Necessary Collusion: Prognostic Communication With Advanced Cancer Patients

It is argued that except in instances where stark frankness is openly requested, a style of communication that allows patients to dictate most of the flow of prognosis information or to avoid it is an ethical strategy of prognostic communication.

Abstract

As a young oncologist, I find myself wrestling with many of the most difficult issues in the practice of oncology: making difficult trade-offs between risk and benefits of arduous treatments, finding sources of strength to deal with the devastating realities of patients’ situations, and determining how to communicate important information to patients in ways that give them honest and useful information, but still allow them to preserve some hope for the future. It is this last issue on which I offer my thoughts here. I have noticed that although common wisdom holds that we should give accurate and honest prognostic information to patients at all times, in practice this is hard to do. So, I find myself engaging in a process of communication about prognosis with patients which, in a sense, allows the cold, hard facts to come out over time, as opposed to presenting them up front. I have found other oncologists who seem to use a similar strategy. I do this because it is a style of communication which, I think, “works” for me and my patients: patients come to deal with the painful knowledge of their ultimate outcomes over time in ways that I think allow them to cope along the way. But I have continuously asked myself whether this is the “right” way to communicate. Is such a strategy of communication ethical? Looking to the literature about prognostic communication with patients with advanced cancer, two lines of thought dominate. The first suggests that patients want accurate estimates of their prognosis and that accurate estimates benefit patients by allowing them to make end-of-life plans consistent with their values. The second suggests that patients desire, above all, to maintain hope for their situations, and that the “management of hope” permits the prognosticating oncologist to take some liberties with prognostic estimates in order to preserve the patient’s ability to maintain hope. These two lines of thinking appear to be at odds with one another. Is there, however, an ethical way of resolving the tensions between these two views? In the end, I believe that except in instances where stark frankness is openly requested, a style of communication that allows patients to dictate most of the flow of prognostic information or to avoid it is an ethical strategy of prognostic communication. I will refer to this strategy as “necessary collusion.” By collusion I mean the spoken or unspoken agreement we sometimes enter into with some patients to avoid or delay discussing a definitive, numerical prognostic estimate of life expectancy. This article is an examination of whether such collusion is ethical. I am going to argue that such collusion can be ethical, because of certain special characteristics of the situation of patients with advanced cancer and their relationships with their oncologists.