Differentiating Denial From Coping Mechanisms in Oncology

Welcome to Onc Nurse On Call, the new podcast from Oncology Nursing News, hosted by editors-in-chief Patricia Jakel, MN, RN, AOCN, and Stephanie Desrosiers, DNP, MSN, RN, AOCNS, BMTCN, delivering maximum impact in minimum time.

This week, Kelly Grosklags, LICSW, BCD, FAAGC, FT, shared advice for oncology nurses and advanced practice providers (APPs) dealing with grief at the end of patients’ lives. Grosklags, founder of Conversations With Kelly, explained that patients perceived as being in “denial” of their prognosis are often in need of someone to listen to them, or they are perceived that way because a provider requires closure of the patient.

Patients who seem unable to approach conversations about the end of life may simply need a conversation about why that is the case.

“Sometimes our psyche can’t take in all this information at once, so we have to compartmentalize it,” said Grosklags. “I’ve never met a patient who…looked like they were denying something that [they] didn’t at some point acknowledge. You have to acknowledge something to deny it.”

Understanding the mindset of these patients, Grosklags said, may take stepping back and recontextualizing the patient’s experiences.

“Is this part of my own agenda as a provider that I need them to be able to talk about this?” asked Grosklags. “Why am I so activated by this patient and their ‘inability’ to [acknowledge their prognosis]?”

In response to these situations, Grosklags said the best approach is to ask why the patient is hesitant to broach the topic. Sometimes, these patients may have other priorities within their family. Other times, they may just grieve differently than their care team expects.

Jakel shared the story of a young mother who had been deemed “difficult” and “in denial” by other staff due to her rejecting conversations about the end of her life. However, through regular conversations with the patient about her life and family, Jakel came to know the patient and formed a bond with her.

“We came to the conclusion…that she didn’t want people to take a hammer to her every day to talk about this, but I was going to be the one to tell her when she only had a day or 2 to live,” said Jakel. “I was going to let her know to put on her makeup. It was really important to her to end her life wearing her makeup, and she had 2 sisters who were going to apply the makeup.”

“Putting on makeup” became a code between Jakel and the patient to check in on her prognosis. Throughout the next couple of weeks, she’d check with Jakel to see if she needed to put on her makeup.

“It was her way of telling me, ‘I understand what’s going on and am preparing for that, and this is how I want my end to look,’” said Jakel.

While managing patients’ grief is one issue, managing their own emotions can be another challenge altogether for oncology nurses and APPs.

“The rule of thumb is, if you have emotions and they’re related to the person in the room, it’s absolutely appropriate,” said Grosklags.

She emphasized that not every patient will elicit this powerful a reaction, but allowing oneself to experience this response will only enhance practice.