Tuesday, October 16, 2007

Emotional Rollercoaster, or The Power of Denial

We've all heard the term "denial". It has several meanings:

  1. A refusal to comply with or satisfy a request.
    1. A refusal to grant the truth of a statement or allegation; a contradiction.
    2. Law The opposing by a defendant of an allegation of the plaintiff.
    3. A refusal to accept or believe something, such as a doctrine or belief.
    4. Psychology An unconscious defense mechanism characterized by refusal to acknowledge painful realities, thoughts, or feelings.
    1. A refusal to accept or believe something, such as a doctrine or belief.
    2. Psychology An unconscious defense mechanism characterized by refusal to acknowledge painful realities, thoughts, or feelings.
  2. The act of disowning or disavowing; repudiation.
  3. Abstinence; self-denial. (Dictionary.com)

Definition 3b is the one most people think about when they hear the word "denial". It's a Freudian term which has made it into popular English. It's a pretty self-explanatory term, after all; a person is "in denial" when they refuse to acknowledge the truth of a (usually negative) situation. Denial is necessarily an unconscious defense mechanism; in order to protect the mind from a painful truth, it's pushed aside. Your mind cannot be allowed to consider the truth, whatever it may be, so instead you think "Well, that just can't be true."

It's a term that is far overused, in my opinion, just like many other Freudian terms (Oedipus complex, anyone?) It can be part of the stages of grief, but it tends to be temporary. After all, most of us eventually cave in when we're shown hard evidence of what we fear. A rational person can only deny a situation for so long before the truth becomes indisputable.

For the past week, I've had a patient in my care who has diffusely metastatic cancer. He's got enough life-threatening issues that he has to stay in the ICU, but there's nothing super-acute. If I had to give my totally accurate, super-informed, expert opinion, I'd give him a few weeks to months to live. His kidneys have failed, but he can get dialysis for that; his gut has failed, but he can get TPN for that; his lungs are stable, and his mind is clear. The dialysis makes him hypotensive, and so do the drugs we give him to cure his arrhythmias, so he's still on pressors. Despite all this, it's not unimaginable that he could leave the ICU, go to rehab, and possibly even home for a brief time. Sadly, this will only be brief. His tumor burden is extensive, and chemo left him without kidneys. It's unlikely that oncologists will resume chemotherapy which was only for palliation after such a dreadful reaction.

One of the hardest parts of seeing my patient every day is having to deal with his wife. Last week, she accused all of us of being totally incompetent, of not communicating with each other at all, and of not doing the things medically necessary for her husband. She accused me of not giving her all the information available when I told her that my team would evaluate the chest x-ray on rounds, and that until then I didn't have an official report to give her. She tries to pin us down on specific times for procedures over which we have no control: "So, in a couple of hours? Then if it's seven now, it'll be done by nine?" Only, after a week in the ICU, she still tries to do these things, even after we've done our best to explain why it might take more or less time to obtain even a simple chest x-ray.

She has accused the oncology team of not explaining her husband's prognosis, even though they have spent hours discussing his disease. She then accused them of hiding from her that chemotherapy can cause immunosuppression and kidney failure, even though the chemo consent form clearly documents these risks. She accused us of not performing dialysis quickly enough over the weekend, even when we explained that he hadn't qualified for dialysis over the weekend. What about drug X, my friend works in a pharmacy and he suggested it? Why didn't you perform this [palliative, symptomatic-only procedure] as soon as he got here, we've been asking for it for WEEKS? Why aren't you feeding him [even though he's vomiting bile and obstructed], he hasn't eaten for so long and oh, you just don't think it's imPORtant?

In turn, she has yelled at and offended all of her nurses, every consulting team, the oncologist, every ICU attending, etc. We never know what we might say that will set her off. All of us have spent great lengths of time explaining things to her in great detail, only for her to fixate on one tiny point and perseverate for the next few days. I dread going to see them every morning, because I can't escape with generalities with her, but I never know what I might say that will make her angry and anxious, or what I might have to spend fifteen minutes retracting. She makes it hard for me to do my job, basically.

Now, I've vented all this from my point of view. To me, this is a woman who is interfering with her husband's care. She is so argumentative and demanding that sometimes, the teams cave in to her and give treatment that we were hesitant to give. She makes her husband anxious. There's a flavor of borderline personality to her; she yelled at my attending yesterday for DARING to suggest that a dialysis catheter be placed in the femoral position, but today she told me how much she preferred the same attending to all the others.

From her point of view, there are tons of doctors coming in and out of her husband's room every day. Sometimes, different doctors and their assistants and the nurses tell her different things, which is confusing to someone with or without a medical background. Her husband can't always speak up for himself, so she has to do it for him.

There's more to it than this, though. One of the first questions she asked me during our first meeting was "what will this do to his chemo schedule? He was supposed to have chemo this week." In reality, the chemo was only to try to reduce his tumor burden for a little while--there was nothing curative about it, and it really didn't matter when he was to receive his next dose. Her concern, though, was my first clue. After that, I started to figure it out. Every one of these things she fixates on--it's like we're denying him the one crucial treatment which would cure him.

When viewed in terms of denial, her behavior makes much more sense. After all, her husband was only recently diagnosed, but was already at a late stage in his disease. Only a few months ago, there was no cancer. Her future with her husband has been stolen from her, and she is furious. She can be angry with us, because we are the incompetent doctors who aren't doing everything for her husband, and because it's easier to be angry with us than to be angry at him. To be angry at him is to acknowledge that he is dying, which she can't do. She can focus on each medication, routine chest x-ray, lab, etc, because it can be controlled, which the cancer cannot.

Eventually, this facade will crack. As his condition deteriorates, and she becomes more frantic, something will break. We called a counselor to see her (at her request) but she refused to speak with her. I doubt she's spoken to anyone willingly about his diagnosis and prognosis. Eventually, it will all come out. I don't want her to lose all her hope, but I also don't want this moment of revelation to come to her after it's too late.

I am a selfish human being, though, and I just want her to quit bugging me so much and let me take care of her husband. Just because I'm going into psychiatry and can try to understand her situation doesn't mean I don't get frustrated, too.


Caroline said...

What a long and difficult journey this woman has to face...

Tiny Shrink said...

Very much so.