A 52-year-old man diagnosed with advanced pancreatic cancer comes to the oncologist for follow-up. His cancer is unresectable, and he has been receiving palliative treatment for the past 3 months. The patient has had multiple previous discussions about his prognosis. He has lost 22.6 kg (50 lb) and now feels too weak to play with his children. During the visit, he says, "I am a survivor and know I can beat this. I'm going to do whatever I can to be around for my kids." Which of the following is the most appropriate response to this patient at this time?
Five stages of grief: terminal illness | |
Denial | Denies illness, severity, or prognosis |
Anger | Directly expressed or may be displaced onto physician or others |
Bargaining | Tries to "strike a bargain" in return for surviving illness |
Depression | Becomes sad, detached & hopeless |
Acceptance | Comes to terms with impending death, "at peace" |
The physician is confronted with a patient who is in denial about his terminal illness and remains unrealistically hopeful about surviving pancreatic cancer. Patient reactions to terminal illness are variable and mediated by coping style, personality, culture, values, and religious beliefs. Patients may go through 5 stages in coping with terminal illness (denial, anger, bargaining, depression, acceptance). However, patients do not necessarily experience all the stages of grief or in a prescribed sequence.
Hope, even when unrealistic, can be a powerful mechanism to help patients cope with pain, fear of death, and the ordeal of treatment. If the patient's denial is not interfering with receiving necessary medical care or discussing his goals regarding end-of-life care, it should not be confronted. The physician should be supportive of the patient's hopeful perspective, and at the same time, engage him in discussion regarding important end-of-life care decisions.
(Choices A, B, and D) These responses confront the patient's denial by refuting hope and challenging his self-concept that he is a "survivor" who can beat cancer. They focus on what the physician thinks is important, rather than acknowledging where the patient is emotionally. These statements may be perceived as unsupportive and harsh and have a detrimental effect on the patient's ability to cope with the stress of a terminal illness. If the patient's denial is not interfering with his care, it should not be confronted.
(Choice E) Patients cope with terminal illness differently and should not be pressured to deal with any emotional issue unless it is interfering with medical care or significant relationships.
Educational objective:
Denial is commonly experienced by patients diagnosed with terminal illness and can help them cope with overwhelming thoughts and feelings. When denial is not interfering with receiving end-of life care or discussing goals of care, it should not be confronted.