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By giving news at the patient's pace, you are also giving the patient the opportunity to block you from disclosing further news. We call this and the apparent inability, or unwillingness, to accept bad news "Denial". This is a mechanism that most of us use from time to time in our daily lives, such as failing to return a telephone call when we know that the conversation will be difficult, or when we use the expression "I'll leave it on the back burner" to put off facing an unpleasant situation. It is generally a transient reaction and a way of coping with a life's difficulties.
A typical scenario is where a patient is terminally ill but is planning a holiday. They may show you a brochure and ask which of the Greek Islands you would recommend. There is a danger here, for if you "buy into" the denial and the patient later realizes that there will be no holiday, their frustration could be turned on you for misleading them. It is preferable to respond with caution eg. "I'd like to think you would be well enough to go to Greece. I've not been there but I understand that it is lovely" When the patient comes out of their denial they will realize that you tried to warn them, even though they were not ready, at the time, to heed the warning. Trust between you is then maintained.
Denial can be tested by a question, such as: "Is there ever any time when you are not so sure that you will have your holiday? If the denial is complete, the patient will say "No, I'm definitely going when I'm better" or something similar. A more telling question is "Have you booked yet?" If the answer is "Yes" then it should be accepted that the patient is not ready for reality at this time. In fact, it is very unusual for definite arrangements to have been made, no matter the plans, and as the patient moves to acceptance of the true situation, they may tell you that sometimes, they are not so sure that their plans will be realized. These feelings of uncertainty usually occur in the small hours of the night and are an indication that the denial is no longer complete. Few patients die in denial although the collusion of others may delay the process of acceptance.
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Denial
