Discussing Prognosis: “How Much Do You Want to Know?” Talking to Patients Who Do Not Want Information or Who Are Ambivalent

Dr D had decided to try to ask patients how much they wanted to know about prognosis. Mr X, a 44-year-old man with large B-cell lymphoma, who had relapsed less than 1 year after receiving cyclophosphamide, doxorubicin, vincristine, and prednisone and rituximab, said he did not want to talk about prognosis at all. He said, “The numbers don’t really matter—I have to do what you tell me gives me the best chance.” Mrs Y, a 68-year-old woman with stage III breast cancer coming for her first visit after starting adjuvant chemotherapy, could not seem to decide whether she wanted prognostic information. “I’m worried about knowing, and I’m worried about not knowing,” she said. “What do you think I should do?” A description of a patient-centered approach for discussing prognosis rather than the commonly used strategies of realism, optimism, and avoidance has been published in this issue of the Journal of Clinical Oncology. This approach recommended that oncologists start by asking patients a straightforward opening question, “How much do you want to know about prognosis?” and the approach was illustrated for a patient who was prepared to have an explicit discussion. However, approximately 20% of patients do not want to discuss prognostic information or only want to hear good news. How should an oncologist, like Dr D, handle that situation? This article describes how to approach patients who either do not want to discuss prognostic information or who are ambivalent—who simultaneously want to know and do not want to know.