Death and Denial. Need Advice

[TwoLayi, ADN, BSN, RN]

I am looking for advice on how to respond to a patient who is in denial about their terminal illness. Patient is in an acute care setting and prognosis gives the patient about two weeks to live. MD has communicated all this to the patient and family. Patient has chosen NOT to go on hospice or change code status to DNR. And yes social services has been involved to discuss all this with the patient and family.

The problem I am having as a nurse is responding to the patient when they talk about the future and getting better. I know denial is a stage in death and dying, so do I just play along with this fantasy? Usually, when this patient talks about the future, I just smile and nod. I feel like I am almost lying to the patient, but I don’t want to be cruel either. Any advice on what I might say to the patient to help them be more accepting?

[Hoosier_RN, MSN]

Ask social services how to approach. They should be able to help you to direct the conversation

[JKL33]

1 hour ago, TwoLayi said:

The problem I am having as a nurse is responding to the patient when they talk about the future and getting better. I know denial is a stage in death and dying, so do I just play along with this fantasy? Usually, when this patient talks about the future, I just smile and nod. I feel like I am almost lying to the patient, but I don’t want to be cruel either. Any advice on what I might say to the patient to help them be more accepting?

It isn't our job to help them be more accepting on our timetable in a situation like this. Another way to look at it is that they are in the process of being accepting, but, as you have acknowledged, that often may begin with a period of denial.

Denial is sort of a protective mechanism; it serves a functional purpose, whether conscious/intentional or not. That purpose is to give the patient the minimum emotional fortitude to face each moment and the time to let things sink in a little.

Is there a practical reason why the patient's current stage of grief is causing a particular problem? For example, if there were an important legal matter involved (custody of children, for example) then specific intervention becomes more compelling. Or if the patient is verbalizing things that convey a complete misunderstanding of what was said, it is important that they be given the benefit of another chance to hear the information so that misunderstandings can be clarified. The nurse can have a role in helping to clarify specific factual misunderstandings. For example, if a dying patient about to receive a course of palliative chemotherapy tells the nurse that they expect to be able to return to work next week or makes statement along the line of expecting to be cured, that is the nurse's opening to say something like, "We can talk about that if you would like. Did you have an opportunity to talk with your team about the plan for this new round of chemotherapy? Yes? What kind of information were they able to give you?" Etc. If the nurse assesses that the patient does not understand the goals of treatment, this should be shared with the provider service as soon as possible.

This is just me, but if the patient seems to be musing aloud as a means of hearing a response from you, I would likely gently say something like, "I know you've had to take in a lot of information in the past few days. How do you feel about your understanding of it all...do you have questions, or...?"

[TwoLayi, ADN, BSN, RN]

On 2/3/2020 at 4:32 PM, JKL33 said:

Is there a practical reason why the patient's current stage of grief is causing a particular problem? For example, if there were an important legal matter involved (custody of children, for example) then specific intervention becomes more compelling.

This patient had expressed a fear of dying in the hospital, prior to this prognosis. And at this point, the patient could go home on hospice. Also after the prognosis, the patient bought online tickets to event that is 6 months away, so I was a little concerned about that.

On 2/3/2020 at 4:32 PM, JKL33 said:

"We can talk about that if you would like. Did you have an opportunity to talk with your team about the plan for this new round of chemotherapy? Yes? What kind of information were they able to give you?" Etc. If the nurse assesses that the patient does not understand the goals of treatment, this should be shared with the provider service as soon as possible.

This is just me, but if the patient seems to be musing aloud as a means of hearing a response from you, I would likely gently say something like, "I know you've had to take in a lot of information in the past few days. How do you feel about your understanding of it all...do you have questions, or...?"

Thank you for the examples! Now I know where to start.

[NRSKarenRN, BSN, RN]

How to Talk to Your Patients about End-of-Life Care

http://www.ihi.org/communities/blogs/how-to-talk-to-your-patients-about-end-of-life-care

Quote

End-of-life care conversations are rarely easy. Even seasoned health care professionals can have difficulty finding the right words. With this in mind, IHI developed a new toolkit to help address some of the challenges of engaging with patients and families in end-of-life care conversations over time. In the following interview, one of the authors of IHI’s How to Talk to Your Patients about End-of-Life Care: A Conversation Ready Toolkit for Clinicians describes how to use the case studies and sample dialogues in the toolkit.

http://www.ihi.org/resources/Pages/Tools/Conversation-Ready-Toolkit-for-Clinicians.aspx

Free registration required.

[MunoRN, RN]

The issue with the Full Code status should be easy enough since it's clearly not ethical to offer a patient a futile treatment, but I get that for whatever reason this isn't the practice everywhere.

As for the denial, I'll initially clarify what reality is to ensure that their poor understanding is of their own choice rather than a lack of information, then after that I don't go out of my way to change their mind but I also don't play along with it if the patient it brings it up.