Most patients tend to deny the reality of their situation after being made aware of the terminal nature of their illness. Denial is one way of coping with or protecting oneself against overwhelming anxiety, which otherwise could be incapacitating. This reaction is more marked in the patient who is told abruptly without adequate preparation. Although denial is noted primarily when the patient first learns of impending death, it can appear in different degrees at different times. Even patients who have accepted the terminal nature of their illness will need to employ denial periodically to avoid feelings of hopelessness. The mental burden of impending death is too heavy to carry all the time, and periodic relief

• I will keep you as comfortable as possible.

• I will focus on maintaining your quality of life.

• I want to help you live meaningfully in the time you have left.

• I will do everything I can to help you maintain your independence.

• Maintaining your independence and dignity will be my top priority.

• I will do my best to fulfill your wish to remain at home.

Modified from Stone MJ. Goals of care at the end of life. Baylor University Med Center Proc 2001;14;134-137.

is necessary to carry on customary activities and enjoy the limited time left. As Aring (1971) noted, La Rochefoucauld said, "Neither the sun nor death can be looked at steadily."

Patients who avoid asking about their illness or prognosis when the physician offers every opportunity usually are experiencing denial. Excessive denial usually means that the patient subconsciously knows the truth but wants to avoid facing it consciously. Even when repeatedly given the accurate diagnosis, some patients deny ever having been told. This denial provides constant emotional protection until the patient is ready to face the truth.

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