Nurses sometimes encounter situations whereby requests are made to withhold the truth from a patient. This is referred to as collusion, and creates a scenario of secrecy and mistrust. These requests are often made in relation to disclosing a cancer diagnosis, a life-limiting illness or even imminent death, and are often made by family.

A patient being excluded from knowing their own information was more common in the past, and the trend has been away from this in more recent years. In many cultures though, it is usual practice to keep distressing news from patients. In these instances it is important to respect the cultural beliefs and collaborate with an ‘elder’ or significant person, while keeping the patients interests foremost.

The role of the nurse within this is a difficult one. The majority of patients do 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, but 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. Honest open culturally acceptable communication is usually the best policy, and discussions within the multidisciplinary team can help to clarify what is happening and why, and whether it is in the best interests of the patient. 

Resources

• NSW Health has produced Guidelines for end-of-life care and decision-making
• Current Learning in Palliative Care (CLIP) 15 minute online tutorials: Collusion and Denial
• The International Association of Hospice and Palliative care IAHPC Manual of Palliative Care 2nd Edition has a section on Ethical Issues. 
• The Center for Bioethics, University of Minnesota (US) has a document: End of Life Care: An Ethical Overview 
• 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, such as the Consent to Medical Treatment and Palliative Care Act 1995 (SA) and the Medical Treatment Act 1994 (ACT).
• The General Medical Council in the UK has produced a guidance for doctors that may be of interest: Treatment and Care Towards the End of Life – Good practice in decision-making.

Related CareSearch Pages

Nurses Hub
Communication
Advanced Care Planning
Working with Families

Free Full Text Articles

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, White DB.Hope, truth, and preparing for death: perspectives of surrogate decision makers.Ann Intern Med. 2008 Dec 16;149(12):861-8.

Kirklin D. Truth telling, autonomy and the role of metaphor. J Med Ethics. 2007 Jan;33(1):11-4.

References 

• 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.
• Jotkowitz A, Glick S, Gezundheit B. Truth-telling in a culturally diverse world. Cancer Invest. 2006 Dec;24(8):786-9.
• Vivian R. Truth telling in palliative care nursing: the dilemmas of collusion. Int J Palliat Nurs. 2006 Jul;12(7):341-8. 
• Tuckett AG. Truth-telling in clinical practice and the arguments for and against: a review of the literature. Nurs Ethics. 2004 Sep;11(5):500-13.