Microsoft Word Elisabeth Kubler-Ross On Death And Dying doc

 
Another example of a problem of "to tell or not to tell" is No. D., of whom nobody was sure 
whether he knew the nature of his illness. The staff was convinced that the patient did not know the 
great seriousness of his condition, since he never allowed anybody to get close to him. He never 
asked a question about it, and seemed in general rather feared by the staff. The nurses were ready to 
bet that he would never accept an invitation to discuss the matter with me. Anticipating difficulties, 
I approached him hesitantly and asked him simply, "How sick are you?" "I am full of cancer . . ." 
was his answer. The problem with him was that nobody ever asked a simple straightforward 
question. They mistook his grim look as a closed door; in fact, their own anxiety prevented them 
from finding out what he ,wanted to share so badly with another human being. 
 
If malignancy is presented as a hopeless disease which results in a sense of "what's the use, there is 
nothing we can do anyway," it will be the beginning of a difficult time for the patient and for those 
around him. The patient will feel the increasing isolation, the loss of interest on part of his doctor, 
the isolation and increasing hopelessness. He may rapidly deteriorate or fall into a deep depression 
from which he may not emerge unless someone is able to give him a sense of hope. 
 
(P32) 
 
The family of such patients may share their feelings of sorrow and uselessness, hopelessness and 
despair, and add little to the patient's well-being. They may spend the short remaining time in a 
morbid depression instead of an enriching experience which is often encountered when the 
physician responds as outlined earlier. 
 
I have to emphasize, though, that the patient's reaction does not depend solely on how the doctor 
tells him. The way in which the bad news is communicated is, however, an important factor which 
is often underestimated and which should be given more emphasis in the teaching of medical 
students and supervision of young physicians. 
 
In summary, then, I believe the question should not be stated, "Do I tell my patient?" but should be 
rephrased as, "How do I share this knowledge with- my patient?" The physician should first 
examine his own attitude toward malignancy and death so that he is able to talk about such grave 
matters without undue anxiety. He should listen for cues from the patient which enable him to elicit 
the patient's willingness to face the reality. The more people in the patient's environment who know 
the diagnosis of a malignancy, the sooner the patient himself will realize the true state of affairs 
anyway, since few people are actors enough to maintain a believable mask of cheerfulness over a 
long period of time. Most if not all of the patients know anyway. They sense it by the changed 
attention, by the new and different approach that people take to them, by the lowering of voices or 
avoidance of rounds, by a tearful face of a relative or an ominous, smiling member of the family 
who cannot hide their true feelings. They will pretend not to know when the doctor or relative is 
unable to talk about their true condition, and they will welcome someone who is willing to talk 
about it but allows them to keep their defenses as long as they have the need for them. 
 
Whether the patient is told explicitly or not, he will nevertheless come to this awareness and may 
lose confidence in a doctor who either told him a lie or who did not help him face the seriousness of 
his illness while there might have been time to get his affairs in order. 
 

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It is an art to share this painful news with any patient. The simpler it is done, the easier it is usually 
for a patient who recollects it at a later date, if he can't "hear it" at the moment. Our patients 
appreciated it when they were told in the privacy of a little room rather than being told in the 
hallway of a crowded clinic. 
 
What all of our patients stressed was the sense of empathy which counted more than the immediate 
tragedy of the news. It was the reassurance that everything possible will be done, that they will not 
be "dropped," that there were treatments available, that there was a glimpse of hope-even in the 
most advanced cases. If the news can be conveyed in such a manner, the patient will continue to 
have confidence in the doctor, and he will have time to work through the different reactions which 
will enable him to cope with this new and stressful life situation. 
 
In the following pages is an attempt to summarize what we have learned from our dying patients in 
terms of coping mechanisms at the time of a terminal illness. 
 
========================= 
 
(P34) 
 
III 
 
First Stage: Denial and Isolation 
 
Man barricades against himself. 
 
Tagore, from Stray Birds, LXXIX 
 
Among the over two hundred dying patients we have interviewed, most reacted to the awareness of 
a terminal illness at first with the statement, "No, not me, it cannot be true." This initial denial was 
as true for those patients who were told outright at the beginning of their illness as it was true for 
those who were not told explicitly and who came to this conclusion on their own a bit later on. One 
of our patients described a long and expensive ritual, as she called it, to support her denial. She was 
convinced that the X-rays were "mixed up"; she asked for reassurance that her pathology report 
could not possibly be back so soon and that another patient's report must have been marked with 
her name. When none of this could be confirmed, she quickly asked to leave the hospital, looking 
for another physician in the vain hope "to get a better explanation for my troubles." This patient 
went "shopping around" for many doctors, some of whom gave her reassuring answers, others of 
whom confirmed the previous suspicion. Whether confirmed or not, she reacted in the same manner; 
she asked for examination and re-examination, partially knowing that the original diagnosis was 
correct, but also seeking further evaluations in the hope that the first conclusion was indeed an error, 
at the same time keeping in r contact with a physician in order to have help available "at all 
times" as she said. 
 
(P35) 
 
This anxious denial following the presentation of a diagnosis is more typical of the patient who is 
informed prematurely or abruptly by someone who does not know the patient well or does it 

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