Prognostic Disclosures to Children: A Historical Perspective

Prognostic disclosure to children has perpetually challenged clinicians and parents. In this article, we review the historical literature on prognostic disclosure to children in the United States using cancer as an illness model. Before 1948, there was virtually no literature focused on prognostic disclosure to children. As articles began to be published in the 1950s and 1960s, many clinicians and researchers initially recommended a protective approach to disclosure, where children were shielded from the harms of bad news. We identified 4 main arguments in the literature at this time supporting this protective approach. By the late 1960s, however, a growing number of clinicians and researchers were recommending a more open approach, where children were included in discussions of diagnosis, which at the time was often synonymous with a terminal prognosis. Four different arguments in the literature were used at this time supporting this open approach. Then, by the late 1980s, the recommended approach to prognostic disclosure in pediatrics shifted largely from never tell to always tell. In recent years, however, there has been a growing appreciation for the complexity of prognostic disclosure in pediatrics. Current understanding of pediatric disclosure does not lead to simple black-and-white recommendations for disclosure practices. As with most difficult questions, we are left to balance competing factors on a case-by-case basis. We highlight 4 categories of current considerations related to prognostic disclosure in pediatrics, and we offer several approaches to prognostic disclosure for clinicians who care for these young patients and their families.