Microsoft Word Elisabeth Kubler-Ross On Death And Dying doc

To tell or not to tell, that is the question. 
 
In talking to physicians, hospital chaplains, and nursing staff, we are often impressed about their 
concern for a patient's tolerance of "the truth." "Which truth?" is usually our question. The 
confronting of patients after the diagnosis of a malignancy is made is always difficult. Some 
physicians favor telling the relatives but keeping the facts from the patient in order to avoid an 
emotional outburst. Some doctors are sensitive to their patient's needs and can quite successfully 
present the patient with the awareness of a serious illness without taking all hope away from him. 
 
I personally feel that this question should never come up as a real conflict. The question should not 
be "Should we tell. . . ?" but rather "How do I share this with my patient?" I will try to explain this 
attitude in the following pages. I will therefore have to categorize crudely the many experiences 
that patients have when they are faced with the sudden awareness of their own finality. As we have 
outlined previously, man is not freely willing to look at his own end of life on earth and will only 
occasionally and half-heartedly take a glimpse at the possibility of his own death. One such 
occasion, obviously, is the awareness of a life threatening illness. The mere fact that a patient is 
told that he has cancer brings his possible death to his conscious awareness. 
 
It is often said that people equate a malignancy with terminal illness and regard the two as 
synonymous: This is basically true and can be a blessing or a curse, depending on the manner in 
which the patient and family are managed in this crucial situation. 
 
(P26) 
 
Cancer is still for most people a terminal illness, in spite of increasing numbers of real cures as well 
as meaningful remissions. I believe that we should make it a habit to think about death and dying 
occasionally, I hope before we encounter it in our own life. If we have not done so, the diagnosis of 
cancer in our family will brutally remind us of our own finality. It may be a blessing, therefore, to 
use the time of illness to think about death and dying in terms of ourselves, regardless of whether 
the patient will have to meet death or get an extension of life. 
 
If a doctor can speak freely with his patients about the diagnosis of malignancy without equating it 
necessarily with impending death, he will do the patient a great service. He should at the same time 
leave the door open for hope, namely, new drugs, treatments, chances of new techniques and new 
research. The main thing is that he communicates to the patient that all is not lost; that he is not 
giving him up because of a certain diagnosis; that it is a battle they are going to fight together-
patient, family, and doctor-no matter the end result. Such a patient will not fear isolation, deceit, 
rejection, but will continue to have confidence in the honesty of his physician and know that if 
there is anything that can be done, they will do it together. Such an approach is equally reassuring 
to the family who often feel terribly impotent in such moments. They greatly depend on verbal or 
nonverbal reassurance from the doctor. They are encouraged to know that everything possible will 
be done, if not to prolong life at least to diminish suffering. 
 
If a patient comes in with a lump in the breast, a considerate doctor will prepare her with the 
possibility of a malignancy and tell her that a biopsy, for example, will reveal the true nature of the 
tumor. He will also tell her ahead of time that a more extensive surgery will be required if a 

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malignancy is found. Such a patient has more time to prepare herself for the possibility of a cancer 
and will be better prepared to accept more. 
 
extensive surgery should it be necessary. When the patient awakens from the surgical procedure the 
doctor can say, "I am sorry, we had to do the more extensive surgery." If the patient, responds, 
"Thank God, it was benign," he can simply say, "I wish that were true," and then silently sit with 
her for a while and not run off. Such a patient may pretend not to know for several days. It would 
be cruel for a physician to force her to accept the fact when she clearly communicates that she is 
not vet ready to hear it. The fact that he has told her once will be sufficient to maintain confidence 
in the doctor. Such a patient will seek him out later when she is able and strong enough to face the 
possible fatal outcome of her illness. 
 
Another patient's response may be, "Oh, doctor, how terrible, how long do I have to live?" The 
physician may then tell her how much has been achieved in recent years in terms of extending the 
life span of such patients, and about the possibility of additional surgery which has shown good 
results; he may tell her Hank, that nobody knows how long she can live. I think it is the worst 
possible management of any patient, no matter how strong, to give him a concrete number of 
months or years. Since such information is wrong in any case, and exceptions in both directions are 
the rule, I see no reason why we even consider such information. There may be a need in some rare 
instances where a head of a household should be informed of the shortness of his expected life in 
order to bring his affairs in order. I think even in such cases a tactful understanding physician can 
communicate to his patient that he may be better off putting his affairs in order while he has the 
leisure and strength to do so, rather than to wait too long. Such a patient will most likely get the 
implicit message while still able to maintain the hope which each and every patient has to keep, 
including the ones who say that they are ready to die. Our interviews have shown that all patients 
have kept a door open to the possibility of continued existence, and not one of them has at all times 
maintained that there is no wish to live at all. 
 
When we asked our patients how they had been told, we '.darned that all the patients knew about 
their terminal illness anyway, whether they were explicitly told or not, but depended greatly on the 
physician to present the news in an acceptable manner. 
 
What, then, is an acceptable manner? How does a physician know which patient wants to hear it 
briefly, which one with a long scientific explanation, and which one wants to avoid the 
 
(P28) 
 
issue all together? How do we know when we do not have the advantage of knowing the patient 
well enough before being confronted with such decisions? 
 
The answer depends on two things. The most important one is our own attitude and ability to face 
terminal illness and death. If this is a big problem in our own life, and death is viewed as a 
frightening, horrible, taboo topic, we will never be able to face it calmly and helpfully with a 
patient. And I say "death" on purpose, even if we only have to answer the question of malignancy 
or no malignancy. The former is always associated with impending death, a destructive nature of 
death, and it is the former that evokes all the emotions. If we cannot face death with equanimity, 
how can we be of assistance to our patients? We, then, hope that our patients will not ask us this 

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