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Friends of Flo - Veracity and Truth Telling

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“React at the right point, to the right degree, for the right reason.” A patient asks “am I going to die?” How do you respond? Today on our Friends of Flo podcast we discuss veracity and truth telling. We explore an article by Dr. Margaret Rising discussing cultural communication and the most effective ways to communicate based on different cultures.
Speaker 1:

This episode of Friends of Flo is brought to you by NCLEX mastery. If you're a nursing student and you're about to take your NCLEX, you need to go to the app store right now and download NCLEX mastery.

Tess:

Hello and welcome back were Friends of Flo and it's been awhile since we've got a chance to do a podcast because of the holidays so we are getting back at it. My name is Dr. Tess Judge Ellis and I have with my colleagues all of us colleagues

Andrew:

Dr. Andrews Whitters right here

Rebecca:

and I'm Dr. Rebecca Porter

Tess:

and so we're all nurses. And if you've not joined us before welcome aboard. We've been friends for a long time and colleagues and we like to solve problems and empower nurses through a scholarship approach to practical and really real issues and today we are talking about truth telling or when our ethicist in residence expert Dr. Porter says is veracity.

Rebecca:

Hi. Good morning. Well I got talking to some nurses a little while ago and they were telling me a story that they were feeling really troubled. I would use the word morally distressed because their patient was asking and the family was saying, will my husband survive this injury? And the nurses were pretty clear that the patient was not going to survive. And the physicians were not telling the patient or the family. The patient was unconscious. The family the truth and the family were asking the nurse is he going to die. And based on their years of experience and what I would call practical wisdom as well as their own knowledge. They were pretty sure this patient wasn't going to survive and they really wanted to start helping the family prepare for that, their loved ones death. So I went into the literature.

Tess:

Yes, Rebecca did indeed go into the literature. So we had about nine articles to read that Rebecca sent out. And of course here we are. I have Rebecca just print them out and give them to me and Andrew has his on his phone that he's reading through and so he's a generation of that.

Rebecca:

I'm a literature searching junkie.

Tess:

I mean within ten minutes she had this lit search for us done and so...

Rebecca:

Tessie found this really great article

Tess:

Of all of the articles when we sat and had coffee and talked about this. Of all the articles popped out to me is one by Margaret Rising who called truth telling in an element of culturally competent care at end of life. And this is in the Journal of Transcultural Nursing 2017 volume 28 issue 1 page 48 to 55 it's not long at all. But really this article combines everything because I really love and got into cultural competence about 15 years ago or so. And then of course end of life care is really important and also truth telling. Which got the voracity piece so of these articles I liked this one a lot.

Rebecca:

And can I just back up a bit here. When we think about being a nurse, we think about the core values or virtues that we enact as people and particularly as nurses and those are our relationship with our patient is probably the most key thing, key driver in our work and the second thing is how we communicate with our patients. So true. And the third thing is truth telling. Being an honest person and when we balance all of those things the relationship that we have with our patient how we communicate with our patients and their families and one another and the virtue of telling a truth of veracity. That's one of the core principles, ethical principles in health care.

Tess:

So relationship, patient relationship. Some are arguing now that's the cornerstone value of nursing that unites all of us nurses.

Rebecca:

Right, so if you're put into a position that your relationship has been compromised because of a communication problem or because somebody isn't telling the truth. Where does that leave you feeling and how do you work through this that's what we want to talk about today. Tessie, Margaret Rising.

Tess:

Dr. Rising she's interesting she comes has lots of letters behind her name like all of us do in nursing and I think she's a doctoral student out in Oregon, but I don't know for sure as I was we actually corresponded with her to see if she would call in, but she's teaching at this very minute, but she's actually trained as an attorney. She has a JD so it's kind of interesting.

Rebecca:

At the beginning of that article, she wrote a really interesting scenario, do you wanna just...

Tess:

Yeah, I'll read the scenario. And I think it's interesting because when we talked about...anyway I liked this article a lot. The case study that she brings up is a Chinese grandmother is in the hospital and dying of cancer. Her daughter serves as medical interpreter for several days. It is thought, but not confirmed that the daughter is not telling the patient everything the doctor says about the grandmother's poor prognosis. Alone with the patient and the medical interpreter on the phone the bedside nurse asks, do you have any questions for me? To which the grandmother asks, am I going to die?

Rebecca:

So have you had a patient ask you that?

Andrew:

Yes. Not so much with cross cultural that mean,s but what this article pulls out I think to the third point you brought up veracity and truth. I think that there are often times providers can hide behind the truth using a vernacular or complicated medical words

Tess:

Jargon

Andrew:

Jargon, right. And so when patients pick up on it I think they become confused, anxious and those hospice or end of life situations I've been involved with. You can see that the eyebrows start to raise and arms become cross, people become frustrated. The patients family perspective and that's in the nursing wheelhouse then to sit down or at least my approach is to sit down with the family and then define those words. So for example if you have a chest X-ray and there is the word"opacity", well what is that.

Tess:

Well there's a little something there

Andrew:

And so it's an opportunity for nurses then who do have relationships with patients and families to say, hey we might be looking at possible pneumonia here

Rebecca:

Right, so when you are with...I think it's slightly different for nurse practitioners. I know when I was a nurse practitioner I was the one that was telling people a diagnosis and sometimes we would get into, how are you going to live your life, but for nurses who are frontline who are at the bedside and are standing with the team when misinformation is given or you walk into the room after the physician team has been in there and you ask your patient so what did they tell you today. And they look at you puzzled and well they said something about something on my chest X-ray.

Tess:

Right. How do you get at the truth.

Rebecca:

How do you get at that truth and going back to, so that's one question and is it within our legal and certainly our ethical purview to disclose information to patients. Some physicians believe that or nurse practitioners who are in acute care believe that it is only their responsibility to give test results or to discuss things so what are you gonna tell that bedside nurse from that scenario. How do we get at this practical wisdom and still use our legal and ethical frameworks to be in this kind of dilemma.

Andrew:

Well ethically I think in this situation

Tess:

Which one?

Andrew:

The Chinese one...well even the one I gave with a definition of if there's a bedside nurse who is getting questions from patients saying what exactly is this or what was I told. I think that's a point where you should go back to your you know prescriptive provider whoever and then say, hey can we just define this as a team really quick and you know wrap up this plan of care. Let's button this up so that the patient can understand it and by the way is it okay if I just go ahead and tell the patient what's what's going on. I mean, identify it like sort of a team communicator in that situation

Tess:

But it gets back to some of the things that I liked about this article and I don't know if I can go back to it but it gets to any particular cultural humility she does a great job with that, bringing up cultural humility that and I wish I could get to a good discussion about that.

Rebecca:

Well we can talk about what the dominant culture is and if we look at what the dominant culture is in United States. In most hospitals it's white, English speaking, one of the three major world religions. And that's how, that would be my world view.

Tess:

And that is where bioethics is informed, right? This autonomy, truth-telling

Rebecca:

And that's a very important thing is that not every culture values autonomy in the same way that Americans value autonomy. So if you go to the Middle East or to Eastern religions or the East and place, for instance in China. Autonomy is not a valued principle of ethics. So it's your family...

Tess:

And the other thing that she brings out here in this article too Rebecca is the manner in which we communicate. So she talks a lot and there's cultural competence and understanding cultures there's the high context culture and then there's a low context culture.

Rebecca:

Tell me more about that Tess

Tess:

Well like a high context culture values family decision making hierarchical of elders being more in respect than not values indirect communication not direct communication and that kind of respect of elders among other things. How you communicate is really important in a high context culture and Chinese high context cultures versus here in the U.S. and Canada. And then some of the Scandinavian cultures where low context where we're kind of are more direct communication we tend to not be as reverent and respectful of our elders as in a high context culture. We value equality and equalness. And so she brings out nicely in this article about how communication and how you communicate is just as important. And really what I think is interesting is really the standard of care and best practice is to inquire what the patients know. Right. What they want to know and who else they want to know and how they want to know it

Rebecca:

And then the other part that comes in Turkish from a Sharia court that I'm reading by Kate Hodgkinson in nursing philosophy is that what do we do when patients aren't asking the question that you think that they should be asking or the family isn't asking what you think they should be asking. Maybe they don't know to ask or maybe they're afraid to ask and so that comes from that low context versus high context

Tess:

Right. And it's what it is is a cultural clash of values and that's what cultural humility asks us to do is to understand our own biases and assumptions and where they come from. So if I have a bias an assumption that I want to know and you deserve to know that's where distress comes from is that not necessarily being able to filter where that pit of your stomach feeling that says you ought to know this is important you should know this

Rebecca:

So that's a really good point then to stop and think, from whose perspective am I looking at this. I go back to my reading and learning to understand some of Aristotle Aristotle and philosophy and he taught...

Tess:

Seriously. Aristotle

Rebecca:

Yeah.

Tess:

Okay looking to put on my nerd hat right now Rebecca. But go ahead(laughs)

Rebecca:

Allow me, humor me Tess.

Tess:

Aristotle, very cool

Rebecca:

Aristotle talks about our practical wisdom. The word that is used is furnish us but we have to learn about practical wisdom and what is practical wisdom? It's information that learning passes on from generation to generation. It's not something that you learn in a book today, but it goes on to talk about and that's what you were getting at Tess. Acting at the right point to the right degree for the right reason.

Tess:

Right.

Rebecca:

And so that's the basis of moral reasoning. So if you stop and think...

Tess:

Say it again Rebecca

Rebecca:

We act at the right point to the right degree for the right reason.

Tess:

And that changes over time.

Rebecca:

It changes in context and it changes all the time

Tess:

And this is where the assessment is so important and rising brings us out to that it should be we should regularly assess where people are at and what they want to know.

Rebecca:

Right.

Tess:

And it's through relationship and through communication style and being kind.

Rebecca:

So what do you do? What are you going to do at the bedside, Tess or Andrew? I don't work at the bedside anymore. But when you're in a room with your patient and the son says to you or through the interpreter you are...you learn that they don't want the family does not want the patient to know their diagnosis or prognosis.

Tess:

I would say the first thing you do is take a breath and see where you stand on this. If your gut is saying oh my god I don't know what to say or if it's saying I don't agree with this or you find yourself getting angry and frustrated which is what I would think you would mean by moral distress...

Rebecca:

Or feeling really guilty because you know something that they don't know right and they have a right to know what you think.

Tess:

Right. So I think that's the humility part of it. You know I think when you're confronted with a real clash of values and there's no more sacredness then end of life and these kind of intense and sacred moments that we hold with patience and being and privileged to be in those positions. And it's about understanding yourself. And so when you feel like your when you feel upset when you feel guilty when you feel you should be doing something, that's when you kind of realize this is a clash it's more about your own emotions. And so it's focusing on the patient and perhaps saying something like,"Do you need to know what's helpful for you right now?" And listening being with the person and putting a little duct tape on your own mouth.

Rebecca:

So one of the things when going back to the son that says I don't want my mother to know. How do you respond? And I thought about this one of the things I got is I still can honor truth telling by saying I will not directly tell your mother that she is dying. I won't offer that information. But if she asks me I will sit and talk to her. I will not, I cannot openly lie.

Tess:

Correct.

Rebecca:

There is a way when we go back to that example that Dr. Rising has her paper on her abstract

Tess:

You know what do we do with this case example.

Narrator:

Here at NCLEX Mastery we love nurses and especially nursing students, but we need your feedback about this podcast. If you have ideas on topics or questions you want us to answer, shoot us a message, leave a comment, go to our Facebook page and just tell us what you think because we want to help you in the most specific way that you need that help. Thank you so much.

Tess:

All right we're back now with Friends of Flo, Tess Judge-Ellis,

Andrew:

Dr. Andrew Whitters right here,

Rebecca:

And Rebecca Porter

Tess:

And we're Friends of Flo and we were talking about truth telling and in particular this case from example on the paper from Margaret Rising. Go ahead.

Rebecca:

So going back to how that paper opened with the example Tess can you just sort of summarize it really briefly.

Tess:

Sure. There's a woman who grandmother who's Chinese she's dying of cancer in the hospital. Eventually the nurse is alone with the woman. And it's been kind of clear that the woman's not necessarily been told of her diagnosis. And so when the nurses by the interpreter who happened to be her daughter so the nurse bedside nurse asks the grandmother through the medical interpreter,"Do you have any questions for me?" to which the grandmother asks,"Am I going to die." And we were trying to talk about ways that you could approach this and I think we started out with cultural humility which is first of all recognize your own, oh my gosh

Rebecca:

What do I say what do I do now.

Tess:

And you know let's just say you know we're not perfect with this. You know you're never going to know exactly what to do when this happens.

Rebecca:

And there isn't going to be a perfectly right answer.

Tess:

No in fact Rising goes in and offers a couple different ways to approach it actually.

Rebecca:

So I just want to add in here before you go into that that no matter what route you take through these discussions it probably isn't going to feel really good. It's called your moral remainder.

Tess:

You're such a nerd

Rebecca:

Oh, I love it though

Tess:

A moral remainder, which means that you were always on a journey, aren't we?

Rebecca:

Were always on a journey. There's always junk leftover that we will have to process.

Andrew:

It sounds like they were good at math though too if there's a remainder.

Rebecca:

A decimal point

Tess:

Big and small"r", you know I mean if you had to give it a context. Well you know and I guess going back to like how can you help the new nurse. First of all Rising goes on to say in this paper and bring up that you know oftentimes patients know when they ask this sort of thing and there's a wisdom that people bring forward with them, all right. So take it home. If you have these episodes take it home with you do your own work, journal. Talk to a wise person, a chaplain, an older nurse that you respect absolutely. Do a little personal work and then set it aside

Rebecca:

But you're at the bedside Tess.

Tess:

I know.

Rebecca:

And new nurse practitioners as well.

Tess:

For sure I do a lot of counseling that way and nobody's...It's only because you know I've been doing this, been a nurse for 30 years and NP for 20 years.

Rebecca:

Are you 50 years in nursing?

Tess:

No, 30 years as an RN, this year actually

Rebecca:

Really?

Tess:

St. Louis U. So a couple options for this...

Rebecca:

So when patients ask"Am I dying?" they might...

Tess:

You know she brings up an interesting point in the paper about hope and that sometimes when you people or cultures that don't want to tell the full truth don't want to extinguish hope.

Rebecca:

That's really important Tess, I think that sometimes you can say what are you hoping for. And people will say, I've had friends or patients who have said well they told me there's no hope and there's never not hope. It's what we are hoping for when providers tell somebody there's no hope no hope for you now. What they're saying is that from my perspective my hope is that I was going to cure this disease that you would not die of this, but there's no hope of that now. My perspective from thinking about this over the years as a nurse is that there is always hope there is hope for a peaceful end of life. There's hope for helping somebody finding meaning in every day and a day that they're dying. There's always hope. There's a poem...Hope is like a feather and it's a beautiful poem it talks about how a feather flits down from the sky and changes direction. And that's our hope when people are asking a question. So when you're at the bedside when you're in that exam room with your patient and they ask, am I'm dying? We're going to answer that question intuitively. We're going to use our own practical wisdom from other experiences that we've had. But it's really important like Tess said earlier to be able to reflect on that and think about this to journal it to talk about it with people you respect about how these decisions are made and what kind of person do you want to be and what kind of person do you want to be in that relationship with that patient at that point in time. And so it's not something that you can just fly in a room and that's sometimes when these questions come up it can be in the middle of a nurse giving a Bed Bath and the patients will say, do you think I'm dying? And it's those intimate conversations it can be when you are taking a glass of water to a patient and they say,"Do you think I'm dying?" And that's when you sit down and I think what are the first things you say is tell me more. And that's one of my when I'm trying to take a breath when I'm trying to think oh what the heck do I say now is not the answer except working other questions like, tell me more.

Andrew:

I think that's a patient advocacy role that nurses can take on is asking your patients what they understand and then having them define their goals based on what they know about their diagnosis and if that diagnosis needs additional definition to use the resources that are available to define it for them in some cases even even with asking patients, well, what are your goals? A patients like, I don't know. That's where even a bedside nurse can say well let me reach out to my social worker and let's talk about this some more.

Rebecca:

I think it's important to ask people what this means to you rather than what you understand when you say understood them asking for understanding is like putting somebody on the hot seat. And instead if we can get people to, what does this mean to how you're living your life right now for sure. Because I don't think people want to be put on the hot seat. They're already there. If they are in your office or lying in a bed they are already really vulnerable. And if we can turn that question into what does this mean for your life right now.

Tess:

Well that's our charter as nurses is to be present in the lived experience. I'm gonna go back to that cultural humility as you know we have our biases and assumptions. How can we not you know were raised in our own culture. And you know if you're raised in a strong truth telling autonomy people ought to know kind of culture and you bring that always with you. You will be in a great deal of distress because of that.

Rebecca:

So when that son or the daughter through the interpreter says to you,"Stop. I don't want them to know this, I'm not telling them that. One of the avenues then is to say, tell me more. Tell me about your relationship with your mother. Tell me more about your mother. What does she like, what's her life been like. How has she reacted to difficult things in the past. How do you handle things as a family.

Tess:

Right, is it better to I mean to tell truth and cause disruption in the family? Or is it better to engage the daughter so that the communication style is consistent with their family values to move forward in uncovering what really is going to work best for the mom.

Rebecca:

And again that comes back to that place of humility and compassion. So we're not going to say if you are a new nurse if you are a staff nurse, how are you going to approach your physician team with this when they want to just go and barge in and start having a conversation cause they have a limited time and you have limited time. You've got several really sick patients that you are running around to or you've got a waiting room for the people waiting to talk to you. How are you going to interact. How do you stand up and have another kind of virtue which is courage.

Tess:

And I think this is part of the podcast, is empowering nurses to say, first of all your assessment is moving forward to get to know your patient and where they are at and their knowledge of things and explaining things to people and taking time to do that. Which I think is the movement from novice to more expert journeyman expert is, OK I understand the pumps, I've got my day figured out been decades since I've been an impatient nurse, but my schedule my day the pressures that I have to put bear and then think I wonder you know I wonder where they're at with what's going on. I just know that they had a troublesome visit by the team or by their doctor and I better go back in and follow up and see if they have any questions. Just be with them in a certain presence

Rebecca:

And the word,"tell me more"

Tess:

Tell me more. Tell me more and I don't know Andrew, what do you have to say about that?

Andrew:

I agree. I think I would encourage a new nurse to think about his or her resources that are available to care for their patient. So if there is this ethical situation at hand where there's cross cultural issues and a true knowledge deficit to pull in a nursing diagnosis I would encourage the new nurse to look at the whole body of resources that are available in a care situation. So I'm thinking not just another provider liaison but a social worker, a chaplain. If time is a constraint for the nurse pull in a social worker. Social workers usually...

Rebecca:

A chaplain.

Andrew:

That's sort of their wheelhouse to sit down and chat with the patients a little more, send out those tentacles of...

Rebecca:

And palliative care, people are usually really good at these conversations as well.

Andrew:

I would just take a step back and just think a little more globally about what else do I have in my arsenal of resources for this current situation.

Rebecca:

And very importantly I think we should close with the importance of caring for yourself. After you have been through an emotional discussion or what you find is a very distressing conversation with a patient or a family member is how are you going to care for yourself right now in the moment to be aware of how you were feeling that I feel guilty, I feel angry, I feel upset. This is what I need to care for myself in that moment. How am I going to get through if it's impacting me how am I going to get through the rest of my shift and to really think about it do I need to go get a cup of coffee. Do I need to go sit in a stairwell for five minutes to gather myself and think about this. What am I going to do on my way home? What will I be thinking about on my way home and what will I be telling my best friend to do. Because I am my best friend and so that self care part I think that we've always got to circle back to how am I looking after myself. Being mindful of my own responses and be mindful of my own responses to the situation. And then when you get home one of the really important things both at home and at work is to be in a place of gratitude.

Tess:

Oh clearly.

Rebecca:

And to tell people at work when they've helped you. I'm grateful, thank you for that. And on your way home is to think of two or three things that you were grateful for about the day. Research has shown that it's really important when the best thing we can do for ourselves is to either talk about or write down three things that we're grateful for that day. And it really does help us process things.

Tess:

You know there's no easy answers to these things and these are difficult situations that leave you with that...

Rebecca:

Moral remainder

Tess:

That kind of weirdness that says I went through something and it left me feeling like there was no perfect answer. And so you returned to being kind and you were with someone we were being with them in distress

Rebecca:

And I think it is your way of being a nurse. That we live in a world of wanting certainty. We want to be certain that we've always done the right, the best, the true. And our lives are not like that.

Tess:

We're really waxing poetic right now

Rebecca:

I know, but I think it's important....

Tess:

You're doing a good job, doing a good job folks keep it up. Nursing is a privilege and a lovely, lovely profession.

Rebecca:

It's hard work.

Tess:

It is hard work but it is...

Andrew:

It's frustrating at times. Oh my gosh. Yeah. Go ahead.

Tess:

Well the system makes it that way.

Andrew:

That's true.

Tess:

You know, it's the system and this is why nursing is so great. Is we're going to change the system. It may take decades, but nursing's voice it's time is right now and these and discussions like this on philosophical and bringing in all this type of knowledge from even Aristotle as Rebecca(laughs) even Aristotle.

Andrew:

And mathematics with remainders

Tess:

And mathematics with remainders. This is so important because if we don't have this basis we lose and we get sucked into the system

Rebecca:

We get sucked into the business of medicine

Tess:

And as nurses we can't we have to keep moving forward and...

Rebecca:

And we have to as nurses stand up and part of it is taking the time to reflect. I think that the moral stress we feel the moral remainders we fear are all teaching us...

Tess:

We should welcome them! It's happy yuckiness because we're growing and stretching

Rebecca:

Right.

Tess:

It's when you stay and wallow in it and it ruins your day. And you don't talk to anybody and you seclude yourself with a bottle of wine and bad hallmark. Well actually I love Hallmark movies, but Hallmark movies and you don't grow and learn and talk to others, right Andrew?

Andrew:

Agreed.

Tess:

Okay(laughs) I think we better sign off for now, don't you?

Rebecca:

So everybody take care reflect on what you're doing. You know what you're doing and be good and be kind to yourself.

Tess:

And keep your eye on the patient. Take a deep breath and enjoy caring of others.

Andrew:

This is Andrew telling you to innovate, agitate, and educate.

Narrator:

Friends of Flo is brought to you by NCLEX Mastery go to the app store right now, download NCLEX mastery. And before you leave, if you could just share this with your nursing friends, tell them about us. Leave us feedback, go to our facebook page, tell us what you liked, tell us what you didn't love so much, be nice; but thank you so much. We really appreciate you.