This case highlights the ethical use of nondisclosure from both the palliative care and intensive care teams. Non-disclosure (of our patient’s husband’s death) was justified as a therapeutic exception. Which “allows the physician to withhold information from a patient if that information would psychologically harm the patient and thus imperil the patient’s physical health” (6). From the time our patient was admitted to the hospital, growing concerns developed from both the palliative care and intensive care teams of how medical decision-making would be addressed. Neither our patient nor her husband had a written advanced directive. After discussion with their family members, it was also clear that neither patient had verbally addressed advanced directives with them prior to this hospitalization. Ideally, our patient would serve as her husband’s surrogate and visa versa, but they were both incapable of doing so in this situation. It was their children (with input from extended family members) who provided consents for interventions and therapies as the legal surrogates for decision-making, in accordance with the Family Health Care Decisions Act. They opted to pursue all life sustaining therapies for both parents, thankfully, as this eased any provider discomfort and conflict that would otherwise arise (e.g. if they had elected to forego any interventions for either parent).
The Ethics Committee was informally consulted prior to implementing the therapeutic privilege. The argument provided in support of its use by the Ethics Committee was that 1) withholding of this information was a request initiated by her own family members; 2) this was a notably emotionally and physically frail patient (i.e. she presented with decreasing functionality for activities of daily living while her husband was admitted, had declining performance status, and had stopped taking even basic medications for her own health conditions); 3) once the patient was deemed stable enough to receive the news, rapid disclosure would be made to inform her that her husband had died; and 4) there was no imminent decision-making that would require disclosure for her to provide informed consent (e.g. acute needs for disclosure to proceed with consent for autopsy or funeral planning).
This case is an example of the use of deception by not disclosing the husband’s death to the patient immediately after extubation. In the medical profession, deception is considered wrong. Some consider withholding information the moral equivalent of lying (6). In our case, we did not disclose sensitive information to the patient about her husband’s death, and when she asked about her husband, we deferred answering those questions. We did not directly lie to the patient (i.e. we did not tell her he was still alive), but we did not disclose the truth of the events that had occurred. There are two different opinions in literature, one stating that there is a moral distinction between lying and deception and second that favors them equal (3). Both opinions have defenses. Some regard deception as dishonest and morally equivalent to lying if not even worse, because it creates a false belief (3), and with deception, the physician my loose their focus of his/her real intentions in the patient care process. A summary of opinions across academia generally conclude that all lying and all deception (verbal or nonverbal) are equal and wrong when used in medicine, as these practices endanger trust, break rapport, and are unethical and disrespectful (7). We believe that while maintaining cognition of the ethical implications of non-disclosure, we were justified in withholding this information based on the medical principle of Primum Non Nocere (First, do no harm). Our reasoning for non-disclosure in this particular case is that the delay in informing the wife was brief and limited to a short state while she herself was recovering. Our disclosure was rapid, done after a withholding period of three days. Withholding was done at the surrogate’s request, and there were no actions of decision making required during the period of non-disclosure. As stated, we wanted to allow the patient to come to terms with the events, both physically and emotionally, especially after she had demonstrated both depressive symptoms and delirium. A physician must always weigh beneficence against non-maleficence, balancing benefit against avoiding potential harms, putting into perspective both the benefit and the potential harm that may be caused. A potential justification for modifying the truth is that it is likely to produce a greater advantage for the patient and less harm, bearing in mind that harm includes direct trauma, anger, feelings of betrayal and loss of trust in the healthcare system (6). We discussed our decision with the family who preferred the delay to break the news and supported our judgment of when and how to disclose. Our patient was informed about her husband’s death three days later in the presence of family members. She cried, and she was upset for the loss of her lifelong companion, which are appropriate reactions of grief. She exhibited great self-awareness of her psychological instability whilst her husband was initially admitted. She acknowledged her feelings of depression, her withdrawn behavior, and that she had stopped caring for herself in his absence. As she acknowledged her own frailty, she agreed with the request (made by her family members) to withhold this information and the rationale of waiting to disclose the information sooner. This is a unique case where we were challenged in balancing the necessity to inform the patient (principle of autonomy) and the desire to ensure the patient’s wellbeing by minimizing suffering (principle of nonmaleficence).