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Projection
The Mind's Necessary Use of Denial in an End-of-Life Scenario
Personal Perspective: A case presentation of a mother's denial.
Posted October 16, 2022 Reviewed by Jessica Schrader
I was asked to come into the room where the family was holding vigil. I knew about Keri from last night when her condition took a turn for the worse, becoming unresponsive, with her vitals showing a low-grade fever. Keri was diagnosed with glioblastoma four years ago and has undergone all available chemotherapy, radiation, and surgery for this disease. She had responded so well that she outlived her traditional poor prognosis by upwards of two to three years.
While she was in remission, she bore a child, but unfortunately, her disease had advanced, and now she was at the end of her life. Keri’s family, including her fiancé, father, mother, and many of her friends, were huddled in a sizeable and comfortable room where each member could keep their private space about them. Keri’s friends sat together in a small group while her fiancé, father, and mother kept themselves at a triangular distance, with Keri at the center.
Keri was admitted to our inpatient hospice unit last night because of a change in her clinical condition. Understandably, the mood was solemn and stressful with the gravity of the situation palpable. Social work, chaplaincy, bereavement counselors, and nurses were all circling about trying to connect with the family to provide and bring support and solace. The hospice team told me that the family was waiting for the physician (me) to come in and speak to them about the current situation and the next steps. I knew that the family was not ready for Keri’s imminent passing, as they had asked us to start intravenous fluids and not give her any medications that could possibly sedate or contribute to her passing. That meant no narcotics or sedative medications for comfort.
I carefully came into the room and introduced myself to as many people as had made the effort to meet my gaze. Some just were too focused on Keri to notice my presence. I sat down on a couch next to Keri and immediately her mom sternly asked me, “So what do you recommend for her? What are you going to do now?”
I felt the intensity of her question but didn’t know how to answer such an open-ended question. Did she want me to tell her that Keri is dying? Did she want me to offer a palliative approach, or was she inferring that she was not happy with hospice and wanted to seek aggressive care in a hospital setting? I got the sense from mom’s intensity that no matter how I answered, my response would be inadequate.
At the same time, Keri’s fiancé snarled, “So what are we going to do now … how are we going to manage this … how are you going to manage this?”
I usually try to get a feel of the situation when I’m in a room and calmly explain the current situation to the family, but now I was positioned in a very uncomfortable scenario where I felt there was no correct answer and finding a rapport with any single person interrogating me was becoming an impossibility.
I had carefully explained what I thought had happened overnight: Keri had aspirated either her saliva or some food she had eaten the evening prior. Because of this, she has a fever and is now unresponsive.
My impression was quickly dismissed by Keri’s mom, who had her own opinion as to what was wrong with Keri. “I know Keri, I take care of her every day, and she’s fine. There’s nothing wrong with her, and she’ll bounce back as she has done before.” She then asked me again, “So what do you want to do with her?” Without missing a beat, Keri’s fiance again forcibly confronted me immediately after she asked that question, “So what is going on with her now? How are we going to manage this?”
I tactfully responded to both of them by saying that Keri is dying. Just as I had delivered that last word, “dying,” her fiancé said, “No shit, I’m not an idiot! I know she’s dying, so what are you going to do now?”
I responded, “Keri looks uncomfortable. She is moaning; her facial expression appears to me that she looks uncomfortable, and her rapid breathing also denotes discomfort. I would like to start her on at least a bit of narcotic and a sedative routinely to help with her suffering.”
Keri’s mom looked at me and explicitly reiterated that Keri was fine and did not need any medicines that could harm her such as narcotics and sedatives and for me to leave her daughter alone. In fact, she felt so angered by my opinion that she insisted that I leave the room as I was making her feel very uncomfortable.
I respected Keri’s mom's request and left the room.
Keri’s mom was in denial. The reality of her seeing her daughter lying there as a patient in a hospice unit and not in her house where she was eating and interacting the other night, could not consciously register. The reality of a sudden and profound decline just was too difficult to accept, and denial was needed to protect her from this grave reality.
Keri’s mom expected me to align with her safe representation of reality. When I told her that Keri was dying, I triggered her repressed understanding of her daughter’s imminent death and put that knowing closer to consciousness. Since her mind was still not ready to deal with that, I became her mind’s projection of the true reality externalized and was antagonized by its need to protect itself. I became the external representation of what it feared the most—her daughter's death. In her mind, I became the Reaper and as her mind needed to protect itself by eliminating the threat (me) at any cost, I was told to leave the room.
Within the next day, with the help of many of my colleagues including our social worker, bereavement counselors, and via the patient work of her bedside nurses, Keri died peacefully.
I was heartened to learn that after our team’s continued interaction with Keri's family, her mother was able to accept her daughter’s imminent death, and soon after our conversation, changed course and let us start her daughter on the appropriate palliative care medications to make Keri’s death peaceful.
Denial is a potent and necessary defense mechanism that our mind deploys, especially in times of trauma. It functions as the mind’s protector when reality is too hard to bear. Recognizing its appearance is vital for a therapist (therapeutic team) in helping the client/family cope with trauma.
