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Independents' Day

Parents' silence over carcinoma upsets daughter

Three GPs discuss a tricky problem

Case history

Pauline is 47 and had bowel cancer eight years ago. Three years later

she presented with right upper quadrant pain. Ultrasound showed gallstones, but liver secondaries were eventually discovered by MRI.

She remained well on chemotherapy for several years and continued working. Recently she developed ascites, which was drained three times.

It is clear Pauline is entering the terminal phase, but she continues chemotherapy and has resisted contact with the palliative care team.

She will talk about her treatment, but not her long-term outlook.

Her daughter Jade is 16 and attends surgery distressed. She thinks

her mum is dying, but neither parent will talk about it. She asks about Pauline's prognosis and says she has things she wants to say to her

mum, which she is worried she will never get a chance to say.

Dr Sarah Humphery

'I can talk generally about how a cancer patient feels'

This will require sensitivity and time. It will be an advantage if I know the family well and how they interact. As the mother, father and daughter are all my patients I will have to consider both their individual needs and their needs as a family.

I would allow Jade time to talk and cry if she felt able to. I would sympathise, but would have to explain about confidentiality. I would, however, be able to talk generally about how a person can feel with cancer and their fears and that it can take time for them to feel able to talk about this. Pauline may not have come to terms with the prognosis.

I would explore with Jade what she wanted to say and how she could do it. I would encourage her to write it down and think it through beforehand. I would suggest she chose a time when her mother wasn't too tired and they had plenty of time. I would find out how her father was coping and if she felt able to talk to him first.

I would explain that she may be frightened about upsetting her mother or may find it hard to discuss certain subjects. This is normal, but it is important to talk and not regret anything later. I would offer to arrange a family meeting at their home or to speak to her mother if she felt this would help.

Dr Patrick Wills

'I have to represent both Jade and Pauline'

Soap opera stars, members of the Royal Family and Prime Ministers seem to expect their medical details to be public knowledge. Despite this, patient confidentiality occupies a central place in medical practice.

Even some more ordinary patients, however, seem to get more confidentiality than others. As people approach the end of their lives and become more dependent on others, this value is often eroded.

Jade is quite right her mother is dying. It is totally reasonable for her to be concerned and distressed and to seek information.

Her mother may be in denial about her illness but she is still able to decide and determine when and whether medical information should be shared with others. She is also entitled to believe what she wishes about her illness and prognosis.

The consultation with Jade should start with pointing out these limitations, namely the problems with patient confidentiality and the possible conflict of interest. As the GP I am trying to represent both Jade and Pauline. This is a problem for the family doctor. Would a counsellor or psychotherapist be able to see members of the same family, having knowledge about one client which affects another, but which confidentiality would prevent them sharing?

This will be a difficult consultation. Jade is only 16. She is technically an adult but is vulnerable due to her youth and dependent still on parents. It is important to find out what other support is available to her ­for instance, where is Dad?

After a taxing consultation with Jade, I need to review Pauline. Pauline needs help and medical support as the terminal phase of her illness takes over. At the moment she avoids talking about the long-term outlook for her illness. However, I may have been able to gain Jade's permission to share her concerns with Pauline.

There are purely medical issues to deal with as well such as the continuation of chemotherapy and symptom control. She may be amenable now to support from the palliative care team.

If she is not, then she would require extra support from her GP ­ me.

Dr Rachel Pryke

'Her parents probably want to protect her'

Confidentiality is not really an issue. Although I'm not able to divulge details of Pauline's prognosis, Jade knows the main facts and that ultimately she will die.

What does Jade want to say to her mum? Rather than an emotional goodbye, is she concerned about missing information, perhaps about her childhood, or about assuming responsibility as the remaining female of the household? Has she been harbouring a deep-seated anger for a long time, but now feels cheated, because the cancer has prevented her addressing it? These issues may have a powerful effect on her acceptance of her mum's death.

We often fear how people will react when talking about death. Many parents feel ill-equipped to explore difficult issues with their children and say nothing. Even though Jade is now 16 her parents probably see her as a little girl and feel they are protecting her from the truth.

Jade could write her thoughts in a letter to her mum. She could try hedging around activities that lead towards the issues on her mind. For example, she could say she was putting old photos in an album and was wondering about....

Her parents might be happier to discuss things if Jade shows she is mature enough to deal with it. She could say she has read up about her mum's condition on the internet, then say 'I know you don't like to discuss things much, but I wanted to say this'. Support from a bereavement organisation may be useful.

I would remind Jade that, much as she is facing the loss of her mother, she will still have a father, and should try to invest in her relationship with him. She may find a religious approach helpful or she could try to attend surgery with her parents as a third party might make talking easier.

While watching for depressive symptoms, I would try to develop a rapport with Jade as she is heading for troubled times.

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