Indexing Title: JMDEGUZMAN’s Medical Anecdotal Report [05-10] 

MAR Title: Disclosure 

Date of Medical Observation: October 2005 

Narration:

            We recently operated on a 47-year-old male patient diagnosed with pancreatic head mass. He presented with subtle signs and symptoms of jaundice and on and off epigastric pain only for a month or two. A CT scan of the abdomen taken a month ago showed a 3 x 4cm solid mass on the pancreatic head and a slightly distended gallbladder. Tormented by pain, anxiety, confusion and denial he had been on the run ever since. Understanding his situation, avoiding further delays I and my team presented the case to our service consultant. Considering the CT scan findings we were very optimistic for the resectability but keeping in mind we have been late for a month. A second abdominal CT scan could be useful but the resources were meager and our patient was losing patience and hope. His jaundice was rapidly progressing, experiencing more pain, and has lost his appetite. In that case, we’ll just have to find another way of determining resectability. If we want result, action should be done and not just mere interaction. So, we set forth and talked to the patient and explained our plan. Resectability will be determined during laparotomy and options for surgical procedures together with its benefits and risks were fully explained. We offered our patient no false hopes but chance to which he agreed and understands.

            During the operation, we have noted that the mass enlarged to 5cm on its greatest diameter, markedly adherent to posterior structures on its undersurface, and multiple lymphadenopathies along the bile duct, superior mesenteric vessel and celiac axis. A palliative by-pass procedure was done.

            His post-operative recovery was remarkably well. He’d been boasting that only 3 days after the operation he was up and about, jaundice subsiding, and regained his appetite for food. He never felt stronger he’d say and he thought he’s cured. Of course, we have not yet discussed our findings to him personally at this time although I have talked to his wife immediately post-operatively. She asked me if we would be telling this to her husband, I said it would be better for him to know personally that a malignancy is a high probability on his case and that only a palliative treatment was done. Carefully and with compassion, I revealed this to the patient by the time he was fully recovered. I did not expect him however to go through the stages of grief in an instance and just accept what I have said. I offered him whatever help I can to go through this trial and besides I am part of it being his attending. At the end of our talk I was glad to note some sign of resolution on his part as he managed a sigh and a smile. For this I gave him a pat on the back.

Insights: (Discovery, Stimulus, Reinforcements) (Physical, Psychosocial, Ethical)

            In our profession, adequate communication is crucial and is a fundamental ethical requirement for the foundation of trust between us and our patient. Patients have the right to the truth about their health because they have the primary responsibility for their health. However, “What to tell the patient” has been considered one of the more difficult and delicate ethical questions in our part. Some physicians thought that the less patients knew about their critical condition, the better would be the chances of recovery. Some others would even withhold information of impending death, fearing that such knowledge might lead a person to despair.

            Legal and moral concerns prompt us to realize our duties as physicians to inform our patients of their critical condition. As stated in the Ethical and Religious Directives for Catholic Health Facilities and also concerning patient’s rights, information concerning serious sickness or impending death is to be furnished even if the individual does not ask for it.

            Telling a patient something critical takes place over a span of time and is not a one-shot affair. A decision to reveal a grave prognosis, which is “ethical” in itself, may become “unethical” if the physician tells it to the patient bluntly and then withdraws, without offering any emotional support to help the patient resolve his feelings. I believe that the assurance of the attending physician to see it through along with his patient by making himself available to offer any comfort possible, may be more important than the bad news itself. It is the absence of this transmission of compassion, rather than telling of the truth, that produced unfortunate results.