Thursday, January 27, 2005

Your Truth: the Angry Denial Scenario

You have a 45 year old woman admitted to the hospital for uncontrolled dyspnea (difficulty breathing) related to metastatic lung cancer. You know that her increasing dyspnea is a sign she is getting closer to the end of her life. Her dyspnea has gotten progressively so severe during this hospitalization that you predict she has anywhere from one week to a month left to live and will very likely die during this hospitalization, as she is requiring heavy amounts of IV morphine to control her dyspnea. Although she is aware enough of the fact that she is dying that she has requested a palliative care room in the hospital, she refuses to discuss her death. In fact, she refuses to talk to anyone about anything. When people enter her room, she simply tells them to leave. She allowed one social worker to remain in her room long enough to ask a few questions.

This patient was divorced just prior to getting her diagnosis. She has an eight year old daughter from her previous marriage whom is now living with the father. The patient refuses to allow her daughter to visit her in the hospital. When the social worker asked if she would like to say goodbye to her daughter, the patient answered an angry "no." When the social worker asked if she'd like to write a letter to her daughter that the daughter could read later, the patient again answered with an angry "no." That is the most dialogue anyone has been able to have with her.

What would you do? Here are some options:

-Leave her alone as she clearly does not want any company.
-Sit quietly at the bedside, not forcing her to talk, but remaining present in case she wishes to talk.
-Try sending in other members of the team, such as a chaplain, to see if they have any better luck in getting her to talk.
-Ignore her stated wishes and go ahead and arrange for the ex-husband to bring the child in, so that the child may find some resolution for herself.
-Strongly encourage the patient to try anti-depressants and/or anxiolytics (anxiety meds).

Once again, I am not endorsing any one of these options, just listing a few ideas to get the ball rolling. How would you approach this patient and this scenario?

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