A patient presents with a scalp hematoma from a remote fall. When you press on it, it feels very soft but is not swollen. You are confused, and order a CT, which shows complete lysis of the bone,. Further workup suggests metastatic renal cell carcinoma. The patient is avoidant on history and keeps explaining away the findings and concerns. Hours later, while he is awaiting a bed upstairs, he reveals that a year ago his doctor suspected renal cell carcinoma but he refused a workup.
This patient suffers from denial. Whether that is a perfect term is debatable. In this case it is severe but so often denial seems to overlap with avoidance, perhaps even procrastination. It is at times the unwillingness to address an unpleasant reality. In medicine all too often we judge “denial” as a break with reality but we need to understand it as a human experience. Denial is the way some patients try to grasp onto hope. Go read Arthur Miller’s Death of a Salesman if you want a literary exploration of denial and hope.
We shouldn’t always oppose denial. Don’t argue over code status. If they want to be full code don’t gripe about them at the nurse’s station. They are dying. If knowing they will get 30 minutes of CPR in the end gives them comfort then let them have that consolation. If the patient-centered reasons aren’t enough, remember that practicing code situations only makes you better at it.
The literature is accumulating articles portraying denial as a positive thing. Denial mitigates terror and allows patients to continue to function. But in the emergency department we sometimes see patients at an earlier stage, where denial gets in the way of potentially curative treatment. So what should we do?
Accentuate the positive
Without distorting the truth, emphasize the safety and efficacy of your recommendations.
Build a relationship of trust by genuinely connecting as people
Spend some time getting to know them as people. Share anecdotes of those who have had good experiences, which not only illustrates safety but also displays your connection to patients. As emergency physicians we will not get long-term rapport, so build it for your consultants, whose expertise and caring we should commend to the patient (assuming we can do so truthfully).
Tools of persuasion – allowing an “out” lowers the cost of an “in”
Finally, point out that they can always choose to stop treatment later. That way they can say yes without feeling stuck. By giving them an “out” you are lowering the cost of going “in.”
Ultimately, denial is their choice. We will not be able to convince everyone to face the unpleasant reality but we should use the skills and techniques that best address their frame of feeling.
Take Home Points:
-Denial is often a way for the patient to have hope
-Give such patients hope through emphasizing the positives of treatment
-Connect on a genuine, human level
-Remind them they can change their minds later