This is a particularly difficult situation because you have not met this patient or his family before. You are also on-call and therefore under a fair amount of time pressure; your brain will not be very welcoming of the idea of having to undertake some potentially tricky and emotional negotiation with these relatives. However, good communication is an essential part of being a doctor: you are not just a clerking machine!

An experienced SHO would probably satisfy themselves from the end of the bed how acute the clinical situation is and proceed accordingly. I would be inclined to take a few minutes to explain to the relatives that we would not need to discuss the diagnosis during the initial treatment, then assess and manage the patient appropriately, having arranged to sit down for an extended chat with the family afterwards.

Remember the basics: patient first

The first duty is the care of the patient. The emotional needs of his relatives are important but remain secondary. The doctor-patient relationship is founded on trust, and is nurtured by honesty but poisoned by deceit. I would be inclined to find out what he already knows first. Over 50% of patients with a terminal disease know their diagnosis without being told. It would also be useful to find out what he wants to know. A good question here is, ‘Are you the sort of person who likes to know what’s happening or do you like to leave it to the doctors?’ If they don’t want to know the facts, accept it. At the same time you can give permission to ask further questions in the future, should they change their mind.

In this particular scenario, you may choose to elicit the patient’s wishes and then speak with his family to negotiate should he wish to know. You could stop short of discussing definitive diagnoses in the first consultation with him by explaining you need to look up the precise facts in his case notes when they arrive. Now is the time to go and discuss the issues with the family.

Deal with the relatives

Kerrie Bavidge has been an SHO in respiratory medicine and in oncology and has come across this exact scenario a couple of times. She wrote, ‘I start by speaking with the relatives about why they do not want the patient to know the diagnosis. Although I might not agree with them, it is very important to listen to their views and concerns. Ultimately I might go against their wishes, so it is important that they at least feel they were listened to and that my reasoning was explained to them.’

 ‘As for the actual discussion with the relatives, I would tell them that if he asks his diagnosis, I cannot lie to him. I would explain that it might be helpful for him to know his diagnosis, as he may well know that something serious is going on but not feel able to express his fears as no one else is discussing it. It can be damaging to family relationships to keep secrets like this. He may also have things to sort out before he dies, ranging from a will to reconciliation with an estranged relative. It would allow frank discussion of treatment options and palliation with the patient.’ Katie Clarke, a palliative medicine physician in Sydney, sums the whole issue up very neatly. She explains that the patient has a ‘right to know, but not a duty to know’ the facts of their case.

Have all the bases covered

The last thing the doctor, the patient and his relatives would want to happen is for him to find out by accident. He might overhear a nurse handover, or a medical student or doctor may mention cancer, not realising he doesn’t know. Communication with other healthcare professionals is of paramount importance. The patient’s wishes and what he has been told should be recorded in his notes. The nurses looking after him should also be informed about the current situation so that whatever his choice, his care can be handled sensitively.

Finally, there is an important dimension to your life that it may be possible to share with this patient and his family. Hopefully, through the loving, wise and sensitive way you handle the situation you will begin to build a good relationship with them. Remember to pray for them in the situation and later. Asking the question, ‘Do you have a faith that helps you?’ may open up a door to sharing with them the hope they can have in eternity.