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Truth Telling and Collusion

Nurses are sometimes asked to withhold the truth from a patient. This is referred to as collusion, and can easily create a scenario of secrecy and mistrust. These requests are often made in relation to disclosing a life-limiting illness such as cancer, or even imminent death, and can be made by a family member or by the patient themselves.

In western society, it was common in the past to exclude a patient from the truth, but the trend has moved away from this in recent years. However in many cultures, it may still be common practice to keep distressing news from patients. Illness can be viewed as a family concern and autonomy may not be recognised. [1] In these instances it is important to understand and respect the cultural beliefs and collaborate with an ‘elder’ or significant person, while keeping the patients interests foremost. The ethical principles of beneficence (to do good) and non-maleficence (to do no harm) would apply.

The role of the nurse in this context is a difficult one. The majority of patients prefer to be told the truth about what is happening to them. Many will know or guess the truth and also realise that this is being kept from them. Others will not want to know, and this is their choice.

The nurse patient relationship will suffer if the patient feels that they are being lied to or kept from knowing the truth. Culturally acceptable communication is usually the best policy, and discussions within the multidisciplinary team can help to clarify what is happening, why it is happening and whether it is in the best interests of the patient.

A useful framework for nurses to avoid potentially distressing disclosures is to ask the patient: 'What do you know about your illness and what is happening at the moment?' and equally important: 'How much would you like to know?'

Resources

Websites
  • The Southern Cross Bioethics Institute website provides access to information on Bioethical legislation in Australia, much of which is relevant to palliative care, but can be different in each state and territory
  • University of Missouri (US) Centre for Health Ethics – an overview of Truth Telling
Guidelines / Documents / Factsheets

Related CareSearch Pages

Nurses Hub
Communication
Advanced Care Planning
Working with Families

Free Full Text Articles

Wiener L, McConnell DG, Latella L, Ludi E. Cultural and religious considerations in pediatric palliative care. Palliat Support Care. 2013 Feb;11(1):47-67. Epub 2012 May 22.

Ong WY, Yee CM, Lee A. Ethical dilemmas in the care of cancer patients near the end of life. Singapore Med J. 2012 Jan;53(1):11-6.

Low JA, Kiow SL, Main N, Luan KK, Sun PW, Lim M. Reducing collusion between family members and clinicians of patients referred to the palliative care team. Perm J. 2009 Fall;13(4):11-5.

Chaturvedi SK, Loiselle CG, Chandra PS. Communication with relatives and collusion in palliative care: a cross-cultural perspective. Indian J Palliat Care. 2009 Jan;15(1):2-9.

Wood WA, McCabe MS, Goldberg RM. Commentary: Disclosure in oncology -- to whom does the truth belong? Oncologist. 2009 Jan;14(1):77-82. Epub 2009 Jan 15.

Apatira L, Boyd EA, Malvar G, Evans LR, Luce JM, Lo B, et al. Hope, truth, and preparing for death: perspectives of surrogate decision makers. Ann Intern Med. 2008 Dec 16;149(12):861-8.

Khoo SB. Collusion in palliative care. Malays Fam Physician. 2006;1(2&3):62-6.

References

  1. de Pentheny O'Kelly C, Urch C, Brown EA. The impact of culture and religion on truth telling at the end of life. Nephrol Dial Transplant. 2011 Dec;26(12):3838-42.

Relevant Studies

Deschepper R, Bernheim JL, Vander Stichele R, Van den Block L, Michiels E, Van Der Kelen G, et al. Truth-telling at the end of life: a pilot study on the perspective of patients and professional caregivers. Patient Educ Couns. 2008 Apr;71(1):52-6. Epub 2008 Jan 3.

Dunlop S. The dying child: should we tell the truth? Paediatr Nurs. 2008 Jul;20(6):28-31.

Hancock K, Clayton JM, Parker SM, Wal der S, Butow PN, Carrick S, et al. Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review. Palliat Med. 2007 Sep;21(6):507-17.

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Last updated 22 May 2014*