title: Reducing collusion between family members and clinicians of patients referred to the palliative care team.
abstract: OBJECTIVE
  Collusion refers to a secret agreement made between clinicians and family members to hide the diagnosis of a serious or life-threatening illness from the patient. Our goal was to reduce the rate of collusion among the family members of patients referred to our institution's palliative care service such that 80% of patients would be aware of their diagnosis within four weeks of referral to the service. We aimed to achieve this target within six months of starting the project.
  
  
  METHODS
  We undertook a clinical practice improvement project using the methodology of Brent James et al of Intermountain Health to see how we could reduce collusion among clinicians and family members of patients with advanced-stage cancers. This strategy included creating awareness among patients, family, and clinicians of the problems with collusion from the standpoint of each group; adopting an empathetic and compassionate approach to communication; using pamphlets; seeking patients' views; empowering families to reveal the truth to patients; and supporting patients and families until the last moment of each patient's life.
  
  
  RESULTS
  Between December 2004 and June 2008, 655 patients with advanced-stage cancers were referred to us. We were able to maintain an average awareness rate of nearly 80% of patients starting in February 2005, when we implemented awareness measures.
  
  
  CONCLUSIONS
  The deeply entrenched cultural practice of collusion can be changed with simple strategies based on the universal principles of medical ethics and best practices.
authors.affiliation: James Alvin Low, MBBS, FRCP, is a Senior Consultant in the Palliative Care Service within the Department of Geriatric Medicine, Alexandra Hospital, Singapore. E-mail: james_low@alexhosp.com.sg .
authors.forename: James Alvin
authors.initials: JA
authors.lastname: Low
authors.forename: Sim Lai
authors.initials: SL
authors.lastname: Kiow
authors.forename: Norhisham
authors.initials: N
authors.lastname: Main
authors.forename: Koh Kim
authors.initials: KK
authors.lastname: Luan
authors.forename: Pang Weng
authors.initials: PW
authors.lastname: Sun
authors.forename: May
authors.initials: M
authors.lastname: Lim