How do we handle patients like Nancy and her husband, Mark? In the clear face of a diagnosis of lung cancer, she clung to what she knew. In her mind, lung cancer manifested itself differently than how she presented. A diagnosis of lung cancer, in her mind, meant shortness of breath, a nagging cough, something more debilitating than her symptom of a sore back. Her confirmation bias kept her from seeing what we saw. Nancy agreed to treatment, so on some level she accepted her diagnosis. Yet the oncologist and I were both disturbed at her resistance to accepting that after years of smoking, and in spite of her lack of symptoms, she did in fact have lung cancer. Was it enough if she agreed to treatment even while she held on to her skepticism? If we gave her more information about her cancer would that lessen her denial? And the most difficult question of all is what the denial did for her. Was it protective? Reactive? A product of true misinformation? And finally, as we tried to convert her to understand the diagnosis were we actually confirming her bias?
This experience put me in mind of how we care for someone with an altered mental status. We instruct families to deal with the incessant questions of a confused patient by reorienting them. We tell them not to argue, to nod sympathetically as they tell them they are not in a hotel somewhere but that they are in the hospital. Yet denial in someone who is altered is more acceptable to us than someone clear-eyed and otherwise cognizant. How do we bridge the gap? How do we make it more comfortable all around? I’ll start by saying there is no clear path, nor is there a clear destination.
Denial can coexist with hope. The road forward does not have to be a straight line; instead it can be like a game of hopscotch. A patient may jump forward to accepting treatment, back to disbelief, sideways as they pause to consider chemo or radiation. In other words, there are many roads to the same destination. Many times we think as nurses and caregivers that we must keep our patients from taking any detours. Yet the opposite may be true. What we need to do is follow the detour the patient takes us on. We don’t have to force them into understanding their diagnosis the way we do. The communication challenge in this situation is to walk along beside our patients while supporting them and allowing them the room they need. It may sound like a cliché, but it is also sound empathic care to go to where the patient is. Even if it isn’t where we think they should be.
Nancy finished her radiation and chemo without ever fully acknowledging her diagnosis. After all, as she said, “It just doesn’t feel like cancer.”
Ann Brady is the symptom management care coordinator at the CancerCenter, Huntington Hospital, Pasadena, California.
1. Nickerson RS. Confirmation Bias: A Ubiquitous Phenomenon in Many Guises. Rev Gen Psychol. 1998;2(2):175-220.