A 66-year-old, previously healthy woman is admitted to the hospital due to recurrent hemoptysis. Chest x-ray obtained in the emergency department shows a 10-cm perihilar mass in the right lung. The patient undergoes bronchoscopic biopsy, which reveals non-small cell lung cancer. When entering her room to disclose the biopsy results, the physician sees the patient eating lunch with family members and friends who have been at her bedside since admission. They all appear anxious, and the patient tearfully tells the physician, "I've been dreading this moment. I think I already know what my test results are." Which of the following responses by the physician is most appropriate?

Question

A 66-year-old, previously healthy woman is admitted to the hospital due to recurrent hemoptysis.  Chest x-ray obtained in the emergency department shows a 10-cm perihilar mass in the right lung.  The patient undergoes bronchoscopic biopsy, which reveals non-small cell lung cancer.  When entering her room to disclose the biopsy results, the physician sees the patient eating lunch with family members and friends who have been at her bedside since admission.  They all appear anxious, and the patient tearfully tells the physician, "I've been dreading this moment.  I think I already know what my test results are."  Which of the following responses by the physician is most appropriate?

Quizplus · Accepted Answer

When discussing serious, potentially life-threatening illness, patients commonly wish to have family and friends present for support. Having others be present may also facilitate better understanding and retention of information when patients are overwhelmed or distracted by ongoing symptoms of illness. However, patient preferences vary widely, both among and within patient subpopulations (eg, elderly, minorities), regarding which (if any) companions should be present during discussion of serious illness. Therefore, before disclosing any significant information, the physician should first determine how the patient prefers to receive information and which companions should be present during the discussion. The inquiry should be nondirective, avoiding assumptions and giving the patient full scope to express preferences. Care should be taken to avoid alienating involved family members, who may be central in supporting the patient's decision-making and comfort. Only when the patient's preferences are clear should significant information be disclosed. (Choice A) Although a family meeting can be an appropriate forum to share difficult information and answer questions, the physician should first inquire as to the patient's preferences before postponing delivery of results. (Choice C) Some patients (eg, elderly) may express the desire for other family members to be informed first about a health condition; however, this preference should not be assumed. The physician must first discuss with the patient how she wishes to receive information. (Choice D) This response conveys empathy but assumes that the patient prefers all her companions to remain in the room. It also reveals the results are upsetting ("difficult news"). (Choice E) When discussing test results in the presence of a patient's family and friends, reviewing what they already know before proceeding to new information is advisable. However, this statement assumes she has already given consent for her companions to be present during the discussion, which she has not. Educational objective: Before disclosing any significant information to patients, physicians should determine patient preferences for how to receive information and which companions should be present during the discussions. Only when patients' preferences are clear should significant information be disclosed.

A 66-Year-Old, Previously Healthy Woman Is Admitted to the Hospital