Collusion in doctor-patient communication about imminent death: an ethnographic study

Patients who refused chemotherapy

When Mr A fell ill, he had worked in a university hospital for 25 years. For many years he had transported or accompanied oncology patients from the ward to other places in the hospital (for example, for investigations). Most of these patients had been incurable. Years ago Mr A had decided that he would refuse treatment himself if he ever had an incurable disease.

Mrs B had served coffee on an oncology ward in a regional hospital. She had seen many incurable patients, and she had promised herself not to go through all that misery. She had just divorced and was rather gloomy about her prospects when she was diagnosed as having small cell lung cancer. She told the doctor immediately that she would not accept treatment. A few days later she said she wanted to die. After two weeks she experienced severe pain, which was treated with morphine. Nearly four weeks after the diagnosis she died in hospital.

Mrs C had a long history of coping with diseases such as chronic obstructive pulmonary disease and rheumatism. One of her legs had been amputated because of vascular disease. She had stayed in a nursing home when her husband could no longer care for her. Mrs C had suffered pain for many years. She refused treatment for her lung cancer and asked for euthanasia instead, which was refused. A week later she suffered tightness in the chest and a terrible pain. She received morphine and died two days later in the hospital.

Patients who did not show false optimism

Mr D was an architect, as his wife. They talked openly about the pressure on their family life due to his imminent death and about what they should do with their joint architecture office when he died. When the researcher relayed to them her interest in communication, Mrs D described spontaneously that she had observed "false hope" in other patients: "It’s incredible, they really seem to believe that they are going to be cured. We knew from the beginning that the therapy was just life prolonging and we wanted that time to settle up things."

Mr E was a retired lawyer. When the doctor told him that only life prolonging treatment was possible, he said that he would accept that option because he wanted to attend some important future events, the opening of his son’s office and the birth of his first grandchild. During his illness trajectory he repeated over and over again that he would be happy if his life could be prolonged only until those two events had happened.

Mrs F was not highly educated herself but her children were, and they had occupations in health care as well. Each time the doctor gave her some "good news" she would express her happiness. This happiness could not evolve into "false optimism" because her children continuously reminded her of what was said in the first (bad news) consultation: "Do you remember what the doctor said? Recovery is not possible."