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สนับสนุนการจัดทำโดย
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วารสารสมาคมจิตแพทย์แห่งประเทศไทย Thai Patients' Perspectives About Truth Telling Anant
Thanapreasertgorn, M.D.* Abstract Objective To survey the attitudes of the patients towards disclosure of diagnosis and prognosis of serious illness such as cancer, and the knowledge of their illness. Methods The patient samples were recruited from 3 major wards; internal medicine, surgery, and gynecology. From each ward, 15 cancer patients and 25 non-cancer patients were selected by stratified randomization, making the total of 120 patient samples (45 cancer, 75 non-cancer). Patients who were too ill or could not be interviewed of any reasons were excluded. They were interviewed by the structured questionnaire in order to assess the knowledge of their illness and desire for information, and their general attitudes about truth disclosure to cancer patients. Results Eighty-eight percent of the non-cancer patients knew about their diagnosis. Seventy- one percent of the cancer patients knew that they had cancer, and 25.8% of all patients and 15.6% of patients with cancer knew about their treatment plan and prognosis in detail. Eighty eight percent of patients would like to know their prognosis. Conclusions The patients were not satisfied with their knowledge of their illness and treatment plan, half of them felt that the doctor had not given enough information. The patients seemed to have quite open attitudes towards truth disclosure even some of them showed some degrees of ambivalence or disagree. Factors found to have influence on knowledge of their illness and towards truth disclosure were gender, age, education, and the diagnosis of cancer. J Psychiatr Assoc Thailand 1997 ; 42(4) : 212-9. Key words: truth disclosure, cancer * Psychiatry Service, Taksin Hospital, Klongsan Road, Bangkok 10600 ** Department of Psychiatry, Ramathibodi Hospital, Mahidol university, Bangkok10400
มุมมองของผู้ป่วยไทยในการแจ้งข้อมูลเกี่ยวกับโรคที่ป่วยตามความเป็นจริง อนันต์
ธนาประเสริฐกรณ์ พ.บ.* บทคัดย่อ การวิจัยนี้มีวัตถุประสงค์ เพื่อสำรวจเจตคติของผู้ป่วยไทยต่อการที่แพทย์แจ้งการวินิจฉัย และการดำเนินโรคของโรคที่ร้ายแรง เช่น มะเร็ง และสำรวจความรู้เกี่ยวกับโรคที่ตนเองเป็นอยู่ วิธีการ สุ่มตัวอย่างผู้ป่วยในจากแผนกอายุรกรรม ศัลยกรรม และนรีเวชกรรม ในแต่ละแผนกได้เลือกผู้ป่วยที่ป่วยเป็นมะเร็ง 15 คน และผู้ป่วยด้วยโรคอื่น 25 คน โดยได้ผู้ป่วยรวม 120 คน ผู้ป่วยที่ป่วยหนักหรือผู้ป่วยที่ไม่สามารถทำการสัมภาษณ์ได้ไม่รวมอยู่ในกลุ่มตัวอย่างนี้ การสัมภาษณ์ทำโดยใช้ structured questionnaire ในการประเมินความรู้เกี่ยวกับโรคของผู้ป่วยเอง และความต้องการในการทราบข้อมูล และเจตคติทั่วไปเกี่ยวกับการบอกความจริงต่อผู้ป่วยโรคมะเร็ง ผลการวิจัย ร้อยละ 88 ของผู้ป่วยที่ไม่ได้ป่วยเป็นมะเร็งทราบการวินิจฉัยของตนเอง, ร้อยละ 71.1 ของผู้ป่วยโรคมะเร็งทราบว่าตนเองป่วยเป็นมะเร็ง, ร้อยละ 25.8 ของผู้ป่วยทั้งหมด และร้อยละ 15.6 ของผู้ป่วยโรคมะเร็งทราบเกี่ยวกับแผนการรักษาและการพยากรณ์โรค และร้อยละ 88.2 ของผู้ป่วยทั้งหมดต้องการทราบการพยากรณ์โรคของตนเอง สรุป ผู้ป่วยส่วนใหญ่ยังไม่ทราบข้อมูลเกี่ยวกับการเจ็บป่วยของตนเองเพียงพอ โดยที่ครั้งหนึ่งมีความรู้สึกว่าแพทย์ยังให้ข้อมูลไม่เพียงพอ ผู้ป่วยค่อนข้างมีเจตคติที่เปิดกว้างต่อการแจ้งข้อมูลตามความเป็นจริง แม้จะมีความรู้สึกสองจิตสองใจก็ตาม ปัจจัยที่มีผลต่อความรู้เกี่ยวกับโรคของผู้ป่วยเอง และการแจ้งข้อมูลตามความเป็นจริงได้แก่ เพศ, อายุ, และผลการวินิจฉัยว่าเป็นมะเร็ง วารสารสมาคมจิตแพทย์แห่งประเทศไทย 2540; 42(4) : 212-9. คำสำคัญ: การแจ้งข้อมูลตามความเป็นจริง, มะเร็ง * กลุ่มงานจิตเวช
โรงพยาบาลตากสิน ถนนคลองสาน กรุงเทพ 10600 Telling patients that they have cancer is a particular difficult clinical skill1. Attitudes towards health care in general, and towards cancer in particular, have been changing rapidly in recent years with patients now tending to take a more active role in the management of their illness2. Nevertheless, patients differ in their ability to integrate threatening information and that the concordance between disclosure of information and the patents ability to deal with this information would be the ideal3. The purpose of this study is to explore the attitudes and behavior of patients towards disclosure of diagnosis and prognosis of their illness, especially a serious illness such as cancer. We hope that the data gained will provide a better understanding of patients' needs and attitudes towards the truth disclosure. MATERIALS AND METHODS The patient samples were selected from 3 major inpatients wards; internal medicine, surgery and gynecology. From each ward, 15 cancer patients, and 25 non-cancer patients were selected by stratified randomization, making the total of 120 patient samples (45 cancer, 75 non-cancer). Patients who were too ill or could not be interviewed because of any reasons (such as deafness or organic mental syndrome) were excluded. All the eligible patients approached agreed to participate in the study. The patients were then interviewed by a structure questionnaire in order to assess the knowledge of their illness and desire for information about it, and their general attitudes about truth disclosure to cancer patients. The patent sample consisted of 87 women (72.5 and 33 men (27.5%) with a mean age of 42 years (range of 14-80 years). Sixty-six patients (55%) had elementary education (4-6 years), 34 (28.3%) had secondary school education (12 years), and 15 (12.5%) had higher education. In terms of social status and income, about half of the patients were middle or lower middle class, about 40% were lower class, and about 10% were upper middle class. The functional status of the patient was rated according to the Karnofsky Performance status Scale4. Four patients (3.3%) had Karnofsky scale scores at around 60 (required occasional assistance from other but able to care for most needs), 33 (27.5%) had scores around 70 (care for self but unable to carry on normal activities or work), 27 (22.5%) had scores around 80 (normal activities with effort), and 24 (20%) had only minor signs of symptoms (score 90) . RESULTS As shown in table 1, 88% of the non-cancer patients knew their diagnosis, while 71.1% of the cancer patients knew that they had cancer of malignancy and most of these patients (81.2%) felt that telling them the diagnosis truthfully had been correct. However, only 25.8 % of all the patients, and 15.6% of patients with cancer knew about their treatment plans and the pros and cons of the treatment in detail. Almost half (45.8%) thought that their doctors had not give them enough information, and only 24.2 % thought they had a good understanding about their illness and 79% of the patients felt that they needed more information. Most of the patients (38.2%) answered that they would like to know the diagnosis if they had cancer, and 81.5% would also like to know the prognosis either good or bad. However, less (67.2%) would like their relatives to be informed if the relatives had cancer. Many patients (35.8%) also agreed that doctors should not tell the unpleasant truth to patients since it might destroy patients' hope, while about the same number of patients (36.7%) disagreed with the policy. Factors found to have influence on Thai patients attitudes and behavior concerning the disclosure of diagnosis and treatment of their illness were gender, age, education, and the diagnosis of cancer. Female patients had better knowledge about their diagnosis (P=0.007) and treatment plan (P=0.017) than male patients, and there were also most female patients who felt that they had good understanding of their present illness (P=0.012) More female than male patients thought they would like to know the diagnosis and prognosis should they have cancer (92% VS 75%, and 86.2% VS 66.7% , P=0.05 respectively). Concerning age, patients who are older than 60 years old knew less about their diagnosis and treatment plans (P=0.047). Only 40% of these patients in the cancer group knew that they had cancer, while 80% of their younger counterparts know the diagnosis (P=0.044) They also appeared to have less desire to know about their diagnosis and prognosis should they have cancer. Only 71.4% of the patients older than 60 years old would like to know the diagnosis (P=0.002) and 82.8% wanted to know the prognosis (P=0.005). In term of education, patients with higher education wanted to be told if they had cancer more than patients who had less education (P=0.047) It was especially interesting to find many differences between the cancer and the non-cancer group in this study. Cancer patients were less informed about their treatment plans, more than half (51.1%) of the cancer patients knew only a little or almost nothing about the treatment plans, while only 25.3% of the non-cancer group had such little knowledge (P=0.02) Only 42.3% of the cancer patients felt that they had enough understanding about their illness while 65.3% in the non-cancer group felt so (P=0.036). This 90% of the cancer patients felt that they needed more information about their illness whereas only 70% of the non-cancer patients felt so. A very interesting finding was that cancer patients had much more open attitude towards truth disclosure about cancer. More cancer patients than the non-cancer patents wanted to be told the diagnosis (93.3% VS 84%) and the prognosis (88.9% VS 76%, P=0.05%). Most of the cancer patients in the study (80%) also wanted their relatives to be told if the relatives had cancer, comparing to only 58.7% in the non-cancer group (P=0.047). Cancer patients are also the only group in this study who tended to disagree rather much to the idea that doctors should not tell the unpleasant truth to patients because it would discourage the patients. More than half (51.7%) disagreed and only 26.7% agreed with the statement while 46.7% of the non-cancer group agreed with the idea, and 30.7% disagreed (P=0.005). Table1 : Questionnaire item and responses of patients 1. Do you know what your diagnosis is ? Non CA A. knows about Dx in detail 51(68%) B. knows Dx but no detail 15(20%) C. Can describe only symptom 9(12%) CA A.CA/malignancy 32(71.1%) B. tumor 5(11.1%) C. very little /not understanding 6(13.3%) D. other 2(4.5%) 2. How much do you know about your treatment plan? A. know in detail 31(25.8%) B. general knowledge without detail 47(39.2%) C. a little 25(20.8%) D. very little or not at all 17(42.2%) 3. How much did your doctor tell you about your illness? A9(7.5%) B56(46.7%) C36(30%) D19(15.8%) A. very good B. just enough C. not enough D. not at all 4. How good do you understand about your illness? A29(24.2%) B39(32.5%) C42(35%) D10(8.3%) A. very good B. just enough C. just a little D. very little 5. Do you feel that you need more information about your illness? A94(79%) B25(21%) A. yes B. no 6. if you had cancer, would you like to be told? A 105(88.2%) B 7(5.9%) C 7(5.9%) A. yes B. no C. Unsure 7. if you had terminal cancer would you like to know the prognosis A 97(81.5%) B 14(11.2%) C 8(0.7%) A. yes B. No C. unsure 8. If your relative had cancer, would you like him (her) to be told? A 80(67.0%) B 32(26.9%) C 7(5.9%) A. yes B. no C. unsure 9. Do your agree that doctors should not tell the unpleasant truth to patients be cause it will discourage the patients? A 43(35.8%) B 44(36.7%) C 33(37.5%) A. agree B. disagree C. no option 10.If you could choose, would you still like to be told that you had cancer?(only patients who knew that they had cancer) A 26(81.2%) B 2(6.3%) C 4(12.5%) A. yes B. no C. no answer The Karnofsky Performance status scale also an interesting factor found to have influence on the patients attitudes towards the information they received. Patients who have high Karnofsky scale scores, 74.5% thought that the doctors gave enough detailed information of their illness and treatment plan while only 47.2% of the patients who have lower Karnofsky scaly scores (50-60) thought so (P=0.0002). Only 50% of the patients who have lower score felt that they had enough understanding about their illness while 78.4% of the patients who have higher scores felt so. Patients who have higher score also tended to disagree to the idea that doctor should not tell the unpleasant truth to patients because it would discourage of patients, i.e., 50.5% disagreed and 33.3% agreed with the statement, while only 36.3% of patients who have lower score disagreed with the idea and 30.5% agreed (P=0.014). DISCUSSION The patients' data show that the patient knowledge of their illness and treatment plan are not satisfactory, and there is a large group of patients (45.8%) who felt that their doctors had not given them enough information. This calls for a serious attention and an effort from the physician side to improve physician-patient communication Most Thai patient would like to know their diagnosis should they suffer from cancer (88.2%) but became more reluctant in disclosing such diagnosis to their similarly afflicted relatives (67.2%). However, although Thai patients seems to have quite an good attitude towards truth disclosure in general, they still showed some degree of ambivalence towards truth disclosure, since as much as 35.8% did agree with the policy of withholding the unpleasant truth from the patient, and about the same number (36.7%) disagreed with the policy. The data above show the complexity of communication between doctors and patients, which involve not only the transmission of information but also the patient's reaction to an adverse event and his pattern of adaptive behavior when coping with a threat. In categorizing pattern of coping behavior, Meller et al divides patients into those who demand more information about their diagnosis (monitors) and those who cognitively distract from threatening information (blunter)2,5. Paradoxically, patients who complain about lack of information may be the best informed Factors found to have influences on Thai patients' knowledge of their illness and attitude towards truth disclosure were gender, age, education, and the diagnosis of cancer. In summary, female patients, person who younger than 60 years old, and patients with better education tended to have better knowledge and more open attitude. The data on cancer patients are very interesting since it shows that physicians tended to give them less information about their illness most and also the group of patients who had the most open attitude towards truth disclosure in almost all aspects. The functional status of patients represented by Karnofsky scale also influences on patients attitude towards medical care. Patients who have high functional status (high Karnofsky score) thought that they received enough information of their illness and treatment plan and felt that they understood about their illness, while patients who have lower functional status, on contrary, thought that the doctors did not give enough information, thus they had less understanding about their illness. However, although patients with lower functional status seems to desire more information towards their illness and treatment plan they still showed some degree of ambivalence towards truth disclosure since 30.5% did agree with the policy of withholding the unpleasant truth from patient, compared to the patients with high functional status, 33.3% thought so, and about half of patients with high functional status disagreed (50.5%) while lesser number of patients with lower functional status disagreed (36.3%). The major problems that face the doctors in breaking bad news, the anxieties and fears that the doctors have, make it difficult for them to start the conversation, and those factors that drive them into taking responsibility for the disease itself, making it even more difficult, are the notions have been stated6. It is useful to know that helping patients become well informed does not create depression but actually assists many patients in sustaining hopeful attitudes. Benefits associated with becoming knowledgeable and actively participating in ones care substantially outweigh the theoretical disadvantage of receiving potentially frightening information. However, that not all patients wish to assume roles in the medical process. In clinical practice, patients' preferences may be readily discerned by physicians who are guided by the patients verbal and behavioral cues7. REFERENCES
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