Conspiracy of Silence

Honesty with the terminal patient will provide the greatest benefits. However, the physician frequently is torn between patient and family, with the patient saying, "Don't tell my wife because she can't handle it," while the wife is saying, "Don't tell my husband because he can't handle it." Although the wishes and desires of the family must be considered when deciding how to care for a dying patient, the physician's primary obligation is to the patient. The method of management must be based on the physician's knowledge of the patient and insight into the patient's desires, feelings, and approach to life. Despite all efforts at deception, the patient knows or will soon learn about his or her condition.

By cooperating with the family in a conspiracy of silence, information that really belongs to the patient is withheld. Only if the physician believes that the patient is not yet ready to cope with the information, or sincerely wishes not to be told, should the information be withheld; however, this is more often the exception than the rule. One patient said, "I knew it was cancer from the moment they started lying to me" (Lamerton, 1976, p. 28). Simpson (1976) described a 63-year-old woman whose family insisted she knew nothing of her inoperable gastric carcinoma. When visited by the physician, "She gave a dry chuckle: 'Only a little ulcer... and my relatives down from Wales to see me for the first time in 15 years, and the priest here at 6 in the morning?'" (p. 193). When such a charade continues, terminally ill patients become more and more isolated because they are unable to communicate their concerns and fears honestly and openly with those closest to them. The elaborate schemes some families and physicians develop to "protect" the patient lead to great tension within the family, as everyone attempts to perpetuate the lie while continuing to interact with the patient.

Similarly, failure to provide the information to the patient's family can lead to a decrease in the quality of their relationship in the time remaining, because the patient's tensions and fears are not understood by family members and friends. Dunphy (1976) described a patient with terminal cancer who asked that his wife not be told. He then quickly planned a world cruise, which they had wanted to take for some time. The wife, unaware of the reason for the hasty departure, was unhappy and complaining throughout the trip, while the husband saw himself as a silent martyr, trying to provide a final measure of happiness for his wife. Only after returning home and reminiscing on this miserable cruise did he tell his wife the truth and the reason for the precipitous departure. Had she been told earlier, their final days together could have been a pleasant and memorable experience. At a time when the terminally ill patient most needs closeness, a lie may serve to push them apart.

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