Collusion in doctor-patient communication about imminent death: an ethnographic study

Objective To discover and explore the factors that result in "false optimis m about recovery" observed in patients with small cell lung cancer. Design A qualitative observational (ethnographic) study in two stages over four years. Setting Lung diseases ward and outpatient clinic in university hospital in the Netherlands. Participants 35 patients with small cell lung cancer. Results "False optimism about recovery" usually developed during the (first ) course of chemotherapy and was most prevalent when the cancer could no lo nger be seen in the x ray pictures. This optimism tended to vanish when the tumour recurred, but it could develop again, though to a lesser extent, du ring further courses of chemotherapy. Patients gradually found out the fact s about their poor prognosis, partly because of physical deterioration and partly through contact with fellow patients who were in a more advanced sta ge of the illness and were dying. "False optimism about recovery" was the r esult an association between doctors' activism and patients' adherence to t he treatment calendar and to the "recovery plot," which allowed them not to acknowledge explicitly what they should and could know. The doctor did and did net want to pronounce a "death sentence" and the patient did and did n ot want to hear it. Conclusion Solutions to the problem of collusion between doctor and patient require an active, patient oriented approach from the doctor. Perhaps solu tions have to be found outside the doctor-patient relationship itself-for e xample, by involving "treatment brokers."