THE HEED FOR UNCERTAINTY a case for prognostic silence

Disclosure of prognosis in end-of-life care is a practice that is widely and increasingly recommended. However, prognostic disclosure is known to be resisted by many dying persons and by physicians, who instead engage in a collusion of silence discussing prognosis either not at all or in vague, indirect terms. Debates about the ethics of prognostic disclosure and non-disclosure have tended to focus on their relative benefits and harms, or on the psychological acceptability of prognostic information to dying persons. Unaddressed, however, is a more fundamental assumption upon which the practice of prognostic disclosure depends: that prognostic certainty is what dying persons ultimately need. In this essay I question this assumption. Reflecting on the experience of my father's recent death, I argue that prognostic certainty is not only unattainable but existentially irrelevant to many dying persons, and that prognostic uncertainty can be a greater need. Respect for individuals' existential need for uncertainty justifies prognostic silence and enables dying persons as well as the loved ones and clinicians who care for them to be open to new possibilities of finding meaning at the end of life.