Ethics OSCE Station Blueprint

Station Name: Pancreatic Cancer

Issue:

Truth Telling

Presenting Situation:

Gwen Jones does not want her husband (Lloyd) to know about his diagnosis of pancreatic cancer. The cancer is inoperable and Mr. Jones is terminally ill.

Activities:

Patient encounter.

Time Required:

10 minutes

This station was developed by Dr. Peter A. Singer (Centre for Bioethics and Department of Medicine, University of Toronto), and Anja Robb (Department of Family and Community Medicine, University of Toronto. It is part of the Ethics OSCE Project which is funded by Educating Future Physicians for Ontario (EFPO). There is an accompanying videotape. This material can be used for teaching or evaluation. It is not copyrighted and may be freely reproduced for educational purposes.

Instructions to Candidate:

You are about to see Gwen Jones, the wife of a man who has been diagnosed as having pancreatic cancer. It is inoperable and he is terminally ill. The patient is still in hospital. Both the wife (who is currently completing her PhD) and the patient's father (who is a medical doctor) do not want you to tell the patient his diagnosis or the fact that he is dying.

You are a doctor on the surgical team looking after Mr. Jones. Please talk to Mrs. Jones about her request.

CHECKLIST ITEMS:
^^^^^^^^^^^^^^^^

YES     NO     The Candidate:


               1.      checks reason why wife does not want
                       husband told about cancer.
----|-----------------------------------------------------------
               2.      states that patient will know something
                       is wrong.
----|-----------------------------------------------------------
               3.      states that patient may ask about
                       diagnosis.
----|-----------------------------------------------------------
               4.      states that when patients eventually
                       find out they lose trust in doctor and
                       family.
----|-----------------------------------------------------------
               5.      states that physician must tell the
                       truth/cannot lie, and/or that physician
                       is primarily responsible to the patient.
----|-----------------------------------------------------------
               6.      states that patient may want to put
                       affairs in order or do things knowing he
                       has a limited time left.
----|-----------------------------------------------------------
               7.      states that patient should have
                       information about his own health/has a
                       right to know.               
----|-----------------------------------------------------------
               8.      states that IF NOT ASKED, physician will
                       not provide more information than
                       patient expresses a desire to know or
                       can handle emotionally.
----|-----------------------------------------------------------
               9.      States that IF ASKED directly, physician
                       will tell patient.
----|-----------------------------------------------------------
               10.     refuses to promise not to tell.
----|------------------------------------------------------------ 
=================================================================

                              
RATE FROM 1-5:
 +------------------------------------------------------------+
 |        |          |          |    VERY    |                |
 | POOR   |   FAIR   |   GOOD   |    GOOD    |    EXCELLENT   |
 |  1     |    2     |    3     |     4      |       5        |
 +------------------------------------------------------------+

1.      How would you rate the candidate's communication skills?                                 
        1      2       3      4      5

2.      How would you rate the candidate's ability to address the
        ethical issue in this case?                 
        1      2       3      4      5

Instructions to Standardized Patients:

Your name is Gwen Jones. You are a married woman with 3 young children. Your husband Lloyd is a business executive who has just been diagnosed as having pancreatic cancer. It is inoperable and he is terminally ill. He is not expected to live beyond 4 months. He became ill about a month ago. He has lost a lot of weight and often feels nauseous. An operation was scheduled. The operation took place last evening. The surgeons were not able to remove the tumour. You and your father-in-law, Rodney Jones, were at the hospital during the operation. After the operation, the surgeon informed you of the diagnosis and suggested you go home to rest. Your husband was in the recovery room and it was suggested you come back to see him the next day.

You and your father-in-law, who is a senior member of the Department of Medicine at a University hospital, had time to discuss how much you wanted your husband to know about his condition. Because of Lloyd's personality and the fact that he recently had a slight depression related to work stress, you decided that he should not be informed of his diagnosis.

Both of you want to spare him from hearing this "death sentence". Both of you feel he "couldn't cope"/"couldn't handle it." If he only has a short time to live, you want him to live it with hope for the future instead of living as though he's dying. He has always been afraid of death and disease. At the best of times he cannot discuss these topics without getting upset. A friend of his died of cancer a few years ago and your husband went into a "terrible state". He was not able to visit his friend in the hospital and going to the funeral home and funeral was out of the question for him. He was weepy, couldn't sleep, and became obsessed with trying to stay healthy. He has often said he wouldn't know how to handle getting seriously ill himself and that he'd rather be dead than have some lingering illness. You think he will give up fighting for life if he knows his diagnosis.

You might use statements such as:
"I know you mean well but it's going to do more harm if he knows!" He needs his strength now to recover from the operation. If you tell him he's going to be so upset it will make him worse!"

"He's going to give up if he finds out!" "Isn't it your duty to prolong his life? I know that if you tell him about this illness he's going to die sooner because he'll give up!"

"It's easy for you to tell him. You'll see him for 15 minutes and probably won't see him again. I'm going to have to live with him and watch how destroyed he will be by the news. I'm going to have to pick up the pieces after you shatter all his hopes of feeling well again."

"I know him better than anyone else and I'm a better judge of what is going to benefit him than anyone else."

"Doesn't the family have any rights? As his wife, don't I have any rights?"

Prompts are used to standardize the scenario and give all candidates an opportunity to address relevant issues.

PROMPT 1 (immediately):
I know my husband's condition is serious. I don't want him to know he has CANCER.

PROMPT 2 (optional):
Are you going to tell him?

PROMPT 3 (by 2-3 minutes):
WHY do you have to tell him?
[You want to hear good reasons. Repeat the "why" if necessary.]

PROMPT 4 (by 4-5 minutes):
I don't want him to know. PROMISE me you won't tell him.

/ PROMPT 5A (by 6-7 minutes):
What if he doesn't ask? PROMPT 5B (by 7-8 minutes):
What are you going to say or do if he asks?

BE PREPARED TO ANSWER QUESTIONS SUCH AS:
Why don't you want him to know? "He couldn't handle it..."
He's going to have questions. Statements like this near very beginning of interview should be deflected.
What do you want me to tell him? "Nothing."
What are you going to tell the children? "I'll figure that out when the time comes. They're my responsibility."
Do you want me to lie to him? "I'm not asking you to lie. I'm asking you not to tell."
What if he asks? "Even if he asks, I don't want you to tell him."

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