Reducing Collusion Between Family Members and Clinicians of Patients Referred to the Palliative Care Team

Abstract

Objective: Collusion refers to a secret agreement made between clinicians and family members to hide the diagnosis of a serious or life-threatening illness from the patient. Our goal was to reduce the rate of collusion among the family members of patients referred to our institution's palliative care service such that 80% of patients would be aware of their diagnosis within four weeks of referral to the service. We aimed to achieve this target within six months of starting the project.Methods: We undertook a clinical practice improvement project using the methodology of Brent James et al of Intermountain Health to see how we could reduce collusion among clinicians and family members of patients with advanced-stage cancers. This strategy included creating awareness among patients, family, and clinicians of the problems with collusion from the standpoint of each group; adopting an empathetic and compassionate approach to communication; using pamphlets; seeking patients' views; empowering families to reveal the truth to patients; and supporting patients and families until the last moment of each patient's life.Results: Between December 2004 and June 2008, 655 patients with advanced-stage cancers were referred to us. We were able to maintain an average awareness rate of nearly 80% of patients starting in February 2005, when we implemented awareness measures. Conclusion:The deeply entrenched cultural practice of collusion can be changed with simple strategies based on the universal principles of medical ethics and best practices.

Understanding the Practice of Collusion on End of Life Care in Singapore

“…A local study conducted in 1993 of a small sample (n=94) comprising of specialists, and general practitioners revealed that 90.4% would tell the family the diagnosis, 84% will accede to the family's request not to disclose the diagnosis to the patient and 23.4% would accede to the family's request not to tell the patient the diagnosis even if the patient insists on knowing it (Tan et al 1993). A later study in 2004 on patients, referred to the hospital's palliative care service, found that 70% of patients were unaware of their diagnosis at time of referral, and 54% wanted to know if their illness was life threatening (Low et al 2009).…”

“…The support from administrators on handling these situations, and mandating the adoption of best practices that are aligned with the relevant legal principles would be helpful in eradicating collusion (Low et al 2009). Although collusion may be entrenched in our communities especially for elderly patients at the end of life a concerted institution-wide measure to eradicate it through educating patients their families and healthcare professionals should work (Low et al 2009). If collusion was not present, the best practice would be to conduct a mental capacity assessment to ascertain whether LKF could make his own treatment decisions.…”

Studying Cost as a Factor in the Choice between Quality and Quantity of Life amongst Patients with Cancer and their Caregivers at a Cancer Centre in Singapore

“…Although it may be argued that family members are not obliged to do so, they often do in the face of regnant sociocultural beliefs that emphasize familial obligations to care for ill family members [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18].…”

“…The latter is seen as critical given that a loss of 'hope' or the presence of stress during periods of illness especially at the end of life is believed to hasten death. The culmination of both these factors often sees children colluding with health professionals to hide or moderate the diagnosis and/or prognosis to protect the parent from 'concern and anxiety' , over their life-limiting illness and not infrequently pursuing second 'opinions' , alternative treatment options and even futile treatment options in order to prolong the life of the patient [3][4][5][6].…”

“…First, the continued dominance of family centric decision-making in end of life care, where decisions may favour the family's interests rather than the patient's. Second, local conceptions of Confucian inspired filial piety which requires that the family provide for the financial, physical, social, spiritual and emotional needs of the patient in recognition for their previous contributions to the family or as a result of their place within the family unit [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]. Third, mounting care costs do create potential for conflicts of interests in meeting the duty to care for the patient and the primacy placed on protecting the interests of the family.…”