“I’m not ready to talk about that, doc.”

(In my mind only) “What do you mean you aren’t ready? You have breast cancer with mets all over your body. You can’t walk from spinal mets causing paraplegia. You just suffered a massive pulmonary embolism and almost got intubated. You have terminal illness. All I ask is that we try to determine who would make decisions if you couldn’t. To consider if you would want your ribs cracked and a tube shoved down your throat before you die. Is that too much to ask? How can you be in so much denial?”

Those words are never said. Nor should they. But the visceral reaction remains. The frustration. The anger. The desire to break through the denial, open her eyes, make her see the truth.

And then what? Strength rises up? She comes to terms with it. Makes peace. Finds acceptance. Her spirit rises. Or does she cry? Fall apart. It’s all too much. Her spirit falls into the depths of hell. Unable to cope with reality. Treatments become useless. The will to live fades and she dies several days later.

But wait, the palliative care team told me I had to at least give her an advance directive. Do I go back in failure? Can I at least sneak one in at bedside? Even though she explicitly told me she doesn’t want to look at it.

Merriam-Webster defines denial as “refusing to admit the truth or reality of something unpleasant.” Well, truth and reality are good. Then denial is bad, right?

Chaplain Kevin said “Denial is a cousin of strength. The mindset that gets us past mile 22 of a marathon. How moms keep pushing hours upon hours in labor. Let us also not forget that denial is a stage of grief. (No) one can arrive at a place of acceptance and peace with loss without some healthy levels of denial. Denial gets a bad rap. But at its core, it’s strength.”

Denial as strength? I never considered that. What about the denial that my divorce was going smoothly? Isn’t that what got me through those dark times? What about my current denial of already feeling burned out in palliative care? Will that denial get me past mile 22? Is denial no longer the wall around the fortress? That which we need to destroy in order to obtain the riches? Could denial be protecting that which we are not entitled to? Are we merely invaders? War mongers focused on conquest.

She left the hospital the next day. A 57-year-old woman, extremely successful as the CEO of her own built from the ground talent agency. Money beyond your wildest dreams. No family or close friends. Presented 2 months ago with leg weakness, found to have spinal mets, now paraplegic and with a PE. Trying to rehab. Hopeful she will recover. Palliative care consulted.

We never discussed advance care planning. What happens if she comes back in cardiac arrest? With mets to the brain and unable to make decisions? Did I fail her on this visit?

Or was denial what allowed her to make it through this hospitalization and return home?