A 65-year-old man is admitted to the inpatient unit of a busy community hospital for worsening shortness of breath over the last few days. He has a 40-pack-year smoking history and was initially diagnosed with chronic obstructive pulmonary disease exacerbation and treated accordingly. Chest x-ray on admission shows a large hilar opacity, and CT scan confirms the presence of a 4-cm mass in the right hilum. During the process of obtaining informed consent for bronchoscopy with biopsy, the patient says, "Doc, please don't tell me what they find, because if it's cancer, I don't want to know." Which of the following is the most appropriate response to this patient's request?

Question

A 65-year-old man is admitted to the inpatient unit of a busy community hospital for worsening shortness of breath over the last few days.  He has a 40-pack-year smoking history and was initially diagnosed with chronic obstructive pulmonary disease exacerbation and treated accordingly.  Chest x-ray on admission shows a large hilar opacity, and CT scan confirms the presence of a 4-cm mass in the right hilum.  During the process of obtaining informed consent for bronchoscopy with biopsy, the patient says, "Doc, please don't tell me what they find, because if it's cancer, I don't want to know."  Which of the following is the most appropriate response to this patient's request?

Quizplus · Accepted Answer

Just as competent patients have the right to refuse medical care and interventions, they also have the right to refuse to receive diagnostic information. Requests to withhold information may stem from personal fears or cultural, religious, or social factors. The patient's wishes should be respected based on the principle of autonomy, and the patient should not feel pressured to change his decision. However, this patient likely has unspoken fears about a cancer diagnosis that can be addressed. An appropriate initial response is to attempt to understand why the patient feels this way. Efforts should be made to gently explore the patient's concerns and elicit questions he may have about potential diagnoses (eg, lung cancer and other possibilities). The physician should try to understand the patient's desires and concerns to develop a trusting relationship that may facilitate future collaborative treatment planning. (Choice A) This statement asks the patient to reconsider whether he wants a bronchoscopy based on his preference not to know the outcome. It could be experienced as putting pressure on the patient not to undergo the procedure and misses the opportunity to ask why the patient doesn't want to know the results. (Choice B) Although explaining how knowing the diagnosis may help the patient make subsequent treatment decisions, doing so prematurely without inquiring about the patient's reasoning may pressure the patient to acquiesce to the physician's desire, which does not respect the patient's autonomy. (Choice D) This response normalizes the tendency to avoid receiving bad news, but it makes the unfounded assumption that not knowing will cause more anxiety than bad news for this particular patient. (Choice E) This response respects the patient's autonomy but is dismissive and excludes future collaborative treatment planning. The physician should attempt to understand the patient's perspective and address his concerns. Educational objective: Patients have the right to have information withheld from them regarding their medical condition. Physicians must respect their wish not to know but should also explore the patient concerns to better understand their preferences and maximize their involvement in subsequent medical decision-making.

A 65-Year-Old Man Is Admitted to the Inpatient Unit of a Busy