Telling Patients the Painful Truth

Mary Jackson (not her real name) is 93 years old, and has been my patient for 35 years.  She stopped school after the 8^th grade. Nevertheless, she is always up on the latest news and is a shrewd judge of people—particularly politicians and members of her family.

The first time I met Mary, she told me that her mother had recently died of cancer.  She made a point of saying that her mother had not known she had cancer. “The doctor said that he did not want to tell my mother she had cancer,” Mary told me, “because people thought cancer was a death sentence, and he did not want to take away her hope. The doctor asked us kids not to say anything to her.”  Mary then pointedly told me, “I want a doctor who will tell me the truth.  I don’t want no lies.  Don’t misunderstand, I don’t want bad news, but if you got bad news I want you to tell me.”

In the years since then Mary has had several major illnesses, some of which were temporarily life-threatening but none of which was a death sentence.  Each time I told her exactly what the situation was, and she seemed to appreciate that.  Indeed, I remember several times when I came to her bedside at the hospital and one of her children was there and she told them “I trust him because he always tells me the truth, good or bad.” 

Now and then Mary would have a symptom that I thought was nothing serious, and that turned out to be nothing serious.  When I gave her the good news she would look at me a little suspiciously and say “Are you sure?”  Usually, it took just another word or two from me to reassure her. But she always required some reassurance.  I think she was underlining for me how important it was for her that I tell her the truth, come what may.

I see Mary in my office about 3 times a year—mainly to make sure her diabetes is in control.  For the past five years, she has always said she was feeling fine and her blood tests have been normal. I last saw her in February, 2007, because she missed her appointment in July.

A few weeks ago Mary’s daughter called me and said her mother was weak and had no appetite. When Mary came to my office later that week, it was clear something was seriously wrong. She had lost weight, and was so weak that she was unsteady on her feet. Her mind was as keen as ever, but for the first time in 93 years she was frail.

The CT scan of her abdomen and chest showed, almost surely, that she had cancer of the ovary that had spread throughout her abdomen and into her lung.  I waited for additional tests to come back before talking to her. The blood tests strongly indicated ovarian cancer.

I asked her four children to meet me at her bedside that evening. I said I had some bad news and I wanted to talk to all of them at the same time.  When all five of us showed up at her bedside together, Mary looked around and said “Uh-oh, what’s wrong now?”

I said: “Mary, you know how you always tell me that you want me to tell you the truth, even if it’s bad news?”

Mary stared at me, and didn’t say anything.  So I continued: “I’m afraid I have some bad news.”  I told her the tests had indicated that she had cancer. It was cancer that had taken away her appetite and made her weak.

Mary stared at me, expressionless, and then said: “Dr. Komaroff, you know my mother died of cancer, and her doctor never told her she had cancer because he didn’t want to take away her hope.  A person has to have hope.”

I was taken aback by that, thought for a minute, and then responded that we might have a treatment to slow the growth of her cancer, that we would try a medicine that might help her appetite, that we would give her physical therapy to try to get some strength back in her legs, and that we would give her treatment for pain if she needed it —fortunately, she had no pain now.

She looked resigned and said, “At least that’s something.”

For a few seconds, no one said anything.  Then Mary’s daughter said: “I’m glad you let us know, Dr. Komaroff, when we could all be with her, and we could all hear it together.”

Mary looked at her daughter and said: “That’s what I like.  Someone who won’t lie to me.”

I think I did the right thing.  I think Mary hated to hear the truth—no one wants to hear bad news.  And for a minute, she was angry at both the messenger and the message.  However, I think she trusts me to do what I can for her, because I told her the truth.  

What do you think?

Anthony Komaroff, M.D., is the Simcox-Clifford-Higby professor of medicine at Harvard Medical School (HMS), and editor-in-chief of Harvard Health Publications at HMS. He is a practicing senior physician and was formerly director of the Division of General Medicine at Brigham and Women's Hospital.

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