Communication and awareness about dying in the 1990s

Since the 1960s communication and awareness about dying in modern western societies have been topics for debate, with a considerable amount of literature on the need for open communication and the strategies which can be used by health professionals to improve their communication with patients facing a terminal prognosis. Despite the difficulties of comparing studies using different methodologies and the additional problems of ascertaining patients' knowledge and awareness about their impending deaths, the trend is clear. In advanced industrial societies there is increasing evidence that doctors have shifted from a policy of ‘withholding’ to a policy of ‘revealing’ to the patient his or her terminal prognosis. This change in medical practice is further supported by other data which show an increase in the percentage of those patients who were aware they were dying from chronic diseases, especially cancer. However, despite the perceived trend towards open disclosure of the patient's terminal illness, recent studies have suggested that in their daily encounters with dying patients health workers employ ‘conditional’ rather than ‘full open disclosure’. Such moderating strategies in discussing the patient's prognosis may be employed despite open awareness of a patient's prognosis. This paper examines this apparent paradox by analysing the complex tensions and conflicts of such communication through a discussion of existing literature on modes of communication and patient awareness.