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communicating bad news

The truth, the whole truth, and 'nocebo' effects

Dr Placebo
Last edited 22nd October 2012

Good practice demands that doctors inform their patients about both known and suspected side effects of any medication they prescribe. (In ethics-speak this is because of the requirement to respect patient autonomy.) On the other hand, the very act of providing information about side effects can produce negative effects (these are called ‘nocebo’ effects)! For example in a trial of a drug for unstable angina, patients were divided into two groups. The first group was given a statement outlining possible gastrointestinal (GI) side effects, and the second was not. Six times as more patients in the first group experienced subjective GI side effects.

How can doctors respect patient autonomy by revealing all information about side effects, yet avoid doing harm by causing the very side effects they describe? One answer is to give the information in the right way. We all know people who give negative feedback in a way that tends to increase anxiety. Others give the same information to evoke positive responses. Good teachers, coaches, and doctors all know how to frame information constructively.

Another solution is to ask patients. Some patients do not want to be burdened with details of all known and suspected side effects (serious side effects do, of course, need to be revealed). In these cases we can respect patient autonomy and withhold some information because the patient requested to be (partially) ignorant. Other patients do want to know about each and every side effect, in which case there may be little choice other than to reveal them, albeit in the right way.

So what’s the take home message? Tell the whole truth that the patient wants to hear and nothing but the truth in a way that will maximize benefit and minimize harm.

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