Background: diagnostic uncertainty is ubiquitous. Its communication to patients requires further investigation.

Aims: To determine: 1) What is known about how and why diagnostic uncertainty is communicated in acute care; 2) evidence of the effects of (not) communicating diagnostic uncertainty in the acute setting; 3) associated ethical issues.

Methods: systematic review of Medline, Web of Science and SCOPUS for (acute or emergency care) AND (diagnostic uncertainty) AND (ethics OR behaviours). Critical interpretive synthesis and ethical analysis were conducted.

Results and conclusion: Nine studies (primarily surveys and interviews) were identified. Doctors are not trained in communicating diagnostic uncertainty and perceive it to have negative effects on patients; however not communicating diagnostic uncertainty can disempower patients, resulting in delayed/missed diagnoses or inappropriate use of resource.

References

1. Rising KL, Papanagnou D, Mccarthy D, et al. Emergency Medicine Resident Perceptions About the Need for Increased Training in Communicating Diagnostic Uncertainty. Cureus. 2018; 10: 1-12.
2. Gerrity M, Earp JAL, DeVellis RF, et al. Uncertainty and Professional Work: perceptions of physicians in clinical practice. American Journal of Sociology. 1992; 97: 1022-51.
3. Katz J. Why Doctors Don’t Disclose Uncertainty. The Hastings Center Report. 1984; 14(1): 35.
4. Moskowitz AJ. Dealing with Uncertainty, Risks, and Tradeoffs in Clinical Decisions. Ann Intern Med. 1988; 108: 435-49.
5. O’Riordan M, Dahinden A, Akturk Z. Dealing with uncertainty in general practice An essential skill for the general practitioner. Quality in Primary Care. 2011; 19: 175-81.
6. Simpkin AL, Schwartzstein RM. Tolerating uncertainty—the next medical revolution? New Engl J Med. 2016; 375(18).
7. Bhise V, Rajan SS, Sittig DF, et al. Defining and Measuring Diagnostic Uncertainty in Medicine: A Systematic Review. Journal of General Internal Medicine. 2018; 33: 103-15.
8. Wen LS, Espinola JA, Mosowsky JM, et al. Do emergency department patients receive a pathological diagnosis? A nationally-representative sample. Western Journal of Emergency Medicine. 2015; 16(1): 50.
9. Kirmayer LJ, Groleau D, Looper KJ, et al. Explaining medically unexplained symptoms. The Canadian journal of psychiatry. 2004; 49(10): 663-72.
10. Cox CL, Fritz Z. Should non-disclosures be considered as morally equivalent to lies within the doctor–patient relationship? J Med Ethics. 2016; 42(10): 632-5.
11. Parascandola M, Hawkins JS, Danis M. Patient Autonomy and the Challenge of Clinical Uncertainty. Kennedy Institute of Ethics Journal. 2002; 12(3): 245-64.
12. Flynn D, Knoedler MA, Hess EP, et al. Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review. Academic Emergency Medicine. 2012; 19(8): 959-67.
13. Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Medical Decision Making. 2015; 35(1): 114-31.
14. Council GM. Guidance on professional standards and ethics for doctors: Decision making and consent. Manchester; 2020.
15. Simpkin AL, Armstrong KA. Communicating Uncertainty: a Narrative Review and Framework for Future Research. Journal of General Internal Medicine. 2019; 34: 2586-91.
16. Alam R, Cheraghi-Sohi S, Panagioti M, et al. Managing diagnostic uncertainty in primary care: A systematic critical review. BMC Family Practice. 2017; 18: 79.
17. Cox C, Miller B, Kuhn I, et al. Diagnostic uncertainty in primary care: What is known about its communication, and what are the associated ethical issues? Fam Pract. 2021.
18. Dixon-Woods M, Cavers D, Agarwal S, et al. Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol. 2006; 6: 35.
19. Depraetere J, Vandeviver C, Keygnaert I, et al. The critical interpretive synthesis: an assessment of reporting practices. International Journal of Social Research Methodology. 2020;1-21.
20. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 2001;454.
21. Miao M, Dahm MR, Li J, et al. Managing Uncertainty During the Communication of Diagnostic Test Information Between Patients and Clinicians in Australian Emergency Care. Qual Health Res. 2020; 30(8): 1287-300.
22. Schoenfeld EM, Goff SL, Elia TR, et al. Physician-identified barriers to and facilitators of shared decision-making in the Emergency Department: an exploratory analysis. Emergency Medicine Journal. 2019; 36(6): 346-54.
23. Ackermann S, Heierle A, Bingisser M-b, et al. Discharge Communication in Patients Presenting to the Emergency Department With Chest Pain : Defining the Ideal Content Discharge Communication in Patients Presenting to the Emergency Department With Chest Pain : Defining the Ideal Content. Health Commun. 2016; 31: 557-65.
24. Rising KL, Powell RE, Cameron KA, et al. Development of the Uncertainty Communication Checklist: A Patient-Centered Approach to Patient Discharge From the Emergency Department. Acad Med. 2020; 95(7): 1026-34.
25. Schoenfeld EM, Goff SL, Elia TR, et al. The Physician-asStakeholder: An Exploratory Qualitative Analysis of Physicians’ Motivations for Using Shared Decision Making in the Emergency Department. Acad Emerg Med. 2016; 23(12): 1417-27.
26. Beresford E. Uncertainty and the Shaping of Medical Decisions. The Hastings Centre Report. 1991; 21(4): 6-11.
27. Newman DH, Ackerman B, Kraushar ML, et al. Quantifying Patient-Physician Communication and Perceptions of Risk During Admissions for Possible Acute Coronary Syndromes. Annals of Emergency Medicine. 2015; 66: 13-8.e1.
28. Hess EP, Knoedler MA, Shah ND, et al. The Chest Pain Choice Decision Aid: A Randomized Trial. Circulation: Cardiovascular Quality and Outcomes. 2012; 5: 251-9.
29. Black G, Sheringham J, Spencer-hughes V, et al. Patients ’ Experiences of Cancer Diagnosis as a Result of an Emergency Presentation : A Qualitative Study. PLoS ONE. 2015; 18(8): 1-17.
30. Henry MS. Uncertainty, responsibility, and the evolution of the physician/patient relationship. J Med Ethics. 2006; 32: 321-3.
31. O’Neill O. Some limits of informed consent. J Med Ethics. 2003; 29: 4-7.
32. Daniels N. Justice, health, and healthcare. Am J Bioeth. 2001; 1(2):2-16.
33. Fritz Z, Cox CL. Integrating philosophy, policy and practice to create a just and fair health service. J Med Ethics. 2020; 46(12): 797-802.
34. Han PKJ. Conceptual, Methodological, and Ethical Problems in Communicating Uncertainty in Clinical Evidence. Med Care Res Rev. 2013; 70: 14-36.
35. Politi MC, Clark MA, Ombao H, et al. Communicating uncertainty can lead to less decision satisfaction: A necessary cost of involving patients in shared decision making? Health Expect. 2011; 14: 84-91.
36. Almond S, Mant D, Thompson M. Diagnostic safety-netting. I. 2009; 59(568): 872-4; discussion 4.
37. Tompson A, Nicholson BD, Ziebland S, et al. Quality improvements of safety-netting guidelines for cancer in UK primary care: insights from a qualitative interview study of GPs. Br J Gen Pract. 2019; 69(689): e819-e26.
38. Gillon R. Ethics needs principles--four can encompass the rest- and respect for autonomy should be “first among equals”. J Med Ethics. 2003; 29(5): 307-12.
39. Gillon R. Defending the four principles approach as a good basis for good medical practice and therefore for good medical ethics. J Med Ethics. 2015; 41(1): 111-6.
40. Varelius J. The value of autonomy in medical ethics. Medicine, Health Care and Philosophy. 2006; 9: 337-88.
41. Montgomery (Appellant) v Lanarkshire Health Board (Respondent) [2015] UKSC 11.
42. Richard C, Lajeunesse Y, Lussier MT. Therapeutic privilege: Between the ethics of lying and the practice of truth. J Med Ethics. 2010; 36: 353-7.
43. Johnston C, Holt G. The legal and ethical implications of therapeutic privilege - is it ever justified to withhold treatment information from a competent patient? Clinical ethics. 2006; 1: 146-51.
44. Fallowfield LJ, Jenkins KB, Beveridge HA. Truth may hurt but deceit hurts more communication in palliative care. I. 2002; 16:
    297-303.