Clinicians' lived experience of concealing bad news: a qualitative study in Malaysia and the UK

Abstract

Objective: Clinicians acknowledge that receiving bad news is challenging and life-altering, while recognising that candid communication is needed for effective patient care. In some cultures, patients' relatives commonly ask doctors to hide bad news, with the intention of reducing psychological distress. Although well-intentioned, concealing information has harmful consequences for the patient, their caregivers and the healthcare team. Our study focuses on clinicians' lived experience of this phenomenon. Previous research has provided some exploration of how practitioners navigate this dilemma. Our study aims to deepen understanding, with two goals: improving cultural competence when facing this dilemma and equipping clinicians to navigate this professional challenge.

Design: As this study explored lived experience, we drew on the methodology of phenomenology. To allow deep insight into how clinicians navigate this dilemma, participants took part in focus groups and semistructured interviews. Interviews were audiorecorded, transcribed and analysed using thematic content analysis. The study was strongly influenced by the work of Braun and Clarke, who emphasise the strength in subjectivity in qualitative research. Reporting was guided by the COnsolidated criteria for REporting Qualitative research.

Settings: Recognising that this practice varies significantly across cultures, we recruited clinicians who had experienced a cultural challenge: medical students receiving a UK curriculum in Malaysia and the UK and international medical graduates working in the UK.

Participants: 26 medical students and 16 international medical graduates participated.

Results: For our participants, concealing diagnoses created multiple sources of personal distress. Three major themes emerged: moral discomfort, dilemma and powerlessness. Sympathetic distress at the impact on the patient was stark. However, conflicting personal and professional values created uncertainty. Some of our participants shared the relatives' concern that diagnostic disclosure could potentially harm the patient. Even when our participants wanted to disclose diagnoses, they felt underequipped for communication challenges and faced coercion to conceal information, generating a professional dilemma and a sense of powerlessness.

Conclusion: The crucial next step is for medical education to acknowledge that requests to conceal diagnoses happen. We need to provide a communication strategy for tackling this phenomenon, which upholds the patient's right to knowledge while maintaining collaboration and trust with the patient's family. Furthermore, this dilemma highlights shortcomings in our current approach to teaching medical ethics. Our findings offer globalised healthcare education an opportunity for self-awareness. Learning from and respecting global variation shines a light on our biases, allowing progress towards curriculum decolonisation.

Keywords: MEDICAL EDUCATION & TRAINING; MEDICAL ETHICS; PALLIATIVE CARE.

Figure 1. Coding tree of major and minor themes related to clinicians’ lived experience of concealing bad news.