Intended for healthcare professionals


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

BMJ 2000; 321 doi: (Published 02 December 2000) Cite this as: BMJ 2000;321:1376

The rainbow of coping mechanisms

Anne-Mei The and the co-authors are to be congratulated for their
thought provoking article on the doctor-patient communication and terminal
illness(1.Many of the issues dealt by them will surely resonate with the
day-to-day experiences of many oncologists.

The case, described in box 6 of their article is an example of the
need for practical information by the patients and families (1). Benghiat
et al using a ‘real world’ clinical database found that the majority of
patients treated by palliative chemotherapy, for a wide range of cancers,
died within a year (2). This means that the majority of the patients
receiving palliative chemotherapy just before Christmas would be dead by
the next Christmas. This type of practical information needs to be given,
in the palliative treatment setting, to the families of cancer patients.

In this otherwise excellent article, I would disagree with the
authors conclusion that ‘it is not in the patient’s interest to focus on
the treatment calendar'. This, in my view, is a bit patronizing and is as
unfair as not providing proper information about treatment and prognosis.

Every one of us, at times of stress, have different coping
mechanisms, which are often learnt during early childhood (3). Focusing on
the ‘treatment calendar’ is a type of coping mechanism for these patients
and probably cements their fragile mind, which is in a state of shock. It
is essential that the provision of information is tailored to the
individual patient’s needs and coping mechanisms. One shouldn’t assume
that all the cancer patients need detailed information. A small proportion
of patients don’t want detailed information (4) and avoidance of
‘information overload’ is probably their coping mechanism (5).

The patients, described in the eBMJ version of this article, who did
not want chemotherapy and those who did not have false optimism, have
their own mechanism of coping i.e. ‘facing the truth head on’ but not all
patients would want to cope in that way. If a patient’s false optimism
persists as a coping mechanism even after providing adequate information,
as along as it is not leading to distressing maladaptive behavior, it
needs to be acknowledged and respected with an open mind.

My bias is towards giving information in small packets after an
initial broad outline about diagnosis and prognosis. This needs to be
followed by an active exploration of the need and readiness of the patient
to receive further information (6). This exploration should not end with
the first consultation and should be done at every stage of the illness.
Most importantly, all the communication needs to be done within the
framework of the patient’s ‘normal’ coping mechanism. If there is any
doubt about the patient’s wishes, during any stage of this process, it is
crucial that the patient be directly asked about the need for further
detailed clinical and practical information.


(1) Anne-Mei The, Hak T, Koëter G, Van der Wal G. Collusion in doctor
-patient communication about imminent death: an ethnographic study. BMJ
2000; 321: 1376-1381

(2) Benghiat A, Saunders V, Steele WV. Computerizing the cancer
center. Clin Oncol 1999; 11:33-9

(3) Woolston JL. Theoretical considerations of the adjustment
disorders. J Am Acad Child Adolesc Psychiatry. 1988; 27(3): 280-287

(4) Meredith C, Symonds P, Webster L, Lamont D, Pyper E, Gillis CR,
et al. Information needs of cancer patients in west Scotland: cross
sectional survey of patients' views. BMJ 1996; 313: 724-726

(5) Ingelfinger FJ. "Arrogance." N Engl J Med 1980; 303: 1507-1511

(6) Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP.
SPIKES--A Six-Step Protocol for Delivering Bad News: Application to the
Patient with Cancer. Oncologist.2000; 5: 302-311

Competing interests: No competing interests

03 December 2000
Sundar Santhanam
Specialist Registrar in oncology
Dept. of Oncology, Leicester Royal Infirmary, Leicester LE1 5WW