Trust and truth telling in nurse patient relationship

How to build and maintain trust with patients | Learning article | Pharmaceutical Journal

trust and truth telling in nurse patient relationship

sustained her stay in the hospital with the trust that she was suffering from tumor Nursing Code of Ethics as well as hospital's policy in truth telling [5]. . Relationship between nurse, patient and family can be jeopardized if. Healthcare professionals begin to gain patients' trust by being . Patients' experiences of trust in the patient–nurse relationship—a systematic. *What are the experiences of nurses telling a terminal cancer patient of a to accept a paternalistic relationship; and secondly, withholding the truth has a not to tell the truth, this situation of collusion might destroy trust and nurses often.

Lessons from History John Kleinsman reflects on the use of language and terminology, noting that the words we choose not only reveal but also shape our thinking.

The history of the Nazi genocide offers insights that are relevant for our time, insights that highlight the links between language and action.

Even dying brings its own unique blessings, challenges and opportunities. A Nursing Perspective Yet, for the health professional, there is more to telling the truth than simply being accurate and exact, factual and literal.

Relationships with human beings are far more complex, as is the way we speak the truth. There are many aspects to communicating the truth to patients and families. Adopting a blanket "they must know at all costs" approach, or even having policies and protocols that provide a fixed framework for patient health professional dialogue, does not adequately deal with the complexity of truth telling.

What is called for is a mix of skill, knowledge, wisdom, intuition and insight. Further variables to be considered in an understanding of truth telling include the context, rapport, professional relationships and institutional culture.

Nurse Patient Relationship/Communication

This article will briefly explore some of the issues around truth telling from a nursing perspective. Principles and Truth Telling It is not unusual for nurses to have a number of discussions each day around the issues relating to a particular case. The well known principles of autonomy, beneficence and non-maleficence are used by nurses as guides to assist them in the 'to tell or not to tell' debate. Helpful as they are, however, the reality is that these principles often conflict with each other and require balancing in our efforts to communicate with patients and their families.

Lichter believes it is vital to tell the truth to a patient because they have a right to know. He therefore advocates overriding the principles of non-maleficence whether the "full" truth may in some ways be detrimental to a patient and beneficence whether it is to the patients advantage not to know the full truth in favour of autonomy the right to choose who we wish to be, to make our own decisions and to be in control of what is being done to us.

Kendall argues that "an action can be harmful at the same time as being beneficial" and draws an analogy between truth telling and chemotherapy treatment. While chemotherapy introduces toxins that can cause extreme harm, the outcome of this treatment may well be beneficial for the patient. Likewise, telling the painful truth can be beneficial by allowing patients and families to facilitate planning and decision-making in regard to their lives and future care.

The views of Lichter and Kendall are representative of many others and lead us to conclude that the debate about truth telling in the area of healthcare is no longer around 'to tell' or 'not to tell', but rather about who should tell, when to tell and how to tell. Nurses and Truth Telling A review of the relevant literature reveals that many health professionals will only tell the truth to patients if asked outright.

Recent studies analysing this fact suggest that the culture of the institution in which nurses work has a significant influence on nursing practice when it comes to discussing diagnosis or prognosis with their patients. Kendall,Dunniece et al,Costello Of particular interest is the research that shows how nurses tend to distance themselves from their patients for fear of reprimand from medical staff for disclosing information asked of them by the patient.

Kendall, In recognition of this unsatisfactory state of affairs, codes of nursing ethics and nursing practice have been changed, providing nurses with the opportunity to challenge the traditional premise that doctors alone are responsible for disclosing information, and enabling nurses to be truthful in their responses to patients' questions rather than avoiding them.

See Beauchamp and Childress, For example, whereas earlier versions of the International Council of Nurses "Code for Nurses" highlight the "nurse's obligation to carry out the physicians orders, intelligently and loyally" the revised code of states that "the nurse's primary responsibility is to those people who require nursing care. Further understanding of the impediments that nurses experience in communicating truthfully is essential if changes in their role are to be effected.

A Framework for Truth Telling There are a number of key elements that help to provide a framework that enhances truthful communication. Firstly, there is the need to develop open and honest communication from the very beginning of the patient-health professional relationship. Secondly, the health professional needs to use patient preference as a "gauge" by asking them what they wish to know, how much they wish to know, and determining what they already know.

In other words, it is a responsibility of the health professional to get a 'feel' for the situation, including the patients' perception of the situation. It is not only the giving of the truth that as health professionals we are responsible for, but also the way in which the truth is delivered and received. Many commentators note that the way in which bad news is delivered, and the available support at the time, has a bearing on how people cope with their illnesses and prognosis Bok,Centeno-Cortes,McCabe, The nurse is the health professional that spends most time at the 'bed-side' and this presents a unique opportunity for the establishment of trust.

BokJohnstoneKendall At the end of the 18th century Kant 8 argued for truth and the strict rejection of all lying. In Kant's categorial imperative doctrine, truth telling is a duty imperative which binds unconditionally categorical. A lie is always evil for Kant because it harms human discourse and the dignity of every human person. Kant did away with mitigating circumstances, intentions and consequences. Truth telling is always a duty, whether the other has the right to know or whether innocent persons will be severly harmed.

In Natural Law theory, truth has an objective foundation in the very structure of human nature. Even in Kant, an assumption exists that lying violates an objective moral standard.

trust and truth telling in nurse patient relationship

In both the Catholic and the Kantian tradition, truth telling is a condito sine qua non for individual human integrity. Habitual violations of veracity robs the liar of any sense of who he or she is. Truth telling is necessary in order to become a decent person and even to know oneself. Truth telling is even more obviously necessary in order to sustain human relations. Human beings are essentially relational, and without truthfulness human relations are impossible.

Without honesty, intimacy and marriage dissolve. Without intimacy and marriage, communities cannot exist, small or large, civil or economic. Without honesty and trust, human beings are condemned to an alienating isolation. What is the case for human beings, generally speaking, is even more true for doctors who are by definition in relationships with their patients. Truth obviously is an essential moral good. But, what if truth comes into conflict with other essential moral goods like life itself, or beneficence, or freedom?

Can a lie be justified if it saves a human life or a community, or if another great evil is avoided?

trust and truth telling in nurse patient relationship

Were Augustine and Kant right when they admitted of no exceptions to the duty to tell the truth, or were the Confessor and Casuists right when they insisted on considering consequences, intention and circumstances, and when they considered some lies to be of little or no moral import?

Historically a doctor's benevolent lie told to a sick and worried patient was considered the least evil act of all. In fact, Casuists and Confessors considered benevolent lying to patients to be a good act.

Trying to decide what to say in medical relationships or in clinical contexts is often side-tracked by phony arguments. One such argument claims that there is no moral responsibility to tell the truth because truth in a clinical context is impossible.

trust and truth telling in nurse patient relationship

This argument focuses on the enormous complexity of grasping and then communicating concrete medical truth in its full sense. This argument, understood in abstraction, is respectable, and yet in its application it turns out to be fallacious.

We may recognize and readily admit epistomological complexity as well as an inevitable human failure to achieve "the whole truth". But these recognitions do not make truth telling impossible and do not cancel out or even reduce the moral obligation to be truthful.

The doctor who pauses thoughtfully before responding to a sick, anxious, and vulnerable patient's questions is faced with a clinical moral issue rather than a philosophical perplexity.

The importance of truth-telling in health care

The truth issue here is not that of inevitably limited human cognition trying to grasp the full complexity of a particular person's disease. Rather, it is the question of what to disclose of known information in order to make sure that the disclosure helps the patient or in order to keep the truth which is known from doing a vulnerable patient more harm than good.

This same idea can be expressed in different ways. Rather than speaking about epistomological vs. Objective, quantitative, scientific truth is abstract and yet it is not alien to the clinical setting. Relational, contextual, clinical truth always points toward the incorporation or application of what is objective and abstract. But the two are not synonymous or reducible one to the other. A clinical judgment is different from a laboratory judgment, and the same is true of clinical and abstract truth 9.

The clinical truth strives to address a patient's inquiries without causing the patient unnecessary harm. It cannot ignore objectivity, but is not reducible to it Besides making the distinction between epistomological and clinical truth, one needs also to look at the consequences which follow from rejecting this distinction and collapsing one into the other.

If, in clinical practice, doctors operate under the assumption that truth is impossible and therefore of no concern, patients will be blatantly lied to for whatever reason.

Lies will be used to benefit the doctor, the hospital, the HMO, the insurance company, the doctor's specialist friends, the free market labs in which the doctor is invested, etc. No difference would exist between communication with a competent and an incompetent doctor. Many different parties would stand to gain from considering truth to be impossible. The only parties who would not gain are patients. If patients are ravaged as a result of collapsing the moral into the epistomological, then reasons exist for rejecting the proposition that "truth is impossible.

The value of not doing harm was so strong that lying in order to avoid harm was considered acceptable, a twisted form of medical virtue. Because communicating the truth about disease is difficult, many physicians simply discounted or ignored the moral problem of truthfulness in the doctor-patient relationship. The importance of not doing harm in effect relegated truth telling to the category of "everything else being equal, tell the truth" or "tell the truth as long as it helps rather than harms the patient.

Many moral philosophers referred to physician discourse with patients as an exception to the obligation to tell the truth. The doctor's principal moral obligation was to help and not to harm the patient and consequently, whatever the doctor said to the patient was judged by its effect on these core duties. Today, things have changed. Beneficence and non-malifience remain basic medical ethical principles, but truth is also a medical ethical principle. The importance of truth telling in the clinical context derives from taking more seriously the patient's perspective in medical ethics.

The historical justifications of lying to patients articulate the perspective of the liar, not that of a person being lied to. In most cases people are hurt when they are deliberately deceived.

This is especially true of patients. This may not have been so historically, but it is definitely true today. Today, Bacon's comment that "knowledge is power but honesty is authority," is particularly applicable to doctors. The historical absence of a truth requirement in medical ethics has much to do with the moral assumptions of ancient cultures.

Paternalism in our culture is a bad word, a "disvalue," something to be avoided. In earlier cultures it was an ideal to treat other persons as a father treats a child. Paternalism was something virtuous; the opposite was to treat the other as a slave. In early Greek culture, the good doctor or the good ruler treated the patient or the citizen as a son or daughter rather than a slave.

He did what was best for the "child" but without ever asking for his or her consent. With no involvement in treatment decisions, making known the truth to a patient was less important.

Because patients today can and must consent to whatever is done to them, truthful disclosure of relevant information is a legal and ethical duty. Modern medical ethical codes reflect this shift in the importance of veracity. The code of the American Nurses Association states: Even the "Principles of Medical Ethics" of the American Medical Association, inincluded a reference to honesty. Similar references and recommendations have been included in sub-specialty medical codes orthopedics', surgeons', psychiatrists', obstetricians' and gynecologists'.

The link between patient autonomy and veracity is characteristic of modern medical ethics and is most evident in the American Hospital Association's "Patient's Bill of Right" The requirement of honesty is clearly linked today with the patient's new legal right to give informed and free consent or refusal of treatment. In requiring adequate information for decision making, modern medical ethics broke with the paternalistic tradition. Traditionally the doctor did not tell the truth lest the patient be harmed.

Now, not to harm the patient requires in most instances that patients be truthfully informed and then invited to participate in clinical decision making. If today a physician decides, in light of clinical considerations, to conceal the truth, he or she must bear the burden of proof. A doctor must be able to defend this decision before other professional persons involved in the patient's care. And some member or members of the patient's moral community must be given the truth.

If physicians habitually lie, or conceal truth from patients, they cannot be excused based on a clinical context or a discrete clinical judgement. Go to top Truth and True Professionals If providing truthful information to a patient is a matter of judgment, mistakes are bound to be made.

If the information itself is limited and the amount to be disclosed must be determined by the context of each case, then inevitably there will be inadequacies and failures. It is one thing to fail, to make a mistake, to miscalculate what should have been said.

It is quite another thing, to set out to lie. It is even worse to adopt a pattern of deception. Failure is one thing, becoming a liar is quite different, something incompatible with being a professional.

For a true professional, striving to become an honest person is important. We have seen the strong stand of Immanuel Kant on this issue. Now listen to the person against whom Kant was most often pitted against and with whom he most often disagreed, John Stuart Mill.

In the following quote, he is talking about the feeling of truthfulness or veracity. He said that his feeling is "one of the most useful, and the enfeeblement of that feeling one of the must hurtful, things to which our conduct can be instrumental; and. Because to lose the trust of others is to lose one's own integrity. A doctor can do even greater harm because not being honest damages the climate of trust within the profession.

trust and truth telling in nurse patient relationship

Then, it is not an individual's integrity, but a whole profession's integrity that is lost. If patients are habitually lied to or misinformed or deceived, then the context of medical practice is polluted. The whole profesion is discredited. A recent American movie, Liar Liar, attempted to make a comedy out of the all-pervasiveness of lying in the legal profession.

The film makers seemed most interested in creating laughter but in the process made a not at all funny commentary on how lying and deceit have become pervasive among lawyers. Without lying, the main character could not function in the court system. His lawyer colleagues were repugnant characters. The comic star of the movie saved his life and his marriage and his moral integrity by discovering the importantce of being truthful. Consequently, he had to seek a different type of work.

The image of the legal profession portrayed in this film was sickening. We cannot let this happen to doctors and medical researchers. Something similar must not happen to doctors and the medical profession. Now, more than ever, patients have to be able to trust their doctors and to be able to rely on the truth of what they are told.

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Since truthfulness and veracity are such critical medical virtues, doctors have to work to develop the virtue of truthfulness. This is not an easy task. To become a truthful person we have to struggle first to know the truth. Then we have to struggle with personal prejudices which can distort any information we gather. We have to try to be objective. We have to work to correct a corrupting tendency to confuse one side of a story or one perspective of an event with the whole truth.

And, finally, we have to recognize that self-aggrandizement corrupts the capacity to know the truth and to communicate anything except pathological, narcissistic interests.

Truth for an egoist is reduced to what promotes his ego. The egoist cannot see the truth and therefore cannot tell it. The only thing which can be communicated is his or her own aggrandized self.

Knowing the truth and telling the truth is difficult enough without shadowing weak human capacities for virtues with narcissistic pathological shades. If we are self-deceived we cannot hope to avoid deception in what we disclose. Not to address pathological character distortions is to make lies inevitable.

The classical medical ethical codes were preoccupied with a good physician's personal character traits--rightfully so. The presumption is always for truth and against lying. But the arguments support the need to make humane clinical judgments about what is told, when, how, and how much. Perhaps the best way to sum up the argument is to quote a sensitive and humane physician on this topic: Cicely Saunders, the founder of the Hospice movement.

Every patient needs an explanation of his illness that will be understandable and convincing to him if he is to cooperate in his treatment or be relieved of the burden of unknown fears. This is true whether it is a question of giving a diagnosis in a hopeful situation or of confirming a poor prognosis.

The fact that a patient does not ask does not mean that he has no questions. One visit or talk is rarely enough. It is only by waiting and listening that we can gain an idea of what we should be saying. Silences and gaps are often more revealing than words as we try to learn what a patient is facing as he travels along the constantly changing journey of his illness and his thoughts about it.

So much of the communication will be without words or given indirectly. This is true of all real meetings with people but especially true with those who are facing, knowingly or not, difficult or threatening situations.

It is also particularly true of the very ill. The main argument against a policy of deliberate, invariable denial of unpleasant facts is that it makes such communication extremely difficult, if not impossible. Once the possibility of talking frankly with a patient has been admitted, it does not mean that this will always take place, but the whole atmosphere is changed.

We are then free to wait quietly for clues from each patient, seeing them as individuals from whom we can expect intelligence, courage, and individual decisions. They will feel secure enough to give us these clues when they wish Finally, to tell the truth is not to deny hope. Hope and truth and even friendship and love are all part of an ethics of caring to the end. NOTES Sometimes the patient cannot be told about truths or strong hypothetical suppositions associated with public health requirements.

The importance of truth-telling in health care

Military physicians, for example, are often compormised in truth telling because of their military obligations. The same is true of doctors and researchers working for an industry or the government, or a managed care facility.

The Death of Ivan Ilych. Quote from Bok, Sissela Lying: Sigmund Freud, Collected Papers. Moral Choice in Public and Private Life. If finances in the clinical context complicate truth telling for healthcare professionals, imagine the truth telling problems created by today's healthcare industry.

Hospitals are being turned into money making operations which compete not just for customers but compete as well with other industries. Can patients cound on truth telling in the advertisement of HMO's, insurance companies, and pharamceutical firms?

Increasingly, patients as well as doctors need truthful communications of information, but what they get is most often a manipulative message. Is it reasonable to expect either free-market capitalism or its agents to be truthful?