As death approaches, patients often play games that are actually defensive denials of the inevitable, this psychiatrist says. Recognizing which game is being played is the key to managing the terminal patient. I once overheard a physician for whom I have great respect say, "It's amazing the games people play when they're dying." At first, the remark seemed the ultimate in callousness, or at best an unthinking turn of phrase. The very idea of a patient playing games when he is at death's door is abhorrent, and the idea of a doctor treating him as if he were playing a game is worse. Over the years, however, and primarily as a result of my experience as chief of a psychiatric consultation service in a large teaching hospital, I've come to take that physician's chance remark more seriously. Having been involved in the problems of doctors with terminally ill patients, I've seen how one person can be driven to the point of madness by being told he's going to die, while another suffers because he isn't told. The fact is that people face death as individualistically as they face life. And just as they play games in life to preserve illusions about themselves or their situations, so they unconsciously play games when approaching death. The physician who can recognize which game his patient is playing is better able to manage him in this most difficult time.
Though there are many variations, there are a few basic games for the doctor to recognize. I've given the games names that may at first sound facetious but are in tended to keep this painful subject in perspective.
Accentuate the possible is probably the most common defense against the unacceptable reality of death. I recall a professor in medical school who was given a definite diagnosis of malignant melanoma. Aware that this form of cancer would almost certainly prove fatal, he was understandably shaken. Then he looked up the literature on the disease and found that 4 percent of patients with his ailment survived five years or more. Dismal as this statistic was, it had a miraculous effect on the professor's spirits. He unconsciously assumed that he would be one of those four out of 100 persons who would live the five years or more. The more likely probability that he would be among the 96 percent who died seemed not to occur to him. He was able to live actively and teach effectively until just a few days before his death, less than a year later.
This game, or defense against death, has its counterpart at the gambling tables in Las Vegas. As long as the gambler feels he has a chance to win, the odds make no difference. A doctor who expresses surprise or incredulity when a terminal patient clutches at the gambler's hope is doing him a great disservice. He does the patient a greater disservice if he attempts to straighten out that peculiar logic. When a doctor elects to be forthright with such a patient, he is in fact passing a death sentence.
When I speak to a patient who, on the other hand, seems ready to accept the fact of approaching death, I'm grateful that such a game exists and may urge him to play it to the hilt by saying: "You have a serious illness. We both know that. But it's important for you to know also that some people have lived for 20 years or more with your ailment." It has been rare, indeed, for the patient to ask the next question: "Yes, Doctor, but how many people?" Terminal patients seldom go as far as the professor went to find out the percentages. Odds are most often precisely what the patient doesn't want to know.
Envy makes the heart grow colder, another game played as a defense against the inevitable, can bring needless torment to the terminal patient and his family if not handled understandingly by the physician. Fear of death can produce hatred of loved ones, friends, and associates out of the envy the patient feels toward those lucky enough to survive. In some cases, this amounts to a transference of the death sentence in the patient's mind to those he leaves behind, and it may even include his psychotherapist or family doctor.
One patient I counseled a few years ago had been diagnosed as having an invasive breast cancer. She was knowledgeable enough to guess that the prognosis was not good. She reacted by withdrawing into a world of her own, resented visits by her husband and teen-age children, hardly spoke when they did visit, and treated them as if they were responsible for her condition. She was saying to them, in effect: "Look, you terrible people, you're going to live, and I'm going to die. What do I care about you? Leave me alone." The family, repelled by her sudden animosity, responded by staying away or by answering her unpleasantness with their own. This, in turn, caused the patient to withdraw all the more into her miserable loneliness. It was a classic example of a vicious cycle that often culminates in a patient dying alone though surrounded by family.
Three steps were necessary to bring this patient's situation to a point where she could die in peace and dignity with the comfort of her family's love. The first involved confirming her guess about her condition that she was not too likely to survive. In the second step, I induced her to share with me her grief at having to leave the family behind. This step brought the transference that sometimes takes place, and it was apparent from the patient's dreams that she was unconsciously convinced that I was the one who was going to die, not she. The third step required going to the family and explaining how their reactions to her bad feelings were causing the mother grief and distress.
"When a person nears death," I told them, "it evokes concern in all of us over our own well-being. Without being aware of it, we sometimes withdraw our emotional investment in a dying person. Conversely, a dying person does the same out of a private terror that makes him want to shrink away. So we have an unfortunate withdrawal of one loved one from another at the very time the dying 'person needs a sense of still belonging." The family then minimized the patient's hostility by tolerating it and by suppressing their own, and before the mother died a close relationship had been re established.
Stop the world, I don't want to get off is a game in which the patient tries to re live a happier time in his or her life in order to escape the hopelessness of the present. The time selected usually from the distant past is relived in either reminiscence or fantasy. It's a good guess that the terminal patient who backs off from discussing present-day personal problems in favor of daydreaming about the past is unconsciously closing his eyes to death. This natural defense through denial, though sometimes disquieting, can be a physician's best means of bringing greater contentment to the terminal case. All the doctor need do is to play the game of remembering and to remember himself that shattering the illusion will do neither the patient nor him any good.
An aspirin a day keeps death at bay is another game of denial the physician can exploit to help his dying patient. I've seen patients with less than a month to live brighten up and exhibit intense interest in the events of the day when their doctors made a show of treating their minor ailments. The complaints ranged from unimportant skin rashes or intercurrent flu to the ever-popular physiology of the bowel movement and "correct" diet. Aggressive treatment by the attending physician was able to establish in the patient's mind the impression of continuing interest in and solicitude for all his bodily functions. Were these physicians pandering unnecessarily to the patient's childish dependence on "doing as Mommy says" in order to survive? Perhaps, but when the patient gets a feeling of optimism from having his trivial complaints dealt with, where's the harm?
Nonsense—I can't die now is the game involving a patient's total rejection of death. A person who can screen out any hint of terminality might be expected to have the iron discipline of those who have accomplished much in life. But such patients turn up at both ends of the economic, social, or intellectual spectrum. I once knew a welfare patient with leukemia who, to her dying day, insisted she had only anemia. On the other hand, the widow of a famous intellectual told me that her husband blinded himself quite effectively to his terminal illness, even though he was a man of extraordinary perception and courage. He refused to acknowledge his increasing debility and prepared for projects he could never complete. Every time a doctor hinted at the facts of his condition, the man changed the subject. He went to his death, according to the widow, without once facing the fact that he was dying. The husband's doctors were sage enough not to try to penetrate the patient's protective pretense.
Another terminal patient who played this game wasn't so fortunate. He was a hard-hitting businessman who developed an inoperable cancer. In deciding how to break the news, his doctor took into account only the patient's surface personality. Here, supposedly, was a two-fisted success, a veteran of the rough and tumble business world, a man accustomed to evaluating facts and making decisions. Who better to face the bad news like a man? A closer look would have revealed that he didn't expect to die. He'd steadfastly refused to delegate a shred of authority or to groom a successor for his business, and he habitually committed himself to deals that Methuselah himself couldn't have profited from. All he cared to hear from the doctor was the date when he would be allowed to get back to work.
When the doctor finally told him the truth, he couldn't take the news he turned violent, suffered hallucinations, and had a mental breakdown. Medication eventually brought him back from psycho sis, but he lived thereafter in a dream world, pretending he was in the hospital for a rest only. He died after teetering on the brink of madness for most of his final days.
Considering these games the dying play, it seems clear that it's unwise to tell some terminal patients of impending death. But what of the patient who ought to be told? Obviously, a doctor has to know his patient pretty well. A man who has fled from earlier realities of life isn't likely to be able to stand the crushing reality of his imminent death. But a man who has shown that he can view misfortune as "the way the cookie crumbles" rather than as evidence that "somebody up there dislikes me" is much more likely to want to know and to need to know the whole truth.
The physician can usually test his patient as he goes along by telling only as much of the unpleasant truth as the person indicates : he wants to know. If the patient reaches the ultimate question "Will the condition take my life?" without evidencing defenses of denial, it's a good bet that patient is ready to know the full story.
I recall one patient for whom this stage-by-stage procedure worked very well. He, too, was a businessman, but he had a consistent record of dealing objectively with tragedy. His daughter had died at a tender age, he'd lost a business, and he'd seen his wife grow mentally ill, yet he'd faced these tragedies unflinchingly. When I told him he had a serious illness, he immediately asked if it was cancer. I told him we wouldn't know until we performed surgical exploration and that if he did have a malignancy everything possible would be done for him on the operating table. The patient then went on to volunteer some information that almost demanded further confidences on my part.
"You know, Doctor," he said, "I won't fear death, if that's what's involved. I've had a good life, and I've always realized that I wouldn't live forever." He asked if it might not be a good idea for him to make provisions for his family, "just in case the operation doesn't work out."
There, at last, was the denial defense, well-hidden though it was. This man knew as well as I that the operation wouldn't work out if the tumor were malignant, and we were 99 per cent certain it would be. Now he was ready to hear the truth, but it was up to me to tell him in the terms he had indicated. "Yes," I replied, "why don't you go ahead and make those pro visions, just to be on the safe side?" He took that message, filtered as it was through his possibility-probability defense, almost with relief. He developed a general surface optimism about his life and died a tranquil death several weeks later.
Another similarly stable patient I later heard about was tended by a team of physicians who couldn't bring themselves to tell him the truth. Each of his five doctors passed the buck, hoping that the next in line would play the messenger-of-doom role. The patient, a young journalist, guessed what was going on, became more and more frustrated as the days went by, and finally reached the borderline of psychosis. Normally a mild-mannered person, he began vilifying the nurses, screaming complaints, and refusing meals. Finally, one of the senior attendants unofficially appointed himself the man's primary doc tor, summarized the findings of his col leagues for the patient, and let him know the situation as gently as he could. The change in the patient was amazing. He calmed down at once, resumed normal eating habits, and lived out his final days in relative peace.
"Peace" for the terminal patient is ultimately the name of the game, and psychological management of the patient must have that as its final goal. The challenge is great. It's tempting, for instance, for a doctor to assume that by putting himself in the patient's place he can feel what the patient is feeling about death. It's also tempting for a doctor to write off the dying patient on the grounds that he's done all he could and that his mission is to help the living ones physically, not succor the dying ones emotionally. It's sometimes difficult to tolerate the animosity of the terminal patient and to avoid becoming involved in the mystique of death that distorts considered judgment and humanitarian precepts. But by studying his patient's emotional background and content, by sharing his grief and fear, by leaving him hope, by tending his day-to-day minor illnesses, and by letting him or helping him play his final game, the physician can manage his patient's death even if he can't control it.
