ethics in truth-telling 2

Running head: ETHICS IN TRUTH TELLING 1

Ethics in Truth Telling: When Parent Becomes a Factor

My M. Uong

MUSC College of Nursing


Ethics in Truth Telling: When Parent Becomes a Factor

Patient C was 17 years old and had a serious condition of leukemia for almost 2 years.

She had gone through many options of treatments, yet none were able to help with her condition.

She could only live for few more weeks. She was full of life, even at the stage she was in and the

pain she was enduring. At a point, she was brought home for end-of-life care by her mother and

home care nurse who visited from time to time. Her mother ordered that no one tell this little girl

of her prognosis. To emphasize the seriousness of this order, C’s mother restricted all visits from

C’s father and C’s friends; she repeated this order at every home care nurse’s visit. C could sense

that she was dying, but the fact that no one was talking to her about her terminal condition made

her frustrated and confused. She asked the primary care nurse how much time she had left;

however, every time her mother answered for the nurse by giving C false hopes that she would

get better - that there was a bright future ahead of her. At times when her mother was not in the

room, C expressed to the nurse that she was not afraid of death, that she would want to talk to her

father and friends about dying. The nurse delivered these concerns to C’s mother, who refused to

continue with the discussion. C became more depressed, asked for pain reliefs frequently and

didn’t want to swallow anything. She ignored her mother’s cheerful comments and asked the

nurse to turn music off in her room. When asked what was wrong, she told the nurse that “it’s

just too much trouble to keep up a lie. Maybe it’ll be easier for my mother when I’m gone”

(Turkoski, 2003) .

There are many questions that arise from this ethical dilemma: Who is being harmed and

how can that harm be reduced? (Turkoski, 2003) What are the minors’ rights in medical decision

making? What personal and professional values conflicts are the nurse facing that are preventing


her from telling the truth? What does the professional nursing code of ethics allow the nurse to

do in this situation? This paper discusses these subject matters as well as the possible actions

and outcomes of this dilemma.

The Ethical Issue

Although the adolescent is being harmed by the mother’s decision, the mother is

experiencing anticipatory grief, a form of grief that is an “unconscious process of emotional

response to the threat of loss” (Kehl, 2005) . The mother is a widow, and she does not have much

of a support system. So in this case, the nurse has two patients in his/her care. The ethical issue is

whether to respect the mother’s order or to make an exception to the adolescent’s autonomy to

ease her emotional pain. Before going any further, we must understand the minor’s autonomy of

this specific dilemma. The American Academy of Pediatrics has an established policy to

encourage adolescents to be included in medical decision-making, “but the parental autonomy

and parental right to give consent for a minor is the standard” (Maradiegue, 2003). We have to

assume that the parents act in the best interests for their child, even if the child is cognitively and

emotionally ready to handle the truth and even if the uncertainty is establishing additional stress

to the child’s conditions (Gupta et al., 2008). Also in the state that C is living in, unless the minor

is emancipated, married or in the armed services, they have no legal rights to specific knowledge

or participation in decision-making (Turkoski, 2003). But what if the parent is not in the right

state of mind to make the best decision for her child? The mother at that point doesn’t have a

clue on how to cope with her anticipatory grief, let alone to help her child to cope with the

knowledge of imminent death. Consider the situation and the factors involved, the ethical issue

simplifies to a single question: to tell or not to tell.


Nurses Actions

The 3rd person that is involved in the dilemma: the nurse. The home care nurse is the only

one that has a freedom to make a decision, since the mother is determined to keep her order and

the daughter has no other choice but to play along with the lie. The home care nurse’s role is

very important in this ethical dilemma, because any action he/she decides to take could alter the

clients’ emotional pains to either a lesser or greater degree. The nurse should take the third step

in processing a dilemma by doing values clarification. (Perry & Potter, 2009). The nurse needs to

re-evaluate the professional values and assess the client’s values. In section 1.4, the ANA code of

ethics states that “each nurse has an obligation to be knowledgeable about the moral and legal

rights of all patients to self-determination” (White et al., 2001). So option 1 is to talk to the

mother about what her values are in truth-telling. What is her religion? How would her religion

justify the act of hiding the truth? Also, what is the cultural background of this family? Cultural

values could greatly affect in decision-making. Research shows that most Asian cultures’

families always request the health care providers to keep the bad news silent (Hu, Chiu, Chuang,

& Chen, 2002). The nurse needs to explain to the mother the professional code of ethics and

what the nurse is obligated to do. Option 2 is to get supports for the mother’s anticipatory grief.

In this dilemma, the mother is also at risk of psychological breakdowns and therefore must be

put into the nurse’s care. The nurse can do so by following the Corr and Corr 10 guidelines for

anticipatory mourning (Kehl, 2005). Get the end-of-life specialists to explain how a dying patient

can come to “good death” if unresolved emotions are let out and wishes are fulfilled (Jones,

McCullough, & Richman, 2005). The guidelines also suggest confronting the multiple stresses

that the patient might be experiencing, approaching the patient with holistic perspective and

confidence, and asking the patient’s social network to give more supports (Kehl, 2005). Option 3


is to deliver the messages that C has expressed to the mother so that the mother could

acknowledge the emotional pains that C is experiencing (Turkoski, 2003). Discuss that the

adolescent has come to an age of having the ability to think abstractly, to draw and rank

possibilities and to logically make decisions (Perry & Potter, 2009). The nurse should provide

evidence that the dying patient is sensing that she does not have much time left. Option 4 is

simply to tell the patient the truth of the condition she is in. The nurse should wait for the mother

to leave the room and ask the adolescent to not disclose the information the nurse is about to

share to her mother. After telling the truth, the nurse could encourage the patient to talk about

death, for having a conversation about the process of dying is what she wants. The nurse should

also suggest to help out whatever wishes that the dying patient might have.

The Outcomes

Option 1 would have a good outcome if the mother is open-minded and cooperative in

expressing her personal values. Although, judging by the attempt that the home care nurse took,

the mother had probably heard many opposing arguments to her order (Turkoski, 2003) and was

determined to shut herself off from other opinions. Option 2 could anger the mother because she

would not want to hear that she’s having a problem herself when her child is dying. On the other

hand, if this option is carefully planned out and approached with cautions, not only would the

mother be able to progress into the next task of the Worden’s Grief Tasks Model, that is working

through the pain of grief (Perry & Potter, 2009). She would be able to help the nurse in making

the dying patient’s last few weeks of living most productive and memorable. Option 3 has its

advantages and disadvantages. The mother could probably change her mind if the attempt of

getting the messages across is successful. However, telling the mother what the patient has said


is violating the patient’s confidentiality (Turkoski, 2003). Breach of confidentiality needs to be

carefully considered here. Option 4 would bring out tremendous controversial topics. First it

would pile out to another ethical dilemma: beneficence vs. maleficence. Is this option for the

good of the patient? Does it cause more harm to the patient? In short, does the end justify the

means? If the outcome turns out to be that the patient develops lesser emotional pains and passes

away in peace, then this is a beneficial action to take for the dying patient. However, if the

mother finds out, this option could bring upon a court case of minor’s rights. The nurse could

argue that the mother was undergoing a psychological disturbance and was incapable of making

the decision for the child; however, strong evidences must be presented to back this up. Further

research must be considered for option 4.

The Best Action to Take

Option 4 is risky and should be put last on the list of priorities. Option 3 would involve

yet another legal controversial topic and should be put second to last on the list. Option 2

requires too much time and resources spent on the mother, while the main focus here is the dying

patient in the stage of withdrawal. With the limited timeframe, a decision must be made quickly.

Option 1 seems to be the best action to take. If the nurse could get the mother to sit down to

discuss and exchange personal and professional values, the effect of empathy could establish

trust, “unlocking concerns and communicating support for others” (Perry & Potter, 2009).

Option 2 would probably become unnecessary if option 1 reaches its full potential.

Discussion


Because ethical issues never have right or wrong answers, which option to take usually

depends on the personal values that the nurse possesses. Cultural values play a big part in the

nurse’s decision-making. A study shows that health care providers (mostly nurses and some

physicians) in Portugal, China and Greece believe that disclosure of terminal illnesses to the

patient can cause psychological harm to the patient (Li et al., 2008). Truth-telling is an

important virtue for all nurses. Truth-telling means to tell no lies and to perform no methods of

deception (e.g.: nondisclosure, concealment). Nurses are to stay loyal to their patient, but also to

have respect for their family and to not destroy this support system of the patient (Collis, 2006).

The next time you are to face an ethical dilemma regarding truth-telling, consider these factors

before making an important decision.


References

Collis, S. P. (2006). The Importance of Truth-Telling in Health Care. Nursing Standard, 20(17),

41-45.

Gupta, V. B., Willert, J., Pian, M., & Stein, M. T. (2008). When Disclosing a Serious Diagnosis

to a Minor Conflicts with Family Values. Developmental & Behavioral Pediatrics, 29(3),

231-233.

Hu, W.-Y., Chiu, T.-Y., Chuang, R.-B., & Chen, C.-Y. (2002). Solving Family-related Barriers

to Truthfulness in Cases of Terminal Cancer in Taiwan. Cancer Nursing, 25(6), 486-492.

Jones, J. W., McCullough, L. B., & Richman, B. W. (2005). Truth-telling about terminal

diseases. Surgery, 137(3), 380-382.

Kehl, K. A. (2005). Recognition and Support of Anticipatory Mourning. Journal of Hospice and

Palliative Nursing, 7(4), 206-211.

Li, J.-Y., Liu, C., Zou, L.-Q., Huang, M.-J., Yu, C.-H., You, G.-Y., et al. (2008). To tell or not to

tell: attitudes of Chinese oncology nurses towards truth telling of cancer diagnosis.

Journal of Clinical Nursing, 17(18), 2463-2470.

Maradiegue, A. (2003). Minor's Rights Versus Parental Rights: Review of Legal Issues in

Adolescent Health Care. Journal of Midwifery & Women's Health, 48(3), 170-177.

Perry, A. G., & Potter, P. A. (2009). Fundamentals of Nursing. St. Louis: Mosby Elsevier.

Turkoski, B. B. (2003). A Mother's Orders. Home Healthcare Nurse, 21(2), 81-83.

White, G., Badzek, L., & Thompson, A. (2001). Code of Ethics for Nurses with Interpretive

Statements. Washington: American Nurses Publishing.

ethics in truth-telling 2

Documents