‘The miserable have no other medicine; But only hope.’  Claudio, in Measure for Measure Act 3, Sc.1, by William Shakespeare (1564-1616). 

This Fast Fact discusses the difficult balance between maintaining hope and truth telling, especially as it applies to giving bad news.  One of the most difficult things physicians do is give bad news. Medical students and residents are often afraid that by telling someone the truth about his/her diagnosis, they will be responsible for taking away hope. And yet, are physicians really that powerful? Isn’t it possible that our fear of causing the loss of hope is just another way we can avoid the harsh reality of impending death? This conflict, between truth-telling and fear of destroying hope, is commonly noted by patients and families who feel that “the doctor is not really telling me everything,” a feeling that is highly corrosive to the doctor-patient relationship.

Brody (1981) writes, ‘Hope means different things to different people, and different things to the same person as he/she moves through stages of illness.’ The physician can play a valuable role in helping the individual patient define her or his hopes and fears. When close to death, hope often becomes refocused away from long-term goals and towards short-term or spiritual goals. Hope may mean a pain-free day, a sense of security, love and non-abandonment, or a wedding to attend in the near future. ‘When we talk to patients and find out what is really worrying them, we can almost always give them realistic assurances’ (Brody 1981).Factors that often increase hope in the terminally ill include feeling valued, meaningful relationships, reminiscence, humor, realistic goals, and pain and symptom relief.  Factors that often decrease hope include feeling devalued, abandoned or isolated (“there is nothing more that can be done”), lack of direction and goals, and unrelieved pain and discomfort.

Some strategies for beginning a dialogue about hope and goals include:

• Ask the patient, “Do you have long term hopes and dreams that have been threatened by this illness?”  Support the patient in recognizing and grieving their possible losses.
• Ask the person if there are particular upcoming events they wish to participate in – a wedding, birth, trip, etc.
• Ask “What are your hopes for the future?” and “Do you have specific concerns or fears?”
• Encourage the patient to make short, medium, and long range goals with an understanding that the course of terminal illness is always unpredictable.
• Utilize “I wish…” statements when conveying bad clinical news in order to convey an appropriate degree of humility – “I wish there was more we could do for your cancer but I’m afraid time may be getting short.”

Teaching Tips

• Use the Brody article as a starting point for discussion with trainees
• When faced with the need to give bad news, ask trainees how they feel before they give the news; are they worried about causing a loss of hope? Ask them to reflect further – do they feel hopeless because of the situation? Whose feelings are they trying to protect, their own or the patient’s?
• Ask trainees to make a list of risks and benefits of truth telling.  Use the list as a starting point for group discussion of the hope-truth telling conflict.

References

1. Brody H. Hope. JAMA. 1981; 246:1411-1412.
2. Ambuel, B. Spirituality. In: Weissman D, Ambuel B, Hallenbeck J, eds. Improving End of Life Care: A Resource Guide for Physician Education. 3rd Edition. Milwaukee, WI: Medical College of Wisconsin; 2001.
3. Twycross R, Lichter I.  The terminal phase. In: Doyle D, et al, eds. Oxford Textbook of Palliative Medicine. 2nd Edition. New York, NY: Oxford University Press; 1998: pp. 977-78.
4. Remen RN. Kitchen Table Wisdom: Stories That Heal. New York, NY: Riverhead Books; 1997.

Version History:  This Fast Fact was originally edited by David E Weissman MD.  2nd Edition published July 2005. 3rd Edition published May 2015.  Current version re-copy-edited May 2015.