Physician-Patient Communication Outside U.S.

ASCO Connection
May 04, 2017 4:11 PM

If you read our Exclusive Journal Coverage story on physician-patient communication in Sri Lanka, you know that norms around what information is given to (or kept from) the patient and their family about a cancer diagnosis is changing. In your part of the world, what does physician-patient communication look like? How involved are family members in medical decision-making? How do you see that changing over time?



Antonella Surbone, MD, PhD, FACP
Re: Physician-Patient Communication Outside U.S.
May 19, 2017 1:22 PM

This most interesting piece on truth telling in Sri Lanka reminds me of the situation in Italy, where I grew up and studied before coming to practice in the US in 1985. In 1992, I wrote a piece for JAMA about how Italian cancer patients were kept in the dark or offered half truths, even when treated at Cancer Centers. At the time, I stressed that, while in the Anglo-American culture 'autonomy' was synonymous with 'freedom', in Italy it was rather synonymous with 'isolation'. In fact, like in Sri Lanka, the Italian society was based on family and community values, rather than on individual values and rights as the US society. Consequently, the role of families was to 'protect' the patient from painful news, and doctors took active part in this paternalistic protective stance. I remarked that cancer patients could not be unaware of their illness, since they were the ones suffering from the cancer or its treatments, and eventually dying.Yet a conspiracy of silence took place, and all involved persons pretended not to know. This, however, was hurting patients, in my opinion, and a cultural change was needed.

Dr. Edmund Pellegrino, one of the founders of bioethics, wrote an insightful editorial on how cultural norms influence our understanding and application of the principles of autonomy and beneficence in medicine. Since then, I have studied in depth cultural differences in truth telling and communication and continue to do it. 

In Italy, informed consent has been mandatory for at least two decades for all medical procedures and treatments. Yet, many cancer patients are still not told the truth about their diagnosis and even less about prognosis, mostly because  families often ask the oncologists to withhold information because  their sick relative 'could not withstand the news'. Families make important decisions, including end of life ones, instead of patients.

In the past few years, I have spent some time back in my Country and have taught clincial bioethics to nurse students at their third year of the Nursing Degree Program or to older nurses getting a PhD in Nursing. I always ask my students to present and discuss clinical cases that had presented an ethical dilemma for them: the vast majority is about families and doctors not telling the truth to patients, especially older ones, while patients keep asking nurses to know about their illness and prognosis. In Italy, nurses are bound by their Professional Code not to diclose any information to patients: only doctors can deliver information. 

This is to say that, indeed, changing cultures is way more difficult than modifying norms. I believe the only way is for us, as oncology professionals, to always put our patients first, by respecting their cultural values and norms, but also by afostering their autonomy and active involvement in all decisions about their health. Sometimes, this is best accomplished through verbal information. At other times, we need to find alternative and creative ways to bypass the conspiracy of silence without imposing our western values onto still unprepared patients.