Handling Collusion, Denial
and Anger
Dr Ruparna Khurana
MBBS, DNB(RT), Ex-SR PM AIIMS
Consultant Palliative Medicine, HOPE oncology

• Respect the time frame provided to me
• Don’t want to overburden you with information blast
• Retain time for reflecting what you have understood
• Questions /doubts/confusions
• Understood anything/something/nothing!

Palliative care

Handling Collusion, Denial and Anger

Etymology
• Latin word ‘colludere’
• Col : together
• Ludere : to play
"to play together,“
• Collusion early 16th century
• Situations in which individuals entered into secret agreements.

In PC..
• Patient family
• Family + health care tram
• Patient plus health care team
• Patients generally know…

Reasons for colluding
• Patient will lose hope
• Depression
• Hastens progression  death
• Suicide
• Psychological pain
• Unawareness amongst caregivers
• Denial
• Conflict

Problems of not telling the truth
• No open discussions possible
• Patient will remain unaware of the gravity of the situation
• Conspiracy of silence
• May hinder treatment
• Unsettled/ unresolved issues
• Lack of trust in family members and the healthcare team
• Patient will not be able to plan ahead / Unfinished business

Benefits of breaking the collusion
• Open discussions
• Patients will be at peace and accept
• Restore trust in healthcare system
• Adhere to treatment
• Plan ahead
• Good deatrh

Handling
• Acknowledge – act of love
- need to protect
• Explore – understanding and reasons
- cost to colluders
• Empathise
• Discuss the pros/cons

• Has the patient expressed a wish to know
• What if they were the patient
• Assure the family that diagnosis will not be revealed if patient
is not willing
• Arrange to talk again and raise possibility of all being aware of
reality.

• Gently break the collusion
• Breaking the bad news

• Elisabeth Kubler Ross
• Swiss American
• Psychiatrist
• 1969 Book – Death and Dying

Denial

Patients who appear not to acknowledge their diagnosis
or its gravity, are said to be ‘in denial’

Denial
• Patient's refusal to take on board the bad news
• Not wanting to know the diagnosis
• Not mentally prepared to handle the news
• When a person finds the challenges too overwhelming

• Difficult emotional challenges at the EOL:
Loss of control
Loss of roles and responsibilities
Anger
Guilt
Loneliness and isolation
Spiritual crises

• Coping/ defense mechanism
• Helps to avoid painful thoughts and feelings
which are difficult to deal with
• Serves a protective function by keeping at bay damaging thoughts

• Respect for the essentially protective nature of it.
• Do not judge as “good” or “bad,”
• Instead “Is this reaction/response helping the patient cope with his
challenges?”

Subconscious disavowal
• 71- year- old retired oncology nurse
• Presented @ ED with abdominal pain
• Large fungating chest wall lesion : advanced breast
cancer
• Investigations - chest wall invasion and liver metastasis
• Her version : 20 years, not cancer, dermatitis
• Nothing to worry about.

Handling denial
1) Recognise and confirm : misunderstanding/ misinformation/
neuropathology
2) Determine if its adaptive or maladaptive
3) Provide information tailored to patient’s needs
4) Explore emotional reactions and respond with empathy

Anger

Causes for anger in PC
• Poorly controlled symptoms
• Miscommunication / Lack of communication
• Lack of trust on health care providers
• Collusion, denial
• Unresolved family conflicts
• Frontal lobe disease/ Brain mets

Handling Anger
• Invest some time
• Dial up the empathy
• Keep your cool
• Mind your body language
• Physically protect yourself
• Legally protect yourself
• Try and end the conversation on a positive / helpful note

BATHE technique
• Background: active listening to understand the situation
• Affect:/Acknowledge: Name and validate the emotion. Do NOT counter
• Trouble: Ask what troubles / scares them
• Handling: How are they handling the dying – are they making concrete
plans about their finances, their things, their family?
• Empathy: feel understood, less abandoned and alone. “..I can only imagine
what you are going through…”

ANGER
Effective Ineffective
Acknowledge
anger
Dismiss anger
Identify focus Refute focus
Legitimise
Defend actions of
colleagues
Encourage expression
Anger
increases
Anger is
diffused

Your thoughts

Thank you