Exploring patients’ concerns about dying
• Doctor: “I realize you are aware that we can’t give you any active treatment now, and that you have not long to live. Do you have any specific concerns about that, that you would like to talk about?” • Patient: “I can accept that my time is up. I’ve had a good life, but I feel such a burden on my family and the nurses.” • Doctor: “How do you mean?” • Patient: “I’m so helpless now that they have to do everything for me. My family have to keep visiting and I’m worried about the strain on them.” • Doctor: “Any other concerns?” • Patient: “I get distressed when I see the look in their eyes.” • Doctor: “What exactly do you mean?” • Patient: “I’ve lost so much weight, I look like a skeleton, and it hurts them.” • Doctor: “Any other concerns?” • Patient: “I’m worrying about how I’m going to die.” • Doctor: “Any specific worry?” • Patient: “I’m worried that I’m going to suffocate.”
Occasionally, it is necessary to challenge denial because patients have important unfinished business to conduct, or because they are refusing a treatment that might alleviate symptoms. It is important to confront denial in a manner that avoids causing psychological harm. This can best be achieved by first confronting the patient with inconsistencies in his perception of what is happening. Doctor: “I am concerned that you are still taking insulin in a haphazard way.” Patient: “I only need to take it when I feel like it. I am doing all right.” Doctor: “How, then, do you explain your continued tiredness? You say you are still very thirsty and needing to pass water frequently. That doesn’t square with you saying you feel better.” When such confrontation does not work, it is worth asking the patient if there is a ‘window on denial’: “Is there any time of the day or night when you contemplate that things aren’t so straightforward, even for a few seconds?” When a patient is in persistent denial, it is best to leave him in that defence mode because it means that he is unable to tolerate the pain of confronting reality. There may be further opportunities to overcome his denial when his illness progresses.
A busy practitioner can easily forget the obvious – whenever people communicate, there are multiple cultural influences on their interaction. Cultural background, health beliefs and expectations affect health-care encounters with every patient. To communicate effectively, it is necessary to avoid stereotyping by responding to patients as individuals within their own cultural context. Health professionals must also recognize the influence of their own cultural backgrounds and attitudes on their communication with patients. Communication is sometimes more challenging with those who are different from us. To communicate successfully, we may need to be willing to accept the discomfort of unfamiliarity and uncertainty. Rising to these challenges requires: • sensitivity to cultural diversity, stereotyping and prejudice • general skills of good communication, as with any patient • specific skills to negotiate communication barriers.
The nature of culture
Culture has been described as comprising the shared beliefs, values and attitudes that guide the behaviour of social groupings.1 The term ‘culture’ is used most commonly to describe people of shared national, ethnic or regional origin, but it is important to remember that there is a dynamic social context for every individual’s culture. This includes gender, age, education, socioeconomic background, language, family, occupation, religion, sexual orientation, disability and previous health experiences. Many cultural influences may change with time and personal experience. Differences in nationality and language may act as obvious cultural barriers to effective communication. However, the ‘iceberg model’ (Figure 1) illustrates that many important cultural contexts in a health-care...