Denial, acceptance and the dreaded “D” word

I would like to go home.” These were the words I was not prepared to hear. After all, everything was in place for tomorrow's surgery. The consent form had been signed, the procedure explained. The operating room was booked and all the imaging reviewed. The rest of the team had gone home for the night and I was in house for surgery call.

Just moments before, when my pager rang, I had expected to be called about a general surgery consult in the emergency department, or about a patient on the floor with low urine output. I had not expected the nurse on the other end of the line to tell me that Mr. Lee had reached a decision — he wanted to leave, and he wanted to leave tonight.

As I made my way to the sixth floor, a dozen thoughts swirled in my head. Should I try and talk to Mr. Lee myself or consult the resident? After all, I was a medical student who had never been in this position before. Usually we were delegated to retract, record and review. At the same time, surely the bulk of my clinical experience had prepared me for a conversation of this magnitude. Surely I could get Mr. Lee to see that he needed this operation. Obviously he would understand that if he went home tonight he would … die.

Oh, no. The dreaded “D” word. As the elevator doors opened before me, I realized with a slight sense of horror that I had never actually told a patient that he or she might die. I racked my brain, trying to think of an instance where I had at least participated in a similar conversation. But my mind went blank.

I walked to the nurse's station and picked up Mr. Lee's chart. It was quite thick, reflecting the fact that he had an extensive medical history. He had been admitted a couple of days ago under general surgery with tell-tale symptoms of a bowel obstruction. He had a prior history of lung cancer, which had been resected. However, the current computed tomography scan of his abdomen showed high suspicion of metastatic deposits in his peritoneum, likely leading to his bowel obstruction.

I closed his chart, laid it shakily on top of the chart rack and made my way into his room. I pulled back the curtain that surrounded his space and saw him sitting up frailly in bed. He was only 44, but looked much older. His wife, a slight, serious looking woman, was sitting in a chair at the foot of his bed rubbing his feet, which were thickly covered in 2 layers of socks.

I said hello and pulled the curtain shut behind me, which, although thin, did provide us with some privacy.

“I would like to go home,” Mr. Lee said immediately. His tone was quiet, but strong and resolute. His wife nodded her head in agreement. In her eyes was a look of determination, but when she spoke, her voice was almost pleading, “Yes, we would like to go home tonight.”

Reflexively, I grabbed the edge of my stethoscope, which was hanging snugly around my neck. “Yes, the nurse told me about your decision,” I told them, trying to make eye contact with either of them. “I'm here on behalf of the general surgery team. I thought it was agreed that you would go for surgery tomorrow.”

“Yes, but I feel fine now,” explained Mr. Lee.

My heart started beating a little faster. He seemed so determined and immovable. “I'm glad you're feeling better,” I said, trying to keep my voice level, “but you still need the surgery. You're likely to get worse without surgical intervention.”

“I don't think I need the surgery anymore.” Mr. Lee gave me a small smile as he continued, “We need to go home.” He glanced at his wife and also gave her a small smile. In their eyes was a mixture of both expectation and confidence. I felt as if I were shrinking under their gaze, my body swimming in my standard hospital greens, already 2 sizes too large.

I blinked, not knowing how to deal with this turn of events. What about all the conversations from the past couple of days? What about the scans and the mention of his cancer? Could they have forgotten these conversations? Did I now need to remind them?

I had memorized the stages of grief. I knew of denial, but had never confronted it head on. I recognized it as a defence mechanism, but had no idea how to break through it.

I took a deep breath, and told them the inevitable truth: if he left tonight without any further treatment we would fully expect him to pass away — to die — in the next few days.

I did not know how Mr. Lee would respond to my news. Would his strong façade shatter in the face of harsh reality? Would this be the first time they were really told, without the distraction of medical jargon and fancy surgical lingo, that death was imminent?

“It's okay,” Mr. Lee said. His eyes never faltered from my face. “I know. And I would like to go home. I have small children. I want to play with them, to spend time with them. I don't want them to have to come and see me in the hospital. I want to be with them at home. That is where I belong.”

I was not expecting this response. He knew. He knew all along. He was aware that death was at his doorstep. And he was prepared to accept that sentence.

I realized that I had come in at the tail end of what must have been a long, introspective process for Mr. Lee and his family. This process may have even started with his first cancer diagnosis and surgery. They were not in the stage of denial, but, rather, the stage of acceptance. I realized that someone else in their position may have chosen another path. But for Mr. Lee and his family, this was the end of their respective journey.

After consulting with the rest of the team and seeing that the resident paid Mr. Lee a long, detailed visit, I returned hours later to my call room. I felt a mix of emotions. I was proud of myself for having the courage to participate in such an emotionally charged conversation. But at the same time, I felt foolish for having thought that I knew more about his situation than he and his family.

For weeks afterwards, amid the hustle and bustle of the general surgery service, I often thought of Mr. Lee. If he ever returned to the hospital, it would be under palliative care, not general surgery.

I was curious to see what had happened to him. But, at the same time, I did not want to know. Perhaps I was in a state of denial. Maybe I was the one who had not yet reached the stage of acceptance. Nevertheless, it gave me comfort to think of him at home, with his young children, enjoying their company.