Withholding tragic knowledge may lead to a tragic death: a palliative care perspective: reply.

Abstract

We thank Dr. Ying [1] for her important additions to the discourse on truth-telling and the maintenance of hope. We agree that encouraging unrealistic expectations is inconsistent with beneficence and may lead to harmful treatment decisions. Her examples illustrate how maintaining hope at the expense of realistic expectations can be misleading and harmful if unmodulated by wisdom and care. We believe with her that hope, administered by ear, can bring comfort without inflicting false expectations in the setting of a poor prognosis. Since the half-life of what we accept as objective truth is limited [2], moral absolutism has been largely rejected in favor of a relational model of care and shared decision making. Attention to the subjective versions of truth brings us closer to that model of patientand family-centered care. In her thoughtful review of the ethical aspects of truthtelling [3], palliative care physician Michelle Gold advises that ‘‘insensitivity to the cultural norms or personal preferences of a patient can result in the provision of information to someone who is not willing or ready to hear it and, thus, be a source of distress. The goal of truth telling in medicine is to achieve therapeutic efficacy. The amount of information provided to an individual should be tailored to their specific needs and might change with time. Patients maintain their autonomy in this way, and choose how much ‘truth’ they wish to hear. The physician does not compromise his/her commitment to honesty, and cultural or personal differences can be respected.’’ Gold quotes Robert Brault: ‘‘Today I bent the truth to be kind, and I have no regret, for I am far surer of what is kind than I am of what is true.’’ Surgical curricula are beginning to change in the direction suggested by Ying, as ethics education is emerging as an important part of training and assessment. We encourage surgeons to collaborate with palliative care teams in end of life care, in order to re-direct hope toward successful ordering of emotional and financial affairs, a tranquil death, and an inspiring legacy.