Open awareness and dying: The use of denial and acceptance as coping strategies by hospice patients

Abstract

This paper examines the use of denial and acceptance as interdependent and fluctuating coping strategies by dying patients in a hospice, and discusses some of the reasons why denial and acceptance operate for these patients. 'Open awareness' of dying is now accepted as a central feature of palliative care, and full disclosure of prognosis and diagnosis is seen as a desirable element of care for patients who are dying. However, such openness is not without its tensions and conflicts. The study was conducted in a hospice where patients and nurses interact within an 'open awareness' context and where most patients live in the knowledge of 'certain death but at an unknown time'. The paper examines use of denial and acceptance by hospice patients at various times during their dying. The data are derived from the findings of a prospective qualitative study on the experiences of 12 hospice patients and those of their nurses. Unstructured interviews and participant observation were used as the primary methods of collecting data. Data from interviews were coded and comparative analyses between cases were performed. Denial and acceptance of dying among patients fluctuated during the period of dying and appeared to form an important aspect of their coping process. Denial and acceptance appeared to be used to avoid threats as well as to preserve existing relationships within the context of open awareness. In contrast to some commonly held beliefs, which tend to view denial and acceptance as 'singular, either/or entities', denial and acceptance are best seen as interdependent and fluctuating strategies, used continually by dying patients.