Cultural dimensions of anxiety and truth telling.

Ms. S is a 42-year-old Russian woman who immigrated to the United States two years ago; she recently was diagnosed with stage III-A breast cancer. She underwent a partial mastectomy six weeks ago and was scheduled to begin adjuvant chemotherapy with doxorubicin and cyclophosphamide. Ms. S neither speaks nor understands English, and throughout her diagnosis and initial treatment, she appeared anxious and overwhelmed, wringing her hands or grabbing her sister’s arm for reassurance. Her major and only support system is her sister, who works as a live-in housekeeper for a family. The women have friends but they did not feel comfortable asking them for any help. During initial consultation and treatment work-up, the sister translated for both the physician and the nurse practitioner (NP) managing Ms. S’s care and treatment plan. Via translation, the physician and NP educated the patient about her diagnosis, the treatment plan, and the possible or expected side effects of the chemotherapeutic regimen. She was given prescriptions for antiemetic medications (i.e., lorazepam, prochlorperazine, and granisetron) and instructed on their use and possible side effects. Ms. S arrived unaccompanied to the treatment center to receive her first cycle of chemotherapy. The oncologist and NP were present in the clinic but were seeing other patients. The chemotherapy nurse scheduled to begin treatment for Ms. S sought out the NP to report that the patient had arrived without an interpreter, and thus she felt she could not treat the patient without a way to validate informed consent. The NP immediately enlisted the services of a hospital interpreter, who relayed that the patient neither was aware of her diagnosis nor did she know that she was about to receive chemotherapy. Ms. S was under the impression that she had a rare infection of her breast and would require antibiotic treatment every three weeks. She had not taken the prescribed prechemotherapy antiemetics because she could not read the English instructions. The NP contacted Ms. S’s sister, who informed her that she did not want Ms. S to know about her diagnosis. She was afraid that if Ms. S understood that she had cancer she would “give up.” Ms. S’s sister expressed that in the Russian culture, a diagnosis of cancer is a death sentence, and she was insistent that her sister not be told the truth. She also explained that her sister often was anxious and overwhelmed and knowing the truth may make her unable to carry out life-saving treatments. The sister explained that she was not able to be present for her sister’s treatments because she was afraid she would lose her job. As the time passed for the interdisciplinary staff to make a decision, Ms. S became more anxious as evidenced by wringing her hands and pacing the floor. She told the interpreter that she just wanted to take the bus and go back home.