“I’m just not sure I really need to do all of this. The chemo is so hard and now radiation, too. I need to think about it.” Jill said.

She shook hands with our radiation oncologist as she left. Jill was warm but aloof at the same time, as if she were dismissing everything the doctor told her but was too polite to say she thought it was all hogwash. “Thank you for taking time with me.” She added. This was only our first encounter with her, but her parting comment matched our prediction that she would not return. She must not understand how serious it is.

Everyone was surprised when she came back for a SIM to set up her treatment plan. She fit the profile of a patient in denial, not unusual in cancer treatment. We’ve seen many patients like her before. And we know we cannot force people to be treated. She is in denial.

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Then, in spite of going through treatment planning, a kind of commitment in itself, she failed to show up for her first treatment. When we called to check in, she said, “Oh, I guess I just got the days mixed up.” She is not taking this seriously.

Not only did she seem to not understand, she was also a bit flaky. That was the updated version our team used to explain her behavior. She is kind of flaky.

She made it in for her first 5 treatments, floating in late, joking with our other radiation oncology patients. Her treatment was on track and all appeared to be going well. But in her second week she missed 2 treatments in a row, then a few more the following week, saying it was because she was exhausted from chemo. The radiation oncologist told her the number of missed treatments was going to impact the effectiveness of her treatment. Her response demonstrated true concern, again all very appropriate. “I see. I’ll be sure not to miss anymore.” She was very convincing and everyone believed her sincerity even while we wondered if she would continue her radiation. Maybe she gets it now.

The thing was there was a difference between how things seemed to be with her and how they actually were. One red flag is just one flag, but several flags demand attention. We talked amongst ourselves: her nurse navigator, physician, symptom management nurse, rad/onc nurse. All of us had begun to wonder the same thing: Was there more than noncompliance going on?