br The doctor tells me I do not look
The doctor tells me I do not look ill. He is a senior consultant and he has said many times that I do not look ill.
A seventy-eight-year-old woman with metastases since 2 years, on her second line of palliative chemotherapy.
Negative Characteristics. The informants expressed that being late and stressed out, in addition to giving too much and too detailed information, was consid-ered characteristic for a bad doctor. To present nega-tive information was also associated with bad doctors, especially if it 丝裂霉素 C was provided too frankly. One informant
described the doctor associated with delivering bad news to her as brutal.
But she said there are metastases here and in the lung and .. .I thought .. if I may say so, that she was brutal .. Should you hand it out like that?’’
A seventy-eight-year-old woman with metastases since two years and on her second line of palliative chemotherapy.
All women described that their need for ‘‘all’’ infor-mation at the beginning of their disease changed to a wish for ‘‘useful’’ information, to maintain hope and meaning. They asked less and less questions over time, afraid of receiving bad news. Such a dynamic process of awareness of treatment goals among pa-tients receiving noncurative cancer treatment has been previously published by Burns et al.8 Our study also confirms that when the desire for information and participation in treatment decision diminish over time, the patient may want to put someone else, doctor or family, to be in charge of the situation.12
A limitation with this study is that we only inter-viewed patients on palliative chemotherapy, whereas the experience of those who refrained treatment might be different. Furthermore, patients were 40e80 years old, and patients of other ages may be of different perceptions. However, during analysis, we met saturation in data after six interviews and have additional 14, that is, 20 interviews in total, why we think it is a representative set of data. As informa-tion strategies and truth telling in most cases are described from the doctor’s point of view, a strength is that this study sheds light over the patients preferred mode of truth, that not necessarily are congruent with those of the doctor.
Our study, in line with previous research, identifies hope16e19 and meaning20e23 to be crucial parts of common coping strategies, to reduce depression and anxiety associated with fear of progressive disease and death. Being on palliative chemotherapy with a structured schedule according to this has been sug-gested to facilitate for patients to live in the present, instead of having to deal with anxious thoughts about end of life.24
Discussions regarding treatment can protect both patient and doctor from discussing existential issues like death threat. Such a strategy is called the ‘‘com-mon collusion’’ according to The et al.25 In our study, many women even expressed they continued with treatment to not disappoint their doctor.
Our informants associated treatment discontinua-tion to ineligibility for new treatments that could
represent cure or longer life. Continuous chemo-therapy helped women to hope for new ‘‘miracle’’ treatments, in line with coping strategies and defense mechanisms as described by Yalom, who focuses on the concepts of ‘‘specialness’’ and ‘‘ultimate rescuer.’’23 These mechanisms imply that the actual patient should be the one that miraculously cheats
death and is cured against all odds, also identified by other researchers.11,23,26
In today’s health care system, ‘‘truth’’ is often acknowledged to be the most important issue in patient-doctor communication. However, we must bear in mind that truth is complex, relative, and dy-namic, not neutral. Terminally ill patients may adjust the definition of ‘‘truth’’ with regard to information of prognosis to their needs, to be able to take action and be in control of their lives with maintained hope.27
Like Salander et al. 1998 presented the concept of a ‘‘creative illusion,’’28 we found that the patients wished for different quality and quantity of truth over time. The doctor’s formalized duty to inform is obviously in conflict with these data. Friedrichsen et al.27 described that terminally ill cancer patients used three different truths: 1) The absolute truth was unquestion-able and included detailed information about what to expect from the future. 2) Partial truth was a patient-preferred half-truth, less detailed than the absolute truth, and included for the patient useful and/or pos-itive information. 3) Desirable truth was more or less unrealistic and made vacuoles possible to believe in miracu-lous cure of their late stage of cancer. These strategies counterbalance death with manifestations of life, ac-cepting and denying death at the same time.29