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Cancer Nursing:
doi: 10.1097/01.NCC.0000339240.66538.3a
DEPARTMENTS: From the Editor

Truth Telling, Not Telling, and Listening

Hinds, Pamela S. PhD, RN, FAAN, Editor in Chief

Free Access

"You have cancer."

"Your cancer is not responding to treatment."

"Your child has cancer"

An amazing evolution in what is considered to be the correct clinical practice for sharing with patients their cancer diagnosis or prognosis has taken place in the past 4 decades in multiple locations across the globe. The evolution includes moving away from the clinician practice of not telling the diagnosis or prognosis to truth telling based on the belief that patients have the right to information about their diagnosis and their chances of surviving their disease so that they can make informed decisions about treatment and other life concerns.1 This same right is extended to children with cancer. In this evolution of correct clinical behavior, truth telling has been associated with words such as the moral duty of clinicians and full disclosure that seem to equate truth telling with honest, good, and preferred clinician behaviors.2,3 Truth telling has also been associated with terms such as assault by truth, being unnecessarily cruel, and as imposing information on patients.2,4 Not telling has been associated with words such as evasion, paternalism, concealment, conspiracy of silence, and nondisclosure. Not telling has also been referred to as "corrosive" to the clinician-patient relationship and as protective of patients' hope.4-6 These words of strong mental associations tell us that we are not neutral about truth telling and not telling; the terms themselves are pejorative and imply judgment of a clinician's style of communicating with patients and their families. Judging communication styles in this way invites research about cultural humility in oncology, or the development of a respectful relationship with a patient and others through self-reflection, self-critique, and focused interviewing of patients to learn about how the patient's goals and priorities are similar and different from those of the clinician.7

Cultural humility in the care of oncology patients and their families is apparent in every issue of Cancer Nursing and not just because of the purposeful blending of papers from diverse geographical countries. Cultural humility is as relevant to a single family experiencing cancer as it might be to an entire nation because each family member is likely to have a preference for type and amount of cancer-related information. Cultural humility teaches us that no single standard about sharing the diagnosis or prognosis of cancer can exist. The truth is, truth telling and not telling are clinical treatments. We live in the much appreciated age of tailored or personalized cancer treatments to best match the makeup of our patients. Most times, such tailoring is considered in the context of medication dosing, but communicating cancer diagnoses and prognoses to patients and their families is no less a treatment than medication titration. True cultural humility requires clinicians to make every effort to understand their patients' beliefs and how their patients want themselves and their disease to be treated.8 The truth is, regardless of truth telling or not telling, the care that we provide in oncology needs to be guided by patient preferences for information and for treatment. Goals of care can be established, refined, or refocused at any point in the trajectory of care, whether truth telling or not telling is occurring.

Clinicians who strive to deliver tailored care guided by cultural humility want to know what methods to use to establish care goals with their patients and when to implement these methods. Establishing goals of care with patients does not require a clinician to tell or not tell, but it does require clinicians to listen carefully to patients. The nature of some of the research included in Cancer Nursing seeks to add to our understanding of patient preferences for treatment, family desires about care, and how such patient and family preferences influence cancer care outcomes. We would like to include in our journal in the future more studies that address the tailoring of cancer care based on patient and clinician characteristics, including the potential of differences in care when cultural humility and listening are present in the delivered care. Truth telling is not necessarily communicating; not telling is not the same as not communicating, but listening is a universal form of communication.

My best to you.

Pamela S. Hinds, PhD, RN, FAAN

Editor in Chief, Cancer Nursing

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References

1. National Quality Forum. A National Framework and Preferred Practices for Palliative and Hospice Care Quality. Washington, DC: National Quality Forum; 2006.

2. Taboada P. Request to withhold the truth at the end of life. International Association for Hospice and Palliative Care. http://www.hospicecare.com/Ethics/monthlypiece/ethics2002/pom_aug.htm. Accessed August 9, 2008.

3. Warm E, Weissman D. EPERC Fast fact and concept #21: hope and truth telling. http://www.mywhatever.com/cifwriter/library/eperc/fastfact/ff21.html. Accessed August 9, 2008.

4. Searight HR, Gafford J. Cultural diversity at the end of life: issues and guidelines for family physicians. Am Fam Physician. 2005;71:515-522.

5. Brody H. Hope. JAMA. 1981;246:1411-1412.

6. Glick S, Kristjanson L, Nunez Olarte JM, Ripamonti C, Zylicz Z. International perspectives. Innov End Life Care. 1999;1. http://www2.edc.org/lastacts/archives/archivesJan99/intlpersp.asp. Accessed August 9, 2008.

7. Hunt LM. Beyond cultural competence: applying cultural humility to clinical settings. The Park Ridge Center Bulletin. 2001:24. http://www.parkridgecenter.org/Page1882.html. Accessed August 12, 2008.

8. Brody H, Hunt LM. Moving beyond cultural stereotypes in end-of-life decision making. Am Fam Physician. 2005;71:429-430.

© 2008 Lippincott Williams & Wilkins, Inc.

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