Reluctance to disclose difficult diagnoses: A narrative review comparing communication by psychiatrists and oncologists

Department of Cancer Studies and Molecular Medicine, Leicester Royal Infirmary, Osbourne Building, Leicester LE1 5WW, UK.
Supportive Care Cancer (Impact Factor: 2.36). 08/2007; 15(7):819-28. DOI: 10.1007/s00520-007-0226-y
Source: PubMed


National guidance in most medical specialties supports the full and open disclosure of diagnoses to patients.
Surveys show that most patients want to know their diagnosis, whether it is medical or psychiatric, and a substantial proportion want to know detailed prognostic information. In the past, oncologists have been criticised for failing to reveal a diagnosis of cancer to patients in a sensitive and timely manner. Over the last 30 years, there is evidence that this practice has improved. Yet, clinicians still have difficulty when the diagnosis is not certain, when the prognosis is unfavourable, and when relatives request "not to tell." All of these influences are present in mental health settings.
Psychiatrists and general practitioners may be equally reluctant to reveal difficult diagnoses and prognoses of conditions such as schizophrenia and dementia. The reluctance to reveal a difficult diagnosis may be a routine, but little acknowledged the aspect of medical care that should be incorporated into undergraduate and postgraduate education and openly discussed during peer group supervision.

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    • "All have been narrative literature reviews (Atkinson, 1989; Cleary et al., 2009; Lequesne & Hersh, 2004; Mitchell, 2007; Rose & Thornicroft, 2010) that lacked systematic synthesis. In addition, some focused on communication of news for subtypes of mental health issues (Atkinson, 1989; Lequesne & Hersh, 2004) or concentrated chiefly on making comparisons with the oncology field (Mitchell, 2007). Given this growing evidence base, a systematic synthesis of literature, which includes a broad spectrum of MHD, has been called for in the literature (Cleary et al., 2009). "
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    ABSTRACT: Abstract Background: There is limited understanding of the mechanisms used to effectively communicate with service-users about their mental health diagnoses. Aims: To conduct a systematic synthesis of studies that present data on the communication of a psychiatric diagnosis. Methods: Comprehensive database and manual searches were conducted resulting in the inclusion of 30 quantitative and qualitative papers. Results: The majority of studies were descriptive. The rate of service-users being informed of their diagnosis has increased over the past decade. Consumer communication preferences were not always satisfactorily addressed in practice. Individual characteristics of service-users and clinicians influenced whether a diagnostic discussion took place. Results from intervention studies aimed at facilitating diagnostic communication reported significant improvements in service-user satisfaction and mood and clinician communication skills. Conclusions: This review highlights a gap in the system of communication between clinicians and service-users. To assist clinicians to talk effectively with individuals about their mental health, communication protocols and training need to be further developed and assessed. Such developments would benefit from well-designed randomised controlled trial protocols, should incorporate service-users' preferences and address stigma-related concerns.
    Journal of Mental Health 10/2014; 23(5):261-270. DOI:10.3109/09638237.2014.951474 · 1.40 Impact Factor
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    • "In one study, only one-third of psychiatrists reported that they explicitly stated a diagnosis of schizophrenia, the others preferring instead to use terms such as 'psychosis' or 'breakdown' (Clafferty, McCabe, & Brown, 2001). Factors such as diagnostic uncertainty, pessimism regarding prognosis, concern about stigma and the illness itself interfering with patient ability to comprehend the information are all cited as reasons for not giving a diagnosis of schizophrenia (Bracken & Thomas, 2000; Mitchell, 2007; Seeman, 2010). In a recent study by our group (Outram et al., 2014), just over half the clinicians (9/16) said they agreed with providing patients with a named diagnosis of schizophrenia ; however, most gave multiple reasons for not doing so in practice, and some did not believe it appropriate to give a diagnosis at all. "
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    ABSTRACT: Background: Despite widespread acceptance of the principle that patients should be informed about their diagnosis, many clinicians are reluctant to provide a diagnosis of schizophrenia. This study examines family caregivers' experiences of the communication of a schizophrenia diagnosis and related information. Methods: A generic qualitative methodological approach was used. In all, 13 family caregivers were recruited in regional New South Wales, Australia. Semi-structured interviews were used to explore their experiences and perceptions of discussing the diagnosis, prognosis and treatment of schizophrenia with mental health professionals. Interviews were recorded, transcribed, codes generated and thematic analysis undertaken. Results: Family caregivers described long and difficult pathways to being given a diagnosis, haphazard means of finding out the diagnosis, high unmet needs for information, exclusion from the medical care process and problematic communication and general interactions with mental health clinicians. Caregivers were unanimous about the importance of receiving a timely diagnosis, for them and their relative with schizophrenia. Conclusion: Family caregivers are an integral part of the mental health-care system, and they should be included early in discussions of diagnosis and treatment of a person with schizophrenia. Their perspectives on communicating a diagnosis of schizophrenia provide important information for communication skills training of psychiatrists and other mental health professionals.
    International Journal of Social Psychiatry 05/2014; 61(1). DOI:10.1177/0020764014535751 · 1.15 Impact Factor
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    • "Patients in primary care were aware when their doctors 'colluded' with their views, and did not find it helpful [28]. They have expressed a clear desire for full disclosure of diagnoses as diverse as Alzheimer's and cancer [1]: whether that is also true for patients with unexplained neurology has yet to be determined, but a fair presumption would be that patients want to know what their doctors believe. "
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    ABSTRACT: ObjectiveNeurologists face a dilemma when communicating with their conversion disorder patients – whether to be frank, and risk losing the patient's trust, or to disclose less, in the hope of building a therapeutic relationship. This study reports how neurologists in the UK described dealing with this dilemma in their practice.MethodsPracticing consultant neurologists from an NHS region were recruited by snowball sampling. Twenty-two of 35 consultants in the region were interviewed in depth, and the interviews qualitatively analysed.ResultsThe neurologists were reluctant to disclose conversion disorder as a differential diagnosis until they were certain. They were guided by the receptivity of their patients as to how psychological to make their eventual explanations, but they did not discuss their suspicions about feigning. They described their communications as much easier now than they had seen in training.ConclusionNeurologists adapt their disclosure to their patients, which facilitates communication, but imposes some limits on truth-telling. In particular, it may sometimes result in a changed diagnosis.Practice implicationsAn optimum strategy for communicating diagnoses will need to balance ethical considerations with demonstrated therapeutic benefit.
    Patient Education and Counseling 11/2009; 77(2-77):296-301. DOI:10.1016/j.pec.2009.05.021 · 2.20 Impact Factor
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