Candid to the Bitter End: Indiscriminate Disclosures

Abstract

The physician's obligation to tell the patient the full truth about his or her condition has become an established ethical principle, enabling patients' autonomy, shared decision-making, and patient-centered care. However, indiscriminate application of this obligation may at times be harmful to the patient, contradicting the old Hippocratic imperative of "first do no harm" ("Primum non nocere"), as our 2 recent short patient histories demonstrate. PATIENT 1 A 65-year-old father of 6 was diagnosed with urothelial (transitional cell) carcinoma of the urinary bladder. He was a past smoker (46 pack-years) with hypertension, dyslipidemia, and a remote history of myocardial infarction. Disease was T1N0 (stage I) and treated by transurethral resection and intravesical therapy. A second-look operation and imaging revealed no evidence of disease. One year later right loin pain developed, and computed tomography revealed right hydroureter and minimal hydronephrosis without discernible cause. Results on cystoscopy were normal, but magnetic resonance imaging suggested fullness of the right ureteral outlet. Serum creatinine increased (2.0 mg/dL), ureteral infiltration by transitional cell carcinoma was demonstrated, and nephrostomy was performed with ureteropelvic junction stent placement, creatinine normalization, and nephrostomy removal. However, he was soon readmitted with recurrent vomiting, and retroperitoneal involvement, bilateral ureteral obstruction, and creatinine 3.7 mg/dL were found. After drainage he was referred to a tertiary care center and left us very sick but hopeful. On the third hospital day he was suddenly and bluntly told by a physician, who had seen him once, that a team of oncologists, urologists, and radiologists had reviewed his data, that he had extensive unresponsive disease, and that nothing could be done. He listened in silence. A few hours later a blood pressure of 250/115 was recorded, and atherothrombotic hemiplegia developed. He was sent back to the referring hospital, where we found a broken man.