Collusion in doctor-patient communication about imminent death: an ethnographic study

To discover and explore the factors that result in the "false optimism about recovery" observed in patients with small cell lung cancer.

A qualitative observational (ethnographic) study in 2 stages over 4 years.

Lung diseases ward and outpatient clinic in a university hospital in the Netherlands.

35 patients with small cell lung cancer.

False optimism about recovery usually developed during the first course of chemotherapy and was most prevalent when the cancer could no longer be seen on x-ray films. This optimism tended to vanish when the tumor recurred, but it could develop again, though to a lesser extent, during further courses of chemotherapy. Patients gradually found out the facts about their poor prognosis, partly by their physical deterioration and partly through contact with fellow patients in a more advanced stage of the illness who were dying. False optimism about recovery was the result of an association between physicians' activism and patients' adherence to the treatment calendar and to the "recovery plot," which allowed them to avoid acknowledging explicitly what they should and could know. The physician did and did not want to pronounce a "death sentence," and the patient did and did not want to hear it.

Solutions to the problem of collusion between physician and patient require an active, patient-oriented approach by the physician. Perhaps solutions have to be found outside the physician-patient relationship itself--for example, by involving "treatment brokers."