Should you withhold the diagnosis of cancer?

[Tony64]

My golfing buddy is a hospital CEO and recently had a problem with one of his staff doctors. We've been casual friends and neighbors for a long time, and I've been a regular benefactor of his hospital. He asked me for my objective opinion, but I don't think he liked my response.

One of his doctors was treating an elderly woman for a cancerous intestinal growth. She was of competent mind, but had assigned a power of attorney to her eldest daughter. The doctor discussed the situation with the family, including the patient, the daughter with POA, and two other adult children. The family told the doctor that their mother did not want to hear the CANCER word, so the doctor instead used the word POLYP with a tumor inside that can spread. The patient then agreed to have surgery and all went well until a nurse found a note on the patient's chart saying not to use the CANCER word and "patient unaware of diagnosis". The nurse then called her supervisor and up the chain of command it went until landing squarely in the lap of the hosptial CEO, who then admonished the doctor and wanted to know why he had done surgery without first informing the patient that she had cancer.

Clearly he feels it was wrong for the doctor to do the operation without specifically telling patient she had CANCER. I disagreed and sided with the family and the doctor and suggested that he and his nursing staff had created a problem where none existed.

Maybe my view lacks proper consideration for the old woman though, and I'm curious to hear TRF opinion. Perhaps it's different by culture, ethnicity, or nationality? Maybe there are liability issues I haven't considered, or specific rules of conduct that this doctor may have violated? Either way he was clearly not pleased with my lack of support for his position. I didn't find out what happened to the doctor, and at that point it seemed imprudent to ask.

Of one thing I'm certain and that's the diversity of this forum affords great opportunity for discussion. I'd appreciate any thoughts, especially if anyone has ever been in that situation.

[AF_Rob]

Hearing the word cancer from your doctor will not kill somebody. I don’t care what people want/don’t want to hear when it’s my job to provide a professional opinion.

[landroverking]

Medical POA sums it up for me. I would side with the family.

[AzPaul]

If the doctor was convinced both the patient and the family fully understood the situation, in spite of the non-use of the word 'cancer', and made their decision about surgery based on a fully informed opinion, then I really don't see much of an issue.

[bdex75]

I wonder if the mother was one of those people that said to her family “if I ever get cancer I am not going thru all the treatment bs”?? And the doctor and family knowing this was something that was easily treatable if surgically removed. I get it.

We don’t really know the whole story but if them using the verbiage they used is beneficial to her overall health benefit it is hard to argue.

I watched my mother (at her age 45) go thru treatment after treatment for stage 3 breast cancer. Chemo, radiation, mastectomy, experimental treatments etc. She had virtually zero quality of life until she died at 49. I swore to myself that I would never put myself thru that. But once you have kids and other people to be concerned about your outlook sometimes changes.

Maybe this lady watched her husband of 50 years die after some horrible cancer and treatment and she is emotionally fragile and at this point would welcome the opportunity to see her deceased spouse on the other side. We never really know. But on the other hand isn’t that her right???

Tough call and I don’t envy your buddy’s situation in sorting that out.


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[Sunny Arizona]

I am in the business so to speak and I have a couple of points. If the doctor is in private practice with “privileges” at this hospital he can treat patients as he wishes within the confines of standard of care. With POA in place he is in good ethical footing. Each hospital has an ethic committee if questions arise.
If the doctor is an employee possibly a different story but the physician chair would be the one speaking to the surgeon, not a CEO.
By mentioning a potentially confidential matter the CEO could be in a sensitive situation if something comes of it.

Originally Posted by Tony64

My golfing buddy is a hospital CEO and recently had a problem with one of his staff doctors. We've been casual friends and neighbors for a long time, and I've been a regular benefactor of his hospital. He asked me for my objective opinion, but I don't think he liked my response.

One of his doctors was treating an elderly woman for a cancerous intestinal growth. She was of competent mind, but had assigned a power of attorney to her eldest daughter. The doctor discussed the situation with the family, including the patient, the daughter with POA, and two other adult children. The family told the doctor that their mother did not want to hear the CANCER word, so the doctor instead used the word POLYP with a tumor inside that can spread. The patient then agreed to have surgery and all went well until a nurse found a note on the patient's chart saying not to use the CANCER word and "patient unaware of diagnosis". The nurse then called her supervisor and up the chain of command it went until landing squarely in the lap of the hosptial CEO, who then admonished the doctor and wanted to know why he had done surgery without first informing the patient that she had cancer.

Clearly he feels it was wrong for the doctor to do the operation without specifically telling patient she had CANCER. I disagreed and sided with the family and the doctor and suggested that he and his nursing staff had created a problem where none existed.

Maybe my view lacks proper consideration for the old woman though, and I'm curious to hear TRF opinion. Perhaps it's different by culture, ethnicity, or nationality? Maybe there are liability issues I haven't considered, or specific rules of conduct that this doctor may have violated? Either way he was clearly not pleased with my lack of support for his position. I didn't find out what happened to the doctor, and at that point it seemed imprudent to ask.

Of one thing I'm certain and that's the diversity of this forum affords great opportunity for discussion. I'd appreciate any thoughts, especially if anyone has ever been in that situation.

[hsm]

my granddad was never actually told he had cancer, my mum knew it would destroy him,
he died without being told, he probably knew in himself, in his case I think it was right, plus he dident have surgery as it was inoperable.

[Tony64]

Originally Posted by Sunny Arizona

I am in the business so to speak and I have a couple of points. If the doctor is in private practice with “privileges” at this hospital he can treat patients as he wishes within the confines of standard of care. With POA in place he is in good ethical footing. Each hospital has an ethic committee if questions arise.
If the doctor is an employee possibly a different story but the physician chair would be the one speaking to the surgeon, not a CEO.
By mentioning a potentially confidential matter the CEO could be in a sensitive situation if something comes of it.

Unfortunately I don't have details beyond what I've already stated, and don't know the specific employment relationship between the doctor and hospital. The names of the patient and physician were never discussed.

I asked about the POA, but he said it was required that a competent adult be informed despite others not wanting that for them, and the existence of a POA does not make someone incompetent - in fact he said a POA can't legitimately even be signed by an incompetent person.

Tough call, but without knowing the industry standards my heart is still with the family.

[Tony64]

Originally Posted by AzPaul

If the doctor was convinced both the patient and the family fully understood the situation, in spite of the non-use of the word 'cancer', and made their decision about surgery based on a fully informed opinion, then I really don't see much of an issue.

I don't either, but it seems that the nursing and hospital administration feel differently. "Right to know" apparently means "required to know" before treatment can be initiated.

I know that there are doctors and nurses here that might be able to clarify this better.

What's at issue is at what point does a loving supportive family have the right to shield an elderly family member from information that would be needlessly distressing. Seems reasonable but maybe frowned upon by those in charge.

[Abdullah71601]

How is this conversation not a HIPPA violation? The CEO should be fired for carrying on a casual conversation about personal medical details with a golfing buddy. That’s the real ethical violation in this thread, not the standard of care.

Originally Posted by Tony64

My golfing buddy is a hospital CEO and recently had a problem with one of his staff doctors. We've been casual friends and neighbors for a long time, and I've been a regular benefactor of his hospital. He asked me for my objective opinion, but I don't think he liked my response.

One of his doctors was treating an elderly woman for a cancerous intestinal growth. She was of competent mind, but had assigned a power of attorney to her eldest daughter. The doctor discussed the situation with the family, including the patient, the daughter with POA, and two other adult children. The family told the doctor that their mother did not want to hear the CANCER word, so the doctor instead used the word POLYP with a tumor inside that can spread. The patient then agreed to have surgery and all went well until a nurse found a note on the patient's chart saying not to use the CANCER word and "patient unaware of diagnosis". The nurse then called her supervisor and up the chain of command it went until landing squarely in the lap of the hosptial CEO, who then admonished the doctor and wanted to know why he had done surgery without first informing the patient that she had cancer.

Clearly he feels it was wrong for the doctor to do the operation without specifically telling patient she had CANCER. I disagreed and sided with the family and the doctor and suggested that he and his nursing staff had created a problem where none existed.

Maybe my view lacks proper consideration for the old woman though, and I'm curious to hear TRF opinion. Perhaps it's different by culture, ethnicity, or nationality? Maybe there are liability issues I haven't considered, or specific rules of conduct that this doctor may have violated? Either way he was clearly not pleased with my lack of support for his position. I didn't find out what happened to the doctor, and at that point it seemed imprudent to ask.

Of one thing I'm certain and that's the diversity of this forum affords great opportunity for discussion. I'd appreciate any thoughts, especially if anyone has ever been in that situation.

[breitlings]

I think it is not ok.

[locutus49]

My mother had intestinal cancer 7 years ago. She was 83. She knew she had cancer because they did chemo, etc. She is not stupid. The chief cancer doctor called me and my brother in and said she was terminal, had a couple of months.

She is now 90 and completely lucid. She has the doctors check for cancer every couple years, but she knows if it returns she will likely be a goner.

I have POA. The doctors have always been direct with her and she appreciates the honesty.

Maybe she is unusual, but most seniors we know openly talk about cancer and the various treatments. I think a doctor's job is to be candid with his patient, the family be damned.

[breitlings]

Originally Posted by Abdullah71601

How is this conversation not a HIPPA violation? The CEO should be fired for carrying on a casual conversation about personal medical details with a golfing buddy. That’s the real ethical violation in this thread, not the standard of care.

I think you have to disclose personal details to be a hippa violation. Like so-and-so blah blah blah, not just the blah blah blah.

[Tony64]

Originally Posted by hsm

my granddad was never actually told he had cancer, my mum knew it would destroy him,
he died without being told, he probably knew in himself, in his case I think it was right, plus he dident have surgery as it was inoperable.

IMO that was a kind and compassionate decision. I'm truly sorry for your loss.

[Abdullah71601]

Originally Posted by breitlings

I think you have to disclose personal details to be a hippa violation. Like so-and-so blah blah blah, not just the blah blah blah.

So it’s OK for this clown to be disclosing these cases to a golfing buddy? Rather than confine his concerns with the hospital ethics people, he feels it’s appropriate to blab to some dude he plays golf with.

[Tony64]

Originally Posted by bdex75

I wonder if the mother was one of those people that said to her family “if I ever get cancer I am not going thru all the treatment bs”?? And the doctor and family knowing this was something that was easily treatable if surgically removed. I get it.

We don’t really know the whole story but if them using the verbiage they used is beneficial to her overall health benefit it is hard to argue.

I watched my mother (at her age 45) go thru treatment after treatment for stage 3 breast cancer. Chemo, radiation, mastectomy, experimental treatments etc. She had virtually zero quality of life until she died at 49. I swore to myself that I would never put myself thru that. But once you have kids and other people to be concerned about your outlook sometimes changes.

Maybe this lady watched her husband of 50 years die after some horrible cancer and treatment and she is emotionally fragile and at this point would welcome the opportunity to see her deceased spouse on the other side. We never really know. But on the other hand isn’t that her right???

Tough call and I don’t envy your buddy’s situation in sorting that out.


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That's a terrible situation Brandon, and I'm so sorry that you had to go through that with her.

You're right, there are many important pieces missing from the story, and I appreciate that you shared your thoughts. Knowing the specifics might have made the decision more clear.

[GradyPhilpott]

Originally Posted by breitlings

I think you have to disclose personal details to be a hippa violation. Like so-and-so blah blah blah, not just the blah blah blah.

This is absolutely correct.

[AK797]

Lie to me, is one of the most basic tenets of the human condition, if that's what the sufferer wants and it is not hurting them then I'll abide.

[hsm]

Originally Posted by Tony64

IMO that was a kind and compassionate decision. I'm truly sorry for your loss.

it was 26 years ago, but you never forget these moments in your life, I felt it was a good move on my mothers part at the time, she knew him, others dident.

[Tony64]

Originally Posted by Abdullah71601

How is this conversation not a HIPPA violation?

I think it's always a bad idea to violate a hippa/hippo.

[Star Ferry]

My opinion: not saying "cancer" protects her mental wellbeing and has no impact on physical wellbeing

Reality: hospitals care more about liability than the patient's mental wellbeing. they don't want to be open to the accusation that they provided her a misleading or inaccurate diagnosis

[droptopman]

Originally Posted by Abdullah71601

So it’s OK for this clown to be disclosing these cases to a golfing buddy? Rather than confine his concerns with the hospital ethics people, he feels it’s appropriate to blab to some dude he plays golf with.

Actually if someone could put together "the who" he is talking about based on the information it is a HIPAA violation so I think you are correct. It is tough to prove but I have heard of it on a CFR 42.2 case which is another confidentiality law. No names were ever given but enough details about a case where another person who did not have consent for the protected healthcare information was able to put the details to the individual. The provider lost that case and was fined.

[Tony64]

Originally Posted by Abdullah71601

So it’s OK for this clown to be disclosing these cases to a golfing buddy? Rather than confine his concerns with the hospital ethics people, he feels it’s appropriate to blab to some dude he plays golf with.

With regards to HIPAA complaince, no names or identifiers were used, and I think this safely falls under the category of "De-Identified Health Information", but correct me if I'm wrong.

"De-Identified Health Information. There are no restrictions on the use or disclosure of de-identified health information.De-identified health information neither identifies nor provides a reasonable basis to identify an individual. There are two ways to de-identify information; either: (1) a formal determination by a qualified statistician; or (2) the removal of specified identifiers of the individual and of the individual’s relatives, household members, and employers is required, and is adequate only if the covered entity has no actual knowledge that the remaining information could be used to identify the individual."






https://www.hhs.gov/hipaa/for-profes...ons/index.html

[Tony64]

Originally Posted by droptopman

Actually if someone could put together "the who" he is talking about based on the information it is a HIPAA violation so I think you are correct. It is tough to prove but I have heard of it on a CFR 42.2 case which is another confidentiality law. No names were ever given but enough details about a case where another person who did not have consent for the protected healthcare information was able to put the details to the individual. The provider lost that case and was fined.

Barring some other disclosure by individuals more directly involved, I would think the sheer size of this community hospital would make specific identification improbable based only on the details provided, particularly not knowing the timeframe involved.

[swils8610]

I’m not a lawyer so I’m not sure legally what should or shouldn’t be done. On a personal level it depends on the situation. I would think the family or POA would know what’s best for the patient. If telling the patient could do more harm than good I wouldn’t tell them. Many other factors would influence my decision.


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[droptopman]

Interesting thread. With the POA and the awareness of cancer by the decision makers, I would think that would cover informed consent and ethical concerns. I like the doctors approach regarding the families wishes.

Personally I would want to know but I can see why some would not. I have a pretty specific advanced directive so there is not much they can do to me without my consent.

[Tony64]

Originally Posted by swils8610

I’m not a lawyer so I’m not sure legally what should or shouldn’t be done. On a personal level it depends on the situation. I would think the family or POA would know what’s best for the patient. If telling the patient could do more harm than good I wouldn’t tell them. Many other factors would influence my decision.


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That's how I feel as well Shannon, but some would say it's not anyone's place to decide what's best for an otherwise competent family member, regardless of age.

[droptopman]

Originally Posted by Tony64

Barring some other disclosure by individuals more directly involved, I would think the sheer size of this community hospital would make specific identification improbable based only on the details provided, particularly not knowing the timeframe involved.

True, but this is a pretty specific case with some fairly uncommon details.

The case I was referring to above. A provider was having dinner at a restaurant and was discussing a case. The restaurant is not even in the town/area that the provider works in. The details were overheard by someone at a table close by. The people at that table knew the patient and told the patient they overheard this information. The patient then filed a complaint with the DOH. The provider lost this case as they disclosed enough information for someone without consent to put together the PHI and the individual.

I know it is a total longshot and I am not saying your friend violated the law but these odd cases do happen. I teach medical law and ethics at the local college and do trainings for providers on the subject. Just trying to provide some information on how HIPAA is interpreted.

[Tony64]

Originally Posted by droptopman

True, but this is a pretty specific case with some fairly uncommon details.

The case I was referring to above. A provider was having dinner at a restaurant and was discussing a case. The restaurant is not even in the town/area that the provider works in. The details were overheard by someone at a table close by. The people at that table knew the patient and told the patient they overheard this information. The patient then filed a complaint with the DOH. The provider lost this case as they disclosed enough information for someone without consent to put together the PHI and the individual.

I know it is a total longshot and I am not saying your friend violated the law but these odd cases do happen. I teach medical law and ethics at the local college and do trainings for providers on the subject. Just trying to provide some information on how HIPAA is interpreted.

Thank you Mark, I'm sure it's a fine line that these guys must tread. Good that you're there to keep them straight!

[Grnvette65]

Medical ethics are always tough topics. Clearly he did what the family wanted and the pt did not want to hear the word cancer, a growth that can spread is a nice way to tell the pt what she had. The bigger question is would the lady have gone for the surgery if the cancer word was used, I suspect she would have done the same thing and therefore same outcome. In the end I have to agree the nurse is making trouble(in black and white terms, doc should have been blunt and told pt but in reality life is never black and white) and in this senario what was done was prob the best.