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VOLUME 22 NUMBER 2 JANUARY 15 2004

JOURNAL OF CLINICAL ONCOLOGY O R I G I N A L R E P O R T

The Attitudes of Cancer Patients and Their Families


Toward the Disclosure of Terminal Illness
Young Ho Yun, Chang Geol Lee, Si-young Kim, Sang-wook Lee, Dae Seog Heo, Jun Suk Kim, Keun Seok
Lee, Young Seon Hong, Jung Suk Lee, and Chang Hoon You
From the Research Institute and Hospi- A B S T R A C T
tal, National Cancer Center, Goyang;
Yonsei University College of Medicine,
Purpose
Kyunghee University Hospital; Asan
To ascertain the attitude of cancer patients and their families toward disclosure of terminal illness
Medical Center, Seoul National Univer-
to the patient.
sity Hospital; Korea University Medical
Center; Kangdong Sacred Heart Hospi- Patients and Methods
tal, St Marys Hospital, Seoul, Korea. We constructed a questionnaire that included demographic and clinical information and delivered it to
758 consecutive individuals (433 cancer patients and 325 families that have a relative with cancer) at
Submitted July 8, 2003; accepted
November 7, 2003.
seven university hospitals and one national cancer center in Korea.

Presented at the 39th Annual Meeting of Results


the American Society of Clinical Oncol-
380 cancer patients and one member from each of 281 families that have a relative with cancer
ogy, Chicago, IL, May 31-June 3, 2003. completed the questionnaire. Cancer patients were more likely than family members to believe that
patients should be informed of the terminal illness (96.1% v 76.9%; P .001). Fifty percent of the family
Authors disclosures of potential con-
members and 78.3% of the patients thought that the doctor in charge should be the one who informs
flicts of interest are found at the end of
the patient. Additionally, 71.7% of the patients and 43.6% of the family members thought that patients
this article.
should be informed immediately after the diagnosis. Stepwise multiple logistic regression indicated that
Address reprint requests to Young Ho the patient group was more likely than the family group to want the patient to be informed of the
Yun, MD, PhD, Quality of Cancer Care terminal illness (odds ratio [OR], 9.76; 95% CI, 4.31 to 22.14), by the doctor (OR, 4.00; 95% CI, 2.61 to
Branch, Research Institute and Hospital, 6.11), and immediately after the diagnosis (OR, 3.64; 95% CI, 2.45 to 5.41).
National Cancer Center 809, Madu-dong,
Ilsan-gu, Goyang-si, Gyeonggi-do 411- Conclusion
769, Korea; e-mail: lawyun@ncc.re.kr. Our findings indicated that most cancer patients want to be informed if their illness is terminal, and
physicians should realize that the patient and the family unit may differ in their attitude toward such a
2004 by American Society of Clinical
disclosure. Our results also reflect the importance of how information is given to the patient.
Oncology

0732-183X/04/2202-307/$20.00 J Clin Oncol 22:307-314. 2004 by American Society of Clinical Oncology


DOI: 10.1200/JCO.2004.07.053

tures that patients are not being informed


INTRODUCTION
when their disease progresses to a terminal
Most physicians [1-4] and patients [5-11] phase and when treatment changes from
now accept as ethical the proposition that curative to palliative [14,15]. But if patients
patients are entitled to know their diagnosis. are to take charge of their own care, chal-
In Korea, only 18% of physicians were likely lenge the disease, and make life-support de-
to disclose the bad news to patients in 1982, cisions, they must be made aware of their
but 81.8% agreed to do so in 1990 [12,13]. condition [16-18]. Because patients who
This reflects a change in attitude brought overestimate their survival time prefer more
about by advances in therapy that reduced aggressive treatment [19], telling patients
the cancer death rate, a decrease in pessi- the truth about their terminal cancer may
mism about cancer, and an increase in lead to more appropriate care. It is difficult,
concerns about a patients right to partici- however, to decide what to tell patients, and
pate in care decisions [2,7]. Most patients how and when to tell them. Although recent
with recurrent cancers, however, die as a studies have focused on the cancer patients
result of their malignancy, and there re- attitude toward disclosure of the diagnosis
mains as a significant problem in some cul- of cancer [8-11] and on the attitude toward

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Yun et al

disclosure of terminal cancer [12,20-30], few have fo- reasons; and the appropriate time to inform the patient (Table
cused specifically on the cancer patients attitude toward 1). In the questionnaire, terminal illness was defined as cancer
disclosure of terminal illness [27,28], and no published that was progressing and no longer treatable by conventional
therapy (surgery or radio-, chemo-, or hormone therapy).
studies have focused on the attitudes of the cancer pa-
tients family. Statistical Analysis
Our study was designed to investigate attitudes of can- We used a t test or 2 test to determine significant differences
cer patients and their families attitudes toward the diagno- in dependent and independent variables between the patient and
sis of a terminal cancer. family groups. We used univariate logistic regression analysis to
estimate the odds ratio (OR) for each independent variable (the
PATIENTS AND METHODS OR is the extent to which being a member of a specific group
increased or decreased the probability of agreeing with the model
Participants and Procedures of attitudes toward disclosing bad news). We used indicator vari-
Seven university hospitals and one national cancer center ables for independent variables that were categoric. Odds ratios
were involved in the study. None of the institutions had a stated greater than 1 represent how much more likely it was for a subject
policy about the disclosure of terminal illness. A member of the in a category to believe that patients should be informed of their
research team approached 758 consecutive individuals (433 terminal illness, that the doctor is the appropriate person to in-
cancer outpatients and 325 members of families who have a form the patient, and that the appropriate time to inform the
relative with cancer) who were sitting in the waiting room of patient is immediately after diagnosis. In addition, for factors
surgical, medical, and radio-oncology clinics for a medical significantly associated in univariate analysis, we performed step-
consultation or a routine follow-up visit. For enrollment in the wise multiple regression analyses for each dependent variable to
study, subjects needed to be age 18 years or older, well enough assess which of the independent variables best predicted attitudes
to fill out a questionnaire or communicate with the interviewer, toward the disclosure of terminal cancer. Finally, we performed
and well enough to provide informed consent. They were given within-group stepwise multiple regression analyses to identify
information explaining the study and asked to participate. As factors significantly related to attitudes toward the disclosure of
patients and families were filling out the questionnaires, re- bad news after controlling for the group. For these analyses, we set
searchers were present to ensure that information was not the significance level at P .05. We used the SAS statistical
shared. In cases where the patient was accompanied by family, package, version 8.1 (SAS Institute, Cary, NC, 1990).
the patients were interviewed in a separate room. The study was
approved by the institutional review board of the National
Cancer Center, Goyang, Korea. RESULTS
Materials
We constructed a questionnaire examining attitudes to- Sample Characteristics
ward disclosure of the diagnosis of a terminal illness. We based Six hundred sixty-one (87.2%) of the 758 consecutive
the questionnaire on previous studies of the disclosure of bad individuals380 (87.8%) of the patients and 281 (87%) of the
news and pilot-tested it on healthy volunteers and cancer family members completed the questionnaire with in-
patients. We aimed to learn whether patients and families
formed consent while waiting for their appointment. The most
differed in their attitudes. The questionnaire gathered the fol-
lowing: demographic information (age, sex, relationship to common reasons given for nonparticipation were a lack of
patient, level of education, income, and religiousness); clinical time and poor eyesight. The questionnaire took approximately
information (time since initial diagnosis, awareness of the can- 10 minutes to complete. Table 2 gives the subject characteris-
cer diagnosis, type of primary cancer, disease stage, and Eastern tics. The patient group consisted of more men (P .01), was
Cooperative Oncology Group performance status); preference older (P .001), and had a lower education level (P
for end-of-life care issues (place of care and death); and infor-
.001) than the family group. The patients to whom the
mation on attitude toward the disclosure of terminal illness to
the patient. A series of questions covered the following: pros family group subjects were related were more likely than
and cons of informing patients of the terminal illness, and the the patient subjects to have terminal stage disease (P
reasons; the appropriate person to inform the patient, and the .001) and a worse performance status (P .001).

Table 1. Measures of Attitudes Toward the Disclosure of Terminal Illness


Disclosing
If your (your relatives) illness takes a turn for the worse and can no longer be treated by conventional anti-cancer therapy, do you want yourself (your
relative) to be informed of the situation? (yes/no)
Who should disclose
Who do you think is the appropriate person to inform you (your relative) of the terminal condition? (doctor/family member/clergy/other)
When to disclose
When should you (your relative) be informed of the terminal condition? (immediately/gradually)

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Disclosure of Terminal Illness

Table 2. Characteristics of Study Subjects


Patient Group Family Group
(n 380) (n 281)
No. of No. of
Characteristic Patients % Patients %
Sex
Male 184 48.4 101 35.9
Female 196 51.6 180 64.1
Age, years
Mean 49.6 43.0
SD 12.4 12.7
Relationship to patient
Spouse 127 45.4
Child 75 26.8
Sibling 15 5.3
Other relatives 63 22.5
Education
Did not complete high school 132 35.3 55 19.6
Completed high school 242 64.7 226 80.4
Religiousness
Religious 273 72.8 187 66.6
Nonreligious 102 27.2 94 33.4
Payers monthly income, $US
770 97 28.9 69 25.9
7711,540 131 39.0 101 37.8
1,5412,310 69 20.5 62 23.2
2,311 39 11.6 35 13.1
Time since initial diagnosis, years
1 231 66.6 189 72.7
1 116 33.4 71 27.3
Awareness of the cancer diagnosis
Aware 316 86.8 246 90.8
Not aware 48 13.2 25 9.2
Primary cancer
Breast cancer 55 14.5 23 8.2
Stomach cancer 46 12.1 29 10.3
Lung cancer 36 9.5 36 12.8
Colorectal cancer 29 7.6 34 12.1
Other 214 56.3 159 56.6
Disease stage
Early 87 33.7 52 23.2
Advanced 132 51.2 110 49.1
Terminal 39 15.1 62 27.7
Patients ECOG PS
02 341 91.9 225 80.1
34 30 8.1 56 19.9
Preference for place of care
Home 194 53.3 136 49.1
Institution 170 46.7 141 50.9
Preference for place of death
Home 169 46.9 140 51.3
Institution 191 53.1 133 48.7 Fig 1. The percentage of subjects that answered: (A) Do you want the
NOTE. P was derived by the 2 test. patient to be informed of the truth? (B) Who is the appropriate person to
Abbreviations: SD, standard deviation; ECOG PS, Eastern Cooperative inform the patient? (C) When is the appropriate time to inform the patient?
Oncology Group performance status.

Comparison between patient group and family group (using t test for
mean or 2 test for other variables).
P .01. illness (96.1% v 76.9%; P .001; Fig 1). The reasons that
P .001. subjects gave for answering yes or no to the question of
US $1 1,300 won.
P .05. disclosure are given in Table 3.
Institution included hospital, nursing home, etc. The patient group was also more likely than the family
group to think that the doctor in charge is the appropriate
person to provide the disclosure (P .001), and was more
Difference in Attitude Toward Disclosure of likely to think that the patient should be informed of a
Diagnosis of a Terminal Illness terminal illness immediately after diagnosis (P .001; Fig
The patient group was more likely than the family 1). The reasons that subjects gave for answering doctor in
group to want the patient to be informed of the terminal charge or family member are given in Table 4.

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Yun et al

Table 3. Why Did You Answer Yes or No Regarding Disclosure of a Terminal Illness to the Patient?
Patient Group Family Group
No. of Patients % No. of Patients %

The reason for yes


Disclosure enables the patient to resolve unfinished business 121 33.5 64 29.8
Patients have a right to know the truth about their own condition 89 24.7 58 26.5
Disclosure enables patients to cooperate with health care professionals in their 72 19.9 69 32.1
medical care
Disclosure relieves patient and family of the burden of unnecessary treatments 61 16.9 9 4.2
The patient will learn about the situation eventually 8 2.2 15 7.0
The reason for no
Disclosure can cause the patient psychological and emotional distress 7 46.6 24 38.1
Disclosure may be meaningless and helpless to patient 6 40.0 1 1.6
Disclosure causes patients to lose hope and discourages them from fighting 1 6.7 35 54.0
the disease

Univariate Logistic Regression Analyses of 6.11), and immediately after the diagnosis is made (OR,
Factors Related to Wanting Disclosure 3.64; 95% CI, 2.45 to 5.41). After controlling for the group
Age, religiousness, relationship to patient, time since di- difference, only disease stage was associated with attitude
agnosis, type of primary cancer, disease stage, and perfor- toward the appropriate time to inform patients of the truth.
mance status were likely to influence attitudes, while sex, level Subjects with early stage disease were more likely than sub-
of education, income, awareness of the cancer, preference for jects with terminal stage disease to want the patient to be
place of care and death, and diagnosis were not (Table 5). informed immediately of the diagnosis of terminal illness
(OR, 2.32; 95% CI, 1.32 to 4.09). Age, religiousness, time
Stepwise Multiple Logistic Regression Analyses
since initial diagnosis, and performance status showed no
In stepwise multiple logistic regression analyses, we
association in the multivariate analysis (Table 6).
excluded factors that were not associated in univariate anal-
ysis with attitude toward the disclosure of terminal illness. Within-Group Analyses
For all three of the measures of attitude toward disclosure, For factors significantly associated in univariate analy-
the first factor related to attitude was the difference between sis within each group, we performed stepwise multiple re-
patient and family members. The patient group was more gression analyses for all three of the measures of attitude
likely than the family group to want the patient to be in- toward disclosure. In the patient group analysis, patients
formed of the diagnosis of terminal illness (OR, 9.76; 95% with a higher level of education were more likely than
CI, 4.31 to 22.14), by the doctor (OR, 4.00; 95% CI, 2.61 to patients with a lower level of education (OR, 1.88; 95% CI,

Table 4. Why Do You Think the Person in Charge Is the Appropriate One to Inform the Patient of a Terminal Illness?
Patient Group Family Group
No. of Patients % No. of Patients %

The reason for doctor


The doctor understands the disease and could explain the situation fully 136 44.9 64 44.8
The doctor is trusted 55 18.2 20 14.0
The doctor would be aware of the patients emotional, psychological, 47 15.5 26 18.2
and social conditions as well as the physical ones
It is the doctors duty to provide the information 47 15.5 14 9.8
The doctor could cushion the impact and provide comfort 13 4.3 12 8.4
The reason for family member
It is the familys duty to provide the information 19 32.8 12 9.8
The family member could cushion the impact and provide comfort 16 27.6 29 23.6
The family member would be aware of the patients emotional, 9 15.5 54 43.9
psychological, and social conditions as well as the physical ones
The family member is trusted 6 10.3 8 6.5
The family member understands the disease and could explain the 6 10.3 4 3.3
situation fully
The family member could provide more hope for the future 2 3.4 14 11.4

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Disclosure of Terminal Illness

Table 5. Odds Ratios and 95% CIs From Logistic Regression Analysis Predicting Attitude Toward the Disclosure of a Terminal Illness
Should There Be Disclosure Who Should Disclose When Should Disclosure
(yes) (doctor) Occur (immediately)
Variable Odds Ratio 95% CI Odds Ratio 95% CI Odds Ratio 95% CI

Group
Family 1.00 1.00 1.00
Patient 7.32 4.08 to 13.16 4.23 2.95 to 6.09 3.37 2.44 to 4.66
Sex
Female 1.00 1.00 1.00
Male 1.47 0.90 to 2.40 1.11 0.79 to 1.57 1.10 0.81 to 1.50
Age, years
39 1.00 1.00 1.00
4059 1.53 0.91 to 2.54 2.07 1.41 to 3.05 1.50 1.05 to 2.14
60 2.18 1.03 to 4.62 2.02 1.20 to 3.39 1.99 1.24 to 3.21
Relationship to patient
Spouse 1.00 1.00 1.00
Child 0.61 0.32 to 1.17 0.60 0.33 to 1.10 0.82 0.46 to 1.47
Sibling 3.78 0.48 to 30.0 0.23 0.07 to 0.77 0.72 0.24 to 2.15
Other relatives 0.95 0.46 to 1.96 0.39 0.21 to 0.74 0.81 0.44 to 1.50
Education
Completed high school 1.00 1.00 1.00
Did not complete high school 1.14 0.67 to 1.94 1.30 0.88 to 1.92 0.88 0.63 to 1.24
Religiousness
Nonreligious 1.00 1.00 1.00
Religious 1.78 1.10 to 2.88 1.08 0.75 to 1.57 1.11 0.79 to 1.56
Payers monthly income, $US
770 1.00 1.00 1.00
7711,540 0.91 0.49 to 1.68 0.68 0.44 to 1.07 0.96 0.64 to 1.44
1,5412,310 0.81 0.41 to 1.62 1.05 0.61 to 1.78 0.83 0.52 to 1.32
2,311 1.07 0.44 to 2.56 0.80 0.43 to 1.49 1.47 0.82 to 2.64
Time since initial diagnosis, years
1 1.00 1.00 1.00
1 1.91 1.06 to 3.46 1.14 0.77 to 1.69 0.97 0.69 to 1.37
Awareness of the cancer diagnosis
Not aware 1.00 1.00 1.00
Aware 0.77 0.34 to 1.75 1.35 0.81 to 2.25 1.44 0.90 to 2.30
Primary cancer
Breast cancer 1.20 0.54 to 2.66 1.67 0.91 to 3.07 1.63 0.96 to 2.75
Stomach cancer 0.89 0.43 to 1.86 0.90 0.51 to 1.59 1.60 0.94 to 2.73
Lung cancer 0.85 0.41 to 1.78 1.10 0.62 to 1.96 1.64 0.95 to 2.82
Colorectal cancer 1.10 0.47 to 2.56 0.55 0.31 to 0.97 0.84 0.49 to 1.44
Other 1.00 1.00 1.00
Disease stage
Terminal 1.00 1.00 1.00
Advanced 1.33 0.70 to 2.52 1.85 1.12 to 3.05 1.65 1.03 to 2.62
Early 2.61 1.14 to 5.98 1.64 0.95 to 2.84 2.97 1.74 to 5.08
Patients ECOG PS
34 1.00 1.00 1.00
02 2.15 1.20 to 3.85 1.45 0.89 to 2.36 1.55 0.97 to 2.46
Preference for place of care
Home 1.00 1.00 1.00
Institution 0.83 0.52 to 1.34 1.16 0.82 to 1.65 0.73 0.53 to 1.01
Preference for place of death
Home 1.00 1.00 1.00
Institution 1.26 0.78 to 2.04 1.29 0.90 to 1.83 0.89 0.65 to 1.23

Abbreviation: ECOG PS, Eastern Cooperative Oncology Group performance status.



P .05.
P .001.
P .01.
Relationship to patient was analyzed only in family group.
US $1 1,300 won.
Institution included hospital, nursing home, etc.

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Table 6. Stepwise Multiple Logistic Regression Analysis of Factors Predictive of Attitudes Toward Disclosure of a Terminal Illness
Should There Be Disclosure Who Should Disclose When Should Disclosure Occur
(yes) (doctor) (immediately)
Variable Odds Ratio 95% CI P Odds Ratio 95% CI P Odds Ratio 95% CI P

Step 1
Group
Family 1.00 1.00 1.00
Patient 9.76 4.31 to 22.14 .001 4.00 2.61 to 6.11 .001 3.64 2.45 to 5.41 .001
Step 2
Disease stage
Terminal 1.00
Advanced 1.32 0.81 to 2.17 .48
Early 2.32 1.32 to 4.0) .003

1.05 to 3.36) to think that the doctor is the appropriate Even in the past, when most physicians believed that cancer
person to inform the patient of the terminal illness. In the connoted certain death, approximately 90% of patients in-
within-family group analysis, spouses were more likely than dicated that they would want disclosure [5,6,9,34]. In prac-
other relatives (OR, 2.03; 95% CI, 1.17 to 3.54) to regard the tice, cancer patients want to know their prognosis so that
doctor as the appropriate informer. they can resolve unfinished business, take appropriate care
of themselves in cooperation with health care professionals,
DISCUSSION and relieve themselves and their families of the burden of
useless treatments. Also, they believe they have a right to
A most important finding was that 96.1% of the patient know the truth about their own condition. However, unless
group wanted to be told if they had a terminal illness. This they are invited directly during a consultation, patients
differed significantly from the corresponding proportion in rarely raise the issue [35]. Thus, the physician should assess
the family group (76.9%). The two groups also differed in a patients need for information about the prognosis.
attitude about who should inform the patient about the Many studies have suggested that because cultures
terminal illness, and when. More patients than family mem- vary, Western values that promote the principle of patient
bers wanted the doctor to be the one who informed the autonomy may not be universally applicable [20,21,26,36-
patient and to do so immediately after the illness was diag- 39]. Baile at al [23] provided preliminary data regarding
nosed. These observations should provide persuasive data cultural differences in disclosing cancer diagnosis and prog-
for health professionals who might withhold information nosis. Blackhall et al [26,40] found that ethnicity was the
about a terminal illness on the grounds that patients would primary factor that influenced attitudes toward truth-tell-
prefer not to know about it. ing and patient decision-making. Those results, however,
From the patients point of view, receiving a diagnosis reflected the attitudes of doctors, family members, and
of terminal illness is traumatic and may cause otherwise healthy people. In the present study, which involved Korean
rational people to make irrational choices [7]. Family and cancer patients and their families, we found a strong wish
physicians frequently protect patients from bad news to for disclosure of terminal illness among the patients them-
give them hope for the future [31]. In Japan, China, Greece, selves, and significant difference in attitude between pa-
and Ethiopia, for example, physicians believe that causing tients and family members. Therefore, caution should be
patients to lose hope by telling them about the illness will applied in holding to the family-centered model rather than
only hasten their death, [20,21,28] and physicians in the exploring the patients wishes. Our results suggest that dif-
United Kingdom and Italy are likely to withhold the infor- ferences in attitude toward disclosure of terminal illness
mation from the patient at the familys request [9,15]. Most existing within a single culture may be because of different
physicians endorse the involvement of family members roles and points of view between patients and their family
when disclosing terminal illness and may allow the family to members. International ethical codes and human rights law
make decisions on behalf of an incapacitated patient accept that the right to autonomy or self-determination is
[32,33]. Sometimes family members may consent to far broadly perceived as necessary to human dignity [39].
more aggressive treatment than patients would want for However, without knowledge of the attitudes toward dis-
themselves [7]. Paternalistic decisions by physician or fam- closure of a terminal illness among cancer patients, doctors,
ilies may lead to dissatisfaction with the medical system, family, and healthy people in both Western and Asian pop-
causing increased stress, financial strain, and prolonged and ulations, it is not clear whether differences in attitude are
painful deaths as a result of unwanted, invasive care [7]. due to differences in culture, role, or point of view. Families

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Disclosure of Terminal Illness

who objected to telling the patient the truth were more Our study had several limitations. First, the family
likely than patients to believe that the disclosure would members sitting in the waiting rooms might not have been
cause the patients to lose hope and discourage them from representative of all family members. Second, our study did
fighting the disease. In addition, patients who objected to not allow the participants to complete the questionnaire
being told the truth were more likely than the families to see and deliver it in a sealed envelope, so it may have been
the disclosure as meaningless and conveying a feeling of biased toward positive outcomes. Researchers, however,
helplessness. Those were interesting findings that may un- did not allow the patients and family members to share
derscore the importance of how physicians and families information, which minimized the bias caused by patients
disclose the truth in clinical practice. In fact, the issue of answering according to family expectations. Third, if the
how to disclose the truth is more important than whether or participating institutions were more progressive than non-
not to do so [41]. There are many recommendations on participating institutions regarding disclosure, there could
how a cancer diagnosis should be given to patients. All stress be a bias toward positive outcomes. However, most Korean
the importance of honesty, compassion, sensitivity, clarity, hospitals, like those in this study, do not have an institu-
and allowing some measure of hope [6,42,43]. tional policy regarding the disclosure of diagnoses. Fourth,
Who is the appropriate person to inform the patient of clinical information depended on patient and family
terminal illness? Our study showed that most patients and knowledge about the illness, such as disease stage and per-
half the families would prefer disclosure by the doctor be- formance status, and those might not have been accurate.
cause the doctor understands the disease, could explain the Finally, we did not compare attitudes between the patients
situation fully, and is trusted. In contrast, approximately and family members by matching. Such matching might be
20% of patients and half of families would prefer disclosure useful for patients and family education.
by family members because the family members are aware In summary, our findings suggest that regardless of
of the patients emotional, psychological, and social condi- their role, respondents agreed on the importance of disclo-
tions as well as the physical one, and they could cushion the sure of a terminal illness. This study underscores the fact
impact and provide comfort. In the family group, spouses that most patients wanted to be informed of the diagnosis of
were more than twice as likely as other relatives to regard the a terminal illness, but attitudes toward such disclosure may
doctor as the appropriate informer; they believed that the differ between patient and family. Our results also reflect
doctor understood the disease and could explain the situa- the importance of how information should be given to
tion fully. We need to further investigate the basis for the patients. We suggest further, comprehensive investigations
difference in such preferences according to the relationship to ascertain the contributions of cultural and role differ-
to patients. But too frequently, physicians are ill equipped ences to attitudes toward the disclosure of terminal illness
to handle that disclosure [44]. When discussions about among cancer patients, doctors, family members, and
prognosis are documented in medical charts along with a healthy people in both Western and Asian populations. This
plan for end-of-life care, they can pave the way for further could be done through a cooperative international study.
discussions of that care, and they can enhance the physi-
cians relationship with the patient and the patients family

[45,46]. In addition, laws such as the US Patient Self-Deter- Acknowledgment


mination Act, which requires that patients be informed of This work was supported by National Cancer Center
their right to make their own medical care decisions and Grant N14020.
supports advance directives, may improve communication
between doctors and patients while providing greater assur- Authors Disclosures of Potential
ance that patients will be treated according to their own Conflicts of Interest
values and preferences [47,48]. The authors indicated no potential conflicts of interest.

4. Field D: Special not different: Gen- 8. Ajaj A, Singh MP, Abdulla AJJ: Should el-
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