Table 1

Case scenario applying the ARCHES framework to a conversation with a patient’s family

Case scenario applying the ARCHES framework
An 80-year-old woman is diagnosed with advanced pancreatic cancer. There are no options for curative treatment. Before these findings are discussed with the patient, her sons approach the medical team. They are aware that she is likely to have a serious illness. They insist that she should not be told the diagnosis. They are concerned it would be too distressing for her and would hasten her death.
A	Acknowledge the request	“We understand that you have asked us not to tell your mother about her diagnosis. We would like to talk with you about this and to understand your perspective.”
R	Build the relationship	“When you ask us not to tell her her diagnosis, what is on your mind? Are there particular things that you are worried about? What is she like as a person? What things do you feel are most important to her?”
C	Find common ground	“We can appreciate from what you have said that she is an anxious person. Your priorities are for her to be as comfortable as possible and not to be put under mental distress. These are goals that we share with you.”
H	Honour the patient’s preference and outline harm of non-disclosure of information	“Many families ask us not to tell patients about their diagnoses. As in your case, it is because they love their relative and are worried about them. However, we need to recognise that most patients want to know their diagnosis. We need to honour her choice if she would like to know. When patients understand what is happening, they feel better, physically and mentally. They feel more connected with their family. They are able to be involved in choices about their care. If we try to hide a diagnosis, the patient often feels alienated and will eventually find out the diagnosis in an unsupported way.”
E	Provide emotional support and respond to concerns	“When we break bad news, we take care to do it sensitively. Your mother can always choose not to know her diagnosis and we will check we have her permission before starting the conversation. We will do it gently and in stages, giving her the opportunity to ask questions and to have her feelings and perspective heard.”
S	Devise a supportive solution	“Now that we’ve discussed the situation, we need to make a plan of what we do next. We feel that it is important that we now tell her what is going on. What are your thoughts?” (Outcome 1) “We are glad to hear that you appreciate our need to tell her her diagnosis if she would like to hear it. Our usual approach is to talk to the patient with her family in the room, if she would like that. We can go to see her now.” (Outcome 2) “It is useful for us to know that you are still worried. However, we do feel that it is necessary for us to tell her her diagnosis if she wants to know it. She will then have all the benefits we discussed of understanding what is going on. We appreciate that this is distressing for you. We would be grateful if you could join the discussion so that she has your support when we give her the information.” (Outcome 3) “It is useful to know that you are still worried. We appreciate that she has severe problems with anxiety and that she has previously said she would not want to know if she had cancer. We agree that it would not be in her best interests to have this conversation with her right now. However, if she shows curiosity about what is going on, we will need to reassess this decision.”