimes with restraints until the meds take effect, followed by de-escalation as quickly as is safe is the most ethical approach.

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