#10 Dealing with Denial
Dr. Daniela Lamas is a pulmonary and critical care doctor who shares her misgivings about the blunt news she delivered to a patient who was in total denial of his advanced cancer and very short life expectancy. Her guest opinion piece was published in the New York Times on October 6, 2021 and recently re-appeared in Doximity. The piece is titled, ‘You’re Dying,’ I Told My Patient. I Wish I Hadn’t.” y Patient Didn’t Need Honesty
One can hardly confess and beat herself up an a larger or more diverse stage than that!
Discussions directly with patients regarding the end-of-life can be tough and emotional. The situation with this patient was particularly hard for the physician as the patient was essentially lost to follow-up for the year following the initial diagnosis of his cancer. Despite multiple attempts to reach the patient, he did not begin treatment for colon cancer and only showed up at the hospital again with widely metastatic, painful, end-stage disease. Even then, he seemed to deny his own precipitous decline in condition and requested pain medicine so that he could go home and watch a ballgame on TV.
The physician rather bluntly told the patient that he was dying and might not make it through the night. He reacted quite angrily and basically threw her and her residents out of the room. Dr. Lamas reflected honestly about why she made that statement and the reasons she regretted it.
“In the most generous version of that night, my goal was to give my patient the information he needed so that he could reach out to those he loved, to say whatever he would want to say with the knowledge that his time was short. That was one piece of my response. But I also responded to him with my own anger, at the avoidable nature of this tragedy, at how denial had turned deadly. This man was scared and he was going to die of a disease that might have been cured. And I could do nothing about it. When I told him that he had only a few hours to live, I allowed my frustration to obscure the reality of his suffering. And I caused harm as a result.”
I would offer a few words to the good doctor. She judges the patient and herself rather harshly and I hope she has the grace to forgive herself and him as well. She recognized that the patient was in denial, a common defense mechanism used by humans to shield themselves from pain and suffering. Our patients have the autonomy to make their own decisions about whether to begin or reject treatment. For whatever reason, this gentleman dropped out of sight and in the doctor’s view, denied himself a possible cure. But the doctor is also lying to herself. There is no way to know that the chemotherapy would have actually cured him. He might have died in a car accident on the way to the chemo infusion center. None of us really knows when our patients or ourselves will die.
The other aspect that made the physician so uncomfortable about the news she delivered was the emotion behind it. She thought the man should have returned for life saving treatment. She felt helpless because the patient hadn’t done his part and angrily asked for pain meds and discharge.
We frequently see angry patients and family members who grow frustrated and believe that high drama, anger, and threats in the clinical setting will garner them attention and get them what they want. For whatever reason, this man with end stage metastatic colon cancer, barely maintained on pressors, could not face that fact and lashed out with anger. It may have been the best he could do. Then, the doctor mirrored his anger.
From my soon-to-be-published book, Changing our Thoughts about Difficult Patients: a Guide for Physicians and Healthcare Providers, “Mirroring is the behavior in which one person unconsciously imitates the gestures, speech patterns, or attitudes of another person. The behavior originates during infancy when babies mirror the emotions of their parents. In theory, this unconscious imitation allows a person a greater connection and understanding with the individual they are mirroring. It also allows the individual who is being mirrored to feel a stronger connection with the other individual. Mirroring of emotions is common in our interactions in the clinical setting.
When a patient approaches us with deference and courtesy, it is so easy to respond with the same. Alternatively, when a patient approaches us with aggression and anger, we tend to mirror those emotions. Antagonism and self-righteousness seem to swell in us before we even understand why something is happening, such as a treatment plan being rejected.”
Of course, Dr. Lamas felt frustrated and angry about everything she thought her patient should have done to save himself and how he should face the reality of his impending death. She regrets the very human thoughts and emotions that motivated her rather blunt statement to the patient because she believes she made him angry by piercing his shield of denial. She’s wrong about that too. She can’t control what her patient or any other human thinks. Another person might have accepted the news and called for his clergy person or his family. This particular patient had a thought like: I don’t believe what these white coats are telling me. The patient’s own thoughts caused him to respond with denial and anger. Over 1300 people commented on the opinion piece in the NYT, some agreeing with her approach and some disagreeing.
Interactions with patients are complex and most certainly, Dr. Lamas and her residents learned an important lesson about “honesty” at the end of life. She wrote, “I wish that I had done it differently. I could have paused and told him that yes, he was going to go home. I could have simply been there with him and said nothing at all. That small kindness might have done more for him than the truth.”
Thank you, Dr. Lamas for sharing this story. There is no way you could have foreseen your patient’s response. Your regret and shame are not necessary or helpful. They, are however, unavoidable parts of the human experience and all of us as physicians have felt this way at one time. You and your residents learned a lot. I hope that you can forgive your patient and forgive yourself. Every day we are all just trying to do it a little better than yesterday.
