'Don't Tell Dad'
Mr E is 74 and was admitted two weeks ago with metastatic pancreatic cancer. He is jaundiced and increasingly drowsy, and the team believe he has days to weeks left. He has mild cognitive impairment but is orientated to person, place and time and answers questions coherently. His daughter, who is his next of kin, takes you aside: 'Please don't tell Dad it's cancer. He'd give up. We've always kept bad news from him.' Twenty minutes later Mr E asks you directly: 'The doctors keep whispering. Am I dying?'
1. How do you respond in that moment? Give the words you would use and the reasoning behind them.
Read the worked answer
Do not lie, and do not deflect ('you'd need to ask the doctor' abandons him at the worst possible moment).
Step 1 - acknowledge and explore 'That's a really important question, and I want to get it right for you. Can I sit down? What's made you ask that?' This tells you what he already knows and fears - most patients do know - and stops you giving more than he wants.
Step 2 - check how much he wants to know 'Some people want all the details, and others just want the headlines. Which would be most helpful to you?' This respects his autonomy rather than imposing information.
Step 3 - honest, gentle, without abandoning hope 'You are very unwell. The cancer has spread and the treatment isn't holding it back any more. I'm not going anywhere - we'll keep you comfortable and we'll keep talking about what matters to you.' Do not invent a prognosis in days unless the medical team has agreed it.
Step 4 - stay in the silence. Let him react. Then: 'What worries you most?' and 'Is there anything you want sorted out?'
He has capacity for this decision and is entitled to information about his own body. Deception would damage the trust that makes the rest of his care possible.
2. How do you handle the daughter's request without dismissing it?
Read the worked answer
Acknowledge first, and genuinely 'You're trying to protect him - I can see how much you love him and how frightened you are.' Her request comes from care, not control, and if you treat it as an obstacle she will stop talking to you.
Be honest about what you cannot promise 'I can't promise to keep information from him. If he asks me directly, I'd have to be honest - otherwise he'll know I'm hiding something and he'll lose trust in all of us. But I won't go in and ambush him.'
Explore the fear underneath
- What has she seen before - did someone in the family 'give up' after bad news?
- What is she afraid he will do or say?
- Is there a cultural or family norm at play that matters here?
- Does she fear being the one who has to say it?
Offer a way forward A joint meeting with the consultant, with you present, so he hears it once, clearly, and she hears what he actually says - often a greater relief than she expects. Offer to be there for her afterwards.
Confidentiality The information is his, not hers. Her preference carries real weight as his next of kin, but it does not override his right to know. If conflict persists, involve the consultant and, if needed, the clinical ethics committee or the Decision Support Service.
3. What do you do after the conversation - what is documented, and who else is involved?
Read the worked answer
Document factually and promptly
- That his daughter asked you not to disclose the diagnosis, and what she said.
- That Mr E then asked you directly, and the exact question.
- What you said, and what he said in response - his understanding, his fears, his wishes.
- Any concerns, questions or requests he raised (e.g. where he wants to be cared for, who he wants told).
Record his own words where possible. Do not record your interpretation as fact.
Inform others
- The nurse in charge and the medical team, so the next person is not caught out and he does not have to repeat the conversation.
- Request a medical review of what he has been told and what he understands.
- Refer to palliative care/specialist nursing if not already involved.
- Ask about an advance healthcare directive and his preferred place of care.
Follow up Go back later in the shift - the first conversation is rarely the whole conversation. Support the daughter too; she is bereaved in advance and may now need someone to talk to. Flag it in handover so the next shift knows the position.