A Patient in Disbelief or "Denial" of Illness
In the following interactions with Mr. Carter, you will get to follow the course of his illness by way of observing the interaction between him and his oncologist at four stages of his disease course: At his initial diagnosis, at a well-patient follow up, at a point of disease recurrence and transition to palliative care and at the end of life. You will see in each of these scenarios particular strategies used by the doctor to manage the interaction.
Mr. Carter - Diagnosis
The patient is Mr. Carter, a 56-year-old man who has been coughing up blood. He has had a bronchoscopy, and in this interview the doctor has to tell him that the results show that he has small cell carcinoma of the lung.
The patient's reaction makes the disclosure of the news more complicated: he appears somewhat cavalier—and at times confrontational—and in strong "denial" about the potential seriousness of his symptoms. This gap between his perception and the medical reality is a serious communication issue.
What to watch for
You will see that before disclosing any information, the physician checks the patient's actual understanding of the medical situation, finding indeed that the patient was downplaying or is uninformed about the seriousness of his illness. The physician then acknowledges to the patient that it might not have seemed serious to him (the patient), implying that it was indeed serious. This is one strategy to bridge the gap between the medical facts and the patient’s attitude toward his illness. Note also how the doctor addresses the patient's emotions with empathic responses, resisting the temptation to otherwise find some way to reassure the patient, and possibly create unrealistic expectations or on the other hand to be led into confronting the patient's disbelief.
Mr. Carter - Two-Year Follow Up
Mr. Carter is seen two years after completion of his initial treatment.The patient, you will remember, at the time of his initial diagnosis, was in considerable denial about his disease. His treatment, however, was uneventful, and two years later he is free of disease and feels that he has been cured.
The patient is currently free of evidence of residual disease. However, as we've seen previously, Mr. Carter tends to minimize the significance of negative and unfavorable information. Thus as the chance of future recurrence is significant, one has to tread carefully, supporting the patient and being hopeful, but not making unrealistic promises about the future. So in this scenario, we're once again dealing with possibly unrealistic expectations, and the pitfall of becoming complicit in them.
What to watch for
Note how the physician chooses to agree with how the patient is doing now, but does not fall into the trap of denying the past or prognosticating the future.
Mr. Carter - Transition to Palliative Care
Mr. Carter is in the hospital receiving radiotherapy treatment for palliation of CNS metastases. The physician approaches him to discuss the progression of his disease and DNR orders. The patient continues to express feelings about the course of his illness that must be acknowledged.
Denial can be an ingrained and habitual coping mechanism, as it is with this patient. It is important to remember that it often masks fear and/or anxiety, an awareness that can help the physician be supportive in an otherwise potentially frustrating situation.
What to watch for
The patient makes repeated attempts to change the subject or avoid the discussion—in essence to change the facts. Note how the physician sticks to the facts of the illness while still acknowledging the patient's feelings, and in this way is able to bring the patient around slowly.
Mr. Carter - End Of Life
Mr. Carter is in the hospital receiving radiotherapy treatment for palliation of CNS metastases. The physician must discuss DNR orders with him. The patient continues to express feelings about the course of his illness that must be acknowledged.
In most hospitals now when the end of life is near, it's strongly encouraged that the physician discuss DNR with the patient. Of course, this can be an uncomfortable conversation and there's considerable variation in opinion as to the best time to do it.
What to watch for
Notice the physician's use of empathic techniques such as acknowledgement and repetition to validate the patient's feelings.
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