Take-home message

The ideation of death is a depressive manifestation. It is not uncommon at the time of a cancer diagnosis. When there is no history of psychiatric illness, it can be overcome with a direct and enlightening cognitive approach. The central point is to undo the association of ideas supported only by the patient's fantasy.

(Fictional narrative by the doctor)

James Fleck, MD, PhD: Anticancerweb 25 (12), 2022

Two days passed.

I noticed that Arthur had made an appointment.

I had instructed my secretary to make an immediate appointment for Arthur if contact was made. I noted that she had booked him as my last appointment that afternoon, with no time limit. I remember the word urgent used by Heloise when she contacted me by phone. Interestingly, although cancer usually takes many years to develop, it is always viewed by the patient and family as an emergency. In fact, the urgency was Arthur's distorted approach to the problem.

Artur attended the office accompanied by his wife and children. I had already done all my schedule for that afternoon and they were alone in the office waiting room.

I took a natural approach. I greeted the family, who introduced me to Arthur. I told the family that I would talk to Arthur alone. Everyone nodded and I placed my hand on Arthur's shoulder, leading him into a private room.

We sat facing each other. We made eye contact. Arthur had a pained look in his eyes and was visibly depressed. He gave me the impression of hopelessness and a certain embarrassment in having to face that situation. Still, Arthur took the initiative and asked me: 

Where should I start?

I replied that the order was not important, because we would have to talk about everything. In the end, the questions would fit together like a puzzle. He said he was trying to help, and I suggested starting with what was most concerning him at the time. Artur started to cry and said in a choked voice: 

Doctor, I'm not ready to die.

I asked where the idea of death came from. Arthur replied that he always handled all the adversities of life well, but that he had never thought about the possibility of getting sick. 

He would feel awkward living with physical limitations. He always took good care of his family and was uncomfortable with the idea of causing any trouble. He felt that his family members were not prepared to lose him. He said he tried a few weeks ago to talk to his son about his death. However, he realized that he had not been able to approach the subject and ended up expressing himself in a dubious and poorly understandable way. He mentioned that he felt better when Luis came back to look for him, trying to rescue the dialogue, but that, even in a receptive moment, he was unable to talk about his insecurities. However, upon meeting with his son, he realized that his refractory attitude was also causing suffering for the family and he accepted the suggestion to see a doctor. I interrupted Arthur's story, saying that I could understand his suffering, but that I had found two relevant aspects:

First, he was assuming he was going to die, which wasn't necessarily true. Second, he was underestimating the family's coping capacity. I told him that we would have to explore both situations. 

I pressed again on the point Arthur was avoiding, making more circumstantial and peripheral comments. I explained to Artur that the central issue was his ideation of death. I also rephrased the question more directly:

Arthur, why are you so convinced you're going to die?

Arthur was moved by the question. He replied that he was sure of it. He was already old and many of his friends were dead. Now it would be his turn. He revealed that he never imagined living so long, as his father had died at the age of thirty-five, from tuberculosis. The first sign had been a small amount of bleeding in the sputum. He remembered, as a child, he was with his father when he saw him taking a hanky full of blood out of his pocket. He recalled that after that episode, his father died in a hospital within weeks. Artur never spoke about it with his mother, uncles or brothers, keeping this experience to himself, sparing family suffering. In his version of the story, no one would have been warned about his father's illness, except for him in that involuntary accident. He remembered that his father, at the time, had hidden the hanky and asked him not to comment on the matter, as it was just a small wound on his nose.

Arthur obeyed.

Arthur couldn't stand it, when saw blood in his stools. He said that when looking at the toilet, during the episode of intestinal bleeding, involuntarily remembered his father's situation. At that moment he was sentenced to death. He thought that death would come soon and that, like his father's situation, the family would only find out when everything was already consummated.

I interrupted again.

I told Artur that his childhood experience would have been traumatic and that at the time people were actually less open to dialogue. Possibly, the commitment assumed with his father was the cause of the difficulty in dealing with his current illness. Assuming complicity in hiding the father's bleeding from the family, generated guilt. The guilt magnified the problem. It was necessary to clarify that his father's illness had nothing to do with his current illness and that, even if it had, times were different. Current treatment resources could allow its cure.

I insisted that any blame that might have been going on, had to be removed. When he obeyed his father, keeping his secrecy, he did not become responsible for his father's death. He only respected father's will. Perhaps it would never be possible to discover why the father's illness had such a quick and tragic end. But it definitely wasn't Arthur's fault. He, as a child, could do nothing to change the course of events. Adult people are responsible for their actions.

Arthur interrupted and said: This is precisely why I didn't want to discuss the illness with my wife and children. I remember that for many years I suffered from being the only person to witness my father's illness. I don't want my family going through this.

I explained to Arthur that I understood his point of view, but that it would have been a child's trauma. His wife and children were adults who had a lot of affection and consideration for him. His attitude was depriving them of the opportunity to help him, which was causing their immobility and suffering.

Arthur promptly felt relieved. He agreed with a behavior change. He would talk to the family, sharing his previous story, letting them to help in his care.

I revealed to Arthur that I felt gratified at his attitude and that probably his family would also feel the same. Rescuing a positive attitude did not mean that the childhood trauma would be resolved. It was only a comprehensive view of the problem that temporarily prevented his focus on the current illness. I explained that, if necessary, it could be worked on analytically in the future, with a specialized professional. I wasn't a psychiatrist, but during my medical practice I had followed several situations similar to Arthur's. Whenever there is a diagnosis of cancer, it is accompanied by a personal and family crisis. Life is revisited and several traumatic past experiences are revealed. Perhaps this is motivated by the association of cancer with death. I have always handled these situations with a direct and natural approach. I could not expect psychoanalytic treatment, not even a brief psychiatric consultation, trying primarily to remove the patient's fantasies. The focus is on undoing the associations of ideas as quickly as possible, in order to be able to cope with cancer. This was particularly true for patients who has no evidence of prior psychiatric illness and who are motivated to live.

Seeking psychiatric help to remove care obstacles would additionally weak the patient, precisely at the moment when his life is threatened by cancer. It seems inadequate to me that, at a moment when people are trying to rescue life, an analytical approach to the wounds of the past being carried out at the same time. The focus has to be on treating the organic disease. If there is a need, in the future, the traumatic experiences of the past would be reassessed and treated. What I need, at this critical moment, is just a change in behavior, favoring a coping attitude. Rescuing Arthur's self-confidence, I just promoted a favorable doctor-patient dialogue, with empathy and patent commitment.

We agree to end the first consultation.

*   Attention: The story 10 will be published sequentially from PLOT 1 to PLOT 6 and you will always see the most recent posting. To read Story 10 from the beginning, just click in the numbered links located at the bottom of the homepage. 

James Fleck, MD, PhD is a full professor of clinical oncology at Federal University of Rio Grande do Sul, Brazil

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