Collusion in doctor-patient communication about imminent death: an ethnographic study

doi:10.1136/bmj.321.7273.1376

BMJ 2000;321:1376-1381 ( 2 December )

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Collusion in doctor-patient communication about imminent death: an ethnographic study

See also Education and debate p 1400

Anne-Mei The, researcher, ^a Tony Hak, researcher, ^a Gerard Koëter, professor, ^b Gerrit van der Wal, professor. ^a

^a Institute for Research in Extramural Medicine/Department of Social Medicine, Vrije Universiteit, Van der Boechorststraat 7, 1081 BT Amsterdam, Netherlands, ^b Department of Lung Diseases, University Hospital Groningen, PO Box 30001, 9700 RB Groningen, Netherlands

Correspondence to: A-M The am.the.emgo{at}med.vu.nl

Objective: To discover and explore the factors that resultin "false optimism about recovery" observed in patients with smallcell lungcancer.
Design: A qualitative observational (ethnographic)study in two stages over fouryears.
Setting: Lung diseases ward and outpatient clinicin university hospital in theNetherlands.
Participants: 35 patients with small cell lungcancer.
Results: "False optimism about recovery" usually developedduring the (first) course of chemotherapy and was most prevalentwhen the cancer could no longer be seen in the x ray pictures.This optimism tended to vanish when the tumour recurred, but itcould develop again, though to a lesser extent, during furthercourses of chemotherapy. Patients gradually found out the factsabout their poor prognosis, partly because of physical deteriorationand partly through contact with fellow patients who were in amore advanced stage of the illness and were dying. "False optimismabout recovery" was the result an association between doctors'activism and patients' adherence to the treatment calendar andto the "recovery plot," which allowed them not to acknowledgeexplicitly what they should and could know. The doctor did anddid not want to pronounce a "death sentence" and the patient didand did not want to hearit.
Conclusion: Solutions to the problem of collusion betweendoctor and patient require an active, patient oriented approachfrom the doctor. Perhaps solutions have to be found outside thedoctor-patient relationship itself $---$ for example, by involving"treatmentbrokers."

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