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สนับสนุนการจัดทำโดย
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วารสารสมาคมจิตแพทย์แห่งประเทศไทย Thai Physicians Attitudes Towards Truth Telling Anant
Thanaprasertgorn, M.D. * Abstract Objective To survey the attitudes of physicians towards disclosure of diagnosis and prognosis of serious illness such as cancer, and the practice of truth telling. Methods 19-item questionnaire which covered physicians' attitudes and practice towards the cancer patients, and attitudes towards truth disclosure in general were sent to physicians in hospital, 146 responses (63.5%) were returned. Ten specialties were represented. Among these, 48.3% were faculty members and 51.7% were residents in training. Of all the sample, 33.6% involved regularly or often involved regularly or often in treating cancer patients. Results Seventy percent of the physicians surveyed thought that a patient should be informed about the diagnosis of cancer. Fifty-sixth percent thought they would inform the terminal cancer patients about their diagnosis. Ninety-four percent also thought that patients family should be informed about the diagnosis of cancer. In practice, 86.6% always informed relatives. Conclusions The attitude towards truth disclosure of Thai physicians appears to be more open than countries like Japan or India but less open than North American and Northern European countries, because the physician-patient relationship in Thailand, influenced by Buddhism, gives a lot of importance to the right and freedom. Factors influencing attitudes towards truth disclosure include gender, degree of involvement in the treatment of cancer patients, and the specialties of physicians. The patients' data confirm the physicians' practice. J Psychiatr Assoc Thailand 1997 ; 42(4) : 220-5. Key words: Truth disclosure, cancer *
Psychiatry Service, Taksin Hospital, Klongsan Road, Bangkok 10600 เจตคติของแพทย์ไทยในการแจ้งข้อมูลเกี่ยวกับความเจ็บป่วยตามความเป็นจริง อนันต์
ธนาประเสริฐกรณ์ พ.บ.* บทคัดย่อ การวิจัยนี้มีวัตถุประสงค์เพื่อสำรวจเจตคติของแพทย์ต่อการแจ้งข้อมูลเกี่ยวกับการวินิจฉัย การดำเนินโรคของโรคร้ายแรง เช่น มะเร็ง และการปฏิบัติจริง วิธีการ ใช้ 19-item questionnaire ซึ่งมีเนื้อหาครอบคลุมเรื่องของเจตคติ และวิธีปฏิบัติของแพทย์ต่อผู้ป่วยโรคมะเร็ง และโรคทั่วๆ ไป โดยได้แจกแบบสอบถามกับแพทย์ในโรงพยาบาลรามาธิบดี ซึ่งได้รับการตอบกลับ 146 คน (ร้อยละ 63.5) จาก 10 ภาควิชา โดยที่ร้อยละ 48.3 เป็นอาจารย์แพทย์ และร้อยละ 51.7 เป็นแพทย์ประจำบ้าน ผลการศึกษา ร้อยละ 33.6 ของแพทย์ต้องให้การดูแลรักษาผู้ป่วยมะเร็งเป็นงานประจำผลการวิจัย ร้อยละ 70.4 ของแพทย์คิดว่าควรแจ้งข้อมูลแก่ผู้ป่วยโรคมะเร็งตามความเป็นจริง, ร้อยละ 56.1 คิดว่าจะบอกความจริงแม้ว่าจะเป็นมะเร็งในขั้นสุดท้าย, ร้อยละ 94.3 คิดว่าควรบอกความจริงเกี่ยวกับโรคมะเร็งต่อญาติของผู้ป่วยด้วย เมื่อเปรียบเทียบกับร้อยละ 86.6 ซึ่งแพทย์ปฏิบัติจริง สรุป แพทย์ไทยค่อนข้างมีเจตคติที่เปิดกว้าง เมื่อเทียบกับแพทย์ในประเทศอื่น เช่น ญี่ปุ่น อินเดีย แต่ยังค่อนข้างน้อยกว่า เมื่อเทียบกับประเทศทางอเมริกาเหนือ และยุโรปตอนเหนือ ซึ่งอาจเป็นเพราะว่าความเชื่อและวัฒนธรรมทางพุทธศาสนา มีส่วนทำให้ความสัมพันธ์ของแพทย์และผู้ป่วยค่อนข้างอิสระและเคารพในสิทธิของผู้ป่วย ปัจจัยที่มีผลต่อเจตคติในการแจ้งข้อมูลได้แก่ เพศ การทำงานที่เกี่ยวข้องกับผู้ป่วยโรคมะเร็ง และสาขาวิชาของแพทย์ โดยที่ข้อมูลทางด้านผู้ป่วยช่วยสนับสนุนข้อมูลในด้านการปฏิบัติจริงของแพทย์ วารสารสมาคมจิตแพทย์แห่งประเทศไทย 2540; 42(4) :220-5. คำสำคัญ การแจ้งข้อมูลตามความเป็นจริง มะเร็ง * กลุ่มงานจิตเวช
โรงพยาบาลตากสิน ถนนคลองสาน กรุงเทพ 10600 Should cancer patients be told truth what should the patient be told? How and when should this be done? The manner in which such question are handled is crucial for the patient and may determine his emotional status and capacity for function from that time on1 . A member of survey since 1953 have investigated the physicians approach to the cancer patient regarding the issue of disclosing the diagnosis. In Okens1 survey of 219 physicians at Micheal Rese Hospital 90 % generally did not inform the patient. Many showed inconsistencies in attitudes, personal bias, and resistance to change and to further research suggesting that emotional -laden on priori personal judgments were the real determine of policy. Underlying were feeling of pessimism and futility of cancer. Today there is still a controversy upon this issue of disclosing the diagnosis and prognosis to cancer patients. Attitudes in North America2 Northern Europe3 are more open than Southern Europe3 This study is the firs study in Thailand to explore the attitudes towards disclosure of diagnosis and prognosis of serious illness such as cancer and the practice of truth telling from the perspective of physicians. We hope that the data gained will help physicians in adjusting their policy on truth disclosure. MATERIALS AND METHODS The study is comprised of a survey by a questionnaire in 146 physicians in Ramathibodi Hospital. To survey the attitudes of physicians, our 19-itsm questionnaire which covered physicians' attitudes and practice towards cancer patients, and attitudes towards truth disclosure in general were sent to physicians in the hospital and 146 responses (63.5%) were returned Ten specialties were represented : internal medicine represented 29.5% of total returns, obstetrics and gynecology 17.1% surgery 13%, pediatrics 11% orthopedic 6.8%, psychiatry 6.2% rehabilitation medicine 41%, ophthalmology 4.1% family medicine 3.4% otolaryngology 2.7% and specialty not indicated 2.1% The sample of physicians responded had a mean age of 34.7 years(range 23-66 years) and was 69.5% men. Among these, 48.3% were faculty members and 51.7% were residents in training. Of all sample 33.6% involved regularly or often in treating cancer patients. RESULTS The majority (70.4%) of Thai physicians surveyed in this study thought that patients should be informed about the diagnosis of cancer. Among 129 physicians whose work involved in caring cancer patients and gave clear responses, 28 (21.7%) answered that they always told the diagnosis to cancer patients, 55 (42.7%) told most of their patients, while 39 (30.2%) told some patients, and only 7 (5.4%) rarely or never told the truth. The terms the physicians preferred to use to inform the patients were malignancy (43%), cancer (21.9%), and tumor (26.6%). However, lesser number (56.1%) thought they would inform the terminal cancer patients about their prognosis. The majority of the physicians (94.3%) also though that patients family or close relatives should be informed about the diagnosis of cancer. In practice, 116 physicians (86.6%) said they always informed relatives or did so in most cases. When asked whether they wanted to know the truth if they themselves were to have cancer 91% answered yes, and about 90% also wanted to know the prognosis if they had terminal cancer. However, only 64% wanted the diagnosis to be disclosed to their relatives who had cancer, and even less (48.9%) wanted their relatives to be informed about the prognosis in case of terminal cancer. The details of the results are shown in table 1. Factors found to have influences on the practice and attitudes towards truth disclosure of Thai physicians were gender, the degree of involvement with the care of patients with cancer in their work and different specialty in medicine. Male physicians tended to have more open attitudes in telling the diagnosis of cancer (76.8% VS 52.3%, P=0.024) and in telling the prognosis to terminal patients (63.5% VS 40.5%, P=0.042). Male physicians also had move open attitude towards informing their own relatives about the diagnosis and prognosis in terminal cancer (68% VS 21%, P=0.018; and 53% VS 16%, P=0.025, respectively). More of the physicians whose work involved directly or quite often in the case of cancer patients thought that patients should be informed about the diagnosis of cancer in comparison to other physicians (79.2% VS 66.3%). In Practice, 31% of physicians in this group always disclosed the diagnosis of cancer to their patients and another 37.8% told most of their patients while only 14.4% of other physicians always disclosed the truth, although 41.1% told most but not all the patients (P=0.0002). Physicians from different specialties also showed some differences in attitudes. In general, otolaryngologists, ophthalmologists, gynecologist and pediatricians tended to be more open, orthopedists and surgeons were in the middle and internists tended to be more conservative. Table 1 : Attitudes of Thai physicians towards truth disclosure Agree Disagree Unsure 1. Disclosure of diagnosis to cancer patients 100 (70.4%) 9(6.4%) 33(23.2%) 2. Disclosure of prognosis to terminal cancer patients 78(56.1%) 26(18.7%) 35(25.2%) 3. Disclosure of diagnosis to patients relatives 133(94.3%) 2(1.4%) 6(4.3%) 4. Disclosure of prognosis of terminal cancer to 132(95%) 4(2.9%) 3(2.1%) patients relatives 5. Desire to know the diagnosis if they had cancer 128(91.4%) 6(4.3%) 6(4.3%) 6. Desire to know the prognosis if they had 125(90%) 7(5%) 7(5%) terminal cancer 7. Disclosure of cancer diagnosis to ones relative 89(64%) 14(10%) 36(26%) 8. Disclosure of prognosis of terminal cancer 69(48.9%) 27(19.1%) 45(32%) to ones relative DISCUSSION In comparison with southern and Eastern Europe3, the attitudes towards truth disclosure of Thai physicians seem to be quite open, although not as much as those of physicians in North America and Northern Europe. The data shows that 70.4% of Thai physicians surveyed thought that patients should be informed about the diagnosis of cancer and 64.4% also did so in practice. These figures appear to be in the middle range when compared to 27% in Greece, and 97% in America3. However, the physicians studied seem to be reluctant in telling the prognosis to terminal cancer patients (56.1%). The gender difference in physicians' studies towards truth disclosure found in the study may reflect the tendency of female physicians to put more emphasis on the obligation to do what is expected to be the best for the patient, than on the importance of the patients autonomy. Degree of involvement with the treatment of cancer patients also affect physicians attitudes possibly because their experiences with cancer patients confirm the benefit of truth disclosure. The difference in attitudes among physicians from different specialties shows that these attitudes are affected not only by the cultural difference on the societal level but also by the different tradition of different subgroup in each society. In North America2 and Northern Eurpe,3 the prevalent open attitude towards truth disclosure reflects the predominant form of the physician-patient relationship with an emphasis on individualism, and patients' autonomy and participation4. In contrary, for most countries in Asia including Thailand, the physician-patient relationship is still predominantly a hierhachical one with an emphasis on reciprocity and cooperation on the patients' part4. However, in Thailand this hierarchical mode relationship is not as severe as other countries in Asia, since Thai culture has always put an emphasis on flexibility. Thai culture with the main influence of the southern sect of Buddhism, which stress on the result of ones own need on their lives, also seems to give a lot more importance to the rights and freedom of an individual than other Asian cultures. These reasons may explain why the attitudes towards truth disclosure in Thailand appears to be more open than other countries in Asia but less open than countries in North America and Northern Europe. REFERENCES
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