Ethical Challenges in Trauma Care: Patient Request for Bad News Information

Case 3: Patient Request for Bad News Information in Trauma Centre 

Nurses in trauma centres face distinct ethical challenges. Decisions need to be made quickly with the best information available—and that information is often insufficient. Patients are often critically ill and the team may be struggling to keep them alive. Their emergent condition may change abruptly for the worse; different treatments may have to be tried with very little time for discussion. Of due to trauma. Family and friends may not be available to give consent. Police officers may want to conduct an investigation. Urgent surgery may be required. 

In emergency situations, and particularly when patients are fighting for their lives, the guiding norms or principles with respect to autonomy and truth-telling that apply in non-emergency situations may not apply, or may be weighted differently. Autonomy and truth-telling take a back seat to beneficence or nonmaleficence. The focus of the health team is on the patient’s health condition and trying to secure the best health outcome possible. This case explores the issue of truth-telling in an emergency situation in which to tell the truth could jeopardize a patient’s health, and possibly life. 

Deborah Mullins is on a highway driving in a car with her same sex partner, Carole, and their three-year-old daughter, Samantha. They are hit by a drunk driver in a multivehicle accident. Ambulances quickly arrive on the scene, and Deborah and Carole, both seriously injured, are rushed to a nearby hospital in separate ambulances. Samantha is taken with minor injuries in another ambulance to a children’s hospital ten kilometres away. 

In the hospital emergency room Carole’s vital signs are absent. The trauma team tries to resuscitate her, but their efforts fail. Deborah, awake in the same hospital’s trauma room, is not aware of her partner’s death. She asks about her family. At the same time her vital signs deteriorate because she has lost a lot of blood. Her colour is pale and her lips are cyanotic. One lung has collapsed and her breathing is laboured. She has had kidney damage on one side, sustained from the impact from another vehicle. She urgently needs to have surgery and whether she will survive the surgery is uncertain. If she does survive, she will be in an induced coma for a week to allow her body to heal. Her physical status is unstable, and the nurses and their colleagues fear and know that any further stress could seriously impair her capacity to survive the surgery and post-operative care in a coma. 

Priority of Patient's Best Interest

Deborah receives medications to sedate her and loses consciousness. Then suddenly and briefly she awakes and asks, “How are Carole and Samantha?” The nurses tell her that Samantha is well and at another hospital. No one on the team wants to answer Deborah’s question about Carole. They are aware of the risks of telling her now. One of the nurses evokes the concept of “therapeutic privilege” to justify not telling her the truth. At the same time, there is discomfort about not being honest. One of the nurses points out that Deborah could die in the operating room or intensive care unit without knowing the truth about Carole. 

The police officers ask to speak to Deborah before she goes to surgery. They want a statement from her before she loses consciousness. 

Case 3: Commentary

There are two separate issues in this case: whether to permit police to question the patient and whether to answer the patient’s question promptly and honestly. The emergency room nurses caring for Deborah are primarily oriented toward producing the best outcome possible for her—to maximize benefit and minimize harms to her. The situation is critical; the stakes are high. 

As concerns police access to the patient for questioning, the team’s priority is Deborah as a patient and what is best for her. Any delay in her care caused by police questioning could be seriously detrimental. Moreover, the questioning, even if done sensitively, could lead to distress. Additionally, it could happen that she learns or figures out in the questioning process that her partner has died, and then experiences all the distress that could cause. 

The hospital will have a policy regarding police access to the trauma area and to patient information in view of patient privacy and confidentiality. The nursing staff should be familiar with what the policy permits or requires. Typically, such policies, while recognizing the legitimate forensic and informational needs of police conducting an investigation, prioritize the patient’s medical interests above all. Under the circumstances, permitting the questioning is counter to the patient’s best interests and should not occur at this time. 

The truth-telling issue is thornier. What are the immediate options? One option would be to lie and tell her that her partner is still alive. Another option would be to avoid answering the question, perhaps by deflecting the question or giving a vague response with the intention of telling her the truth at some later, more opportune time. A third option would be to tell her the truth that her partner has died. How should we assess these options? 

Truth-Telling Issue

Undoubtedly, there are good reasons not to tell Deborah the truth under the circumstances. These nurses have extensive experience with trauma cases and understand the potential risk to her health status from the physiological, psychological, and emotional reaction that she could experience given her precarious state. Under the circumstances, learning about her partner’s death could seriously threaten her own fragile status. However, to lie to her, or even to refuse to give her a straight answer, would violate important moral norms that would ordinarily apply in non-emergency situations. Outright lying—saying something that one knows not to be true—is a greater affront to truth-telling norms than withholding information would be. If merely evading an answer would be sufficient for present purposes, it would at least be better than outright lying. The ordinary rule or norm that one should tell the truth has exceptions. Is this an exception? 

The nature of the truth in question makes a difference. The duty to be truthful with patients is most weighty insofar as it is linked with patient autonomy and the ability to make informed choices concerning treatments. Patients need to know in order to make informed choices. Incomplete, and even more so false information, hinders the patient’s ability to make informed decisions. Moreover, information about a patient belongs to the patient and grounds the patient’s right to receive this information. In this case, however, the truth in question is not, in the first instance, about Deborah or her condition but rather about her partner. Deborah is not owed this information in the same way she is owed information about her own health condition. 

One of the nurses has evoked the concept of “therapeutic privilege” to justify not providing her with the information. The concept of therapeutic privilege recognizes exceptions to rules of consent that ordinarily apply. It allows that, if the provision of information to the patient to which the patient would ordinarily be entitled could be seriously harmful, it may be withheld from the patient (Richard et al., 2010). However, in this case therapeutic privilege is not quite relevant because the information is not about the patient herself and not pertinent in the course of an informed consent process. In any event, since the information in question is not Deborah’s information, whatever duties nurses might have, the duty to speak the truth is lesser. If as a rule nurses would otherwise provide such information, the circumstances in the present case seem serious enough to constitute an exception. 

All things considered, the best plan, short of outright lying, may be to avoid or deflect or otherwise delay the question for now until Deborah has her surgery and her condition becomes more stable. The team could plan for this later disclosure of the terrible truth, perhaps arranging to have family members at her side when she is told, or even to have another family member tell her. 

Case conferences and ethics consultations (Swetz et al., 2007) can be helpful in such situations to support the team in determining and providing the best approach to care, but may not be timely enough. Establishing a standard way of responding to these cases, which are not uncommon in trauma units, can be helpful. After responding to this case, the team should consider a critical incident debriefing. Whatever their decision, the team must be extremely sensitive to the physical condition of the patient when they make a disclosure about the status of the patient’s partner. If deception could be justified in a case such as this, it could only be as a last resort, assuming that the less ethically troubling option of avoiding answering the question was not sufficient. 

Case 3: Questions

1.Do planned deception or delayed disclosure have a legitimate role in providing health care to Deborah? Support your answer with reference to ethical principles and values. What would you do if you disagreed with the team decision that Deborah should be protected from receiving this tragic news before her surgery? 

2.Discuss the concept of paternalism and how it applies to this case. 

3.Rules about disclosure of health information to patients and families have exceptions. What exceptions do you think apply in the case of the rule that patients should be told the truth when they ask? 

4.Trauma staff may be asked by police officers to provide personal health information. Review the policy where you study or are employed. What are the guiding ethical principles of this.