When we look back in time and study old cultures and people, we are impressed that death has always been distasteful to man and will probably be.

This is very understandable and can perhaps best be explained by our basic knowledge that, in our unconscious, death is never possible in regard to ourselves.

It is inconceivable for our unconscious to imagine an actual ending of our own life here on earth, and if this life of ours is to end, the ending is always attributed to a malicious intervention from the outside by someone else.

In simple terms, in our unconscious mind we can only be killed; it is inconceivable to die of a natural cause or of old age.

Therefore, death is itself associated with a bad act, a frightening happening, something that in itself calls for retribution and punishment.

One is wise to remember these fundamental facts as they are essential in understanding some of the most important, otherwise unintelligent communication of our patients.

Death has always been, and is still, a fearful, frightening happening, and the fear of death is a universal fear even if we think we have mastered it in many levels.

What has changed is our way of coping and dealing with death and dying and our dying patients.

We would think that our great emancipation, or knowledge of science and man, has given us better ways and means to prepare ourselves and the families of dying patients for this inevitable happening. Instead the days are gone when a man was allowed to die in peace and dignity in his own home.

The more we are making advancements in science, the more we seem to fear and deny the reality of death.

Maybe the question has to be raised: are we becoming less human or more human? Whatever the answer maybe, the patient is suffering more - not physically, perhaps, but emotionally. All his needs have not changed over the centuries, only our ability to gratify them

To tell or not to tell, that is the question.

Doctors, hospital staff, and nursing staff are always concerned for a patient's tolerance of "the truth".

"Which truth" is usually our question. The confronting of patients after the diagnosis of malignancy is made is always difficult.

Some doctor's favor telling the relatives but keeping the facts from the patient in order to avoid an emotional outburst. Some doctors are sensitive to their patient's needs and can quite successfully present the patient with the awareness of a serious illness without taking all hope away from him.

This question should never come up as a real conflict.

The question should not be "Should we tell…? But rather "How do I share this with my patient?"

I will try to explain this attitude. I will therefore have to categorise crudely the many experiences that patients have when they are faced with the sudden awareness of their own finality.

As I have previously said, man is not freely willing to look at his own end of life on earth and will only occasionally and half-heartedly take a glimpse at the possibility of his own death. One such occasion, obviously, is the awareness of a life-threatening illness. The mere fact that a patient is told that he has cancer brings his possible death to his conscious awareness.

It is often said that people equate a malignancy with terminal illness and regard the two as synonymous.

This is basically true and can be a blessing or a curse, depending on the manner in which the patient and family are managed in this crucial situation.

Cancer is still for many people a terminal illness, in spite of increasing numbers of real cures as well as meaningful remissions.

I believe that we should make it a habit to think about death and dying occasionally I hope before we encounter it in our own lives.

If the doctor can speak freely with his patients about the diagnosis of malignancy without equating it necessarily with impending death, he will do the patient a great service.

He should at the same time leave the door open for hope, namely, new drugs, treatments, chances for new techniques and new research.

The main thing is that he communicates to the patient that all is not lost; that he is not giving up because of a certain diagnosis; that it is a battle they are going to fight together -patient, family, and doctor - no matter the end result. Such a patient will not fear isolation, deceit, rejection, but will continue to have confidence in the honesty of his doctor and know that if there is anything that can be done, they will do it together.

Such an approach is equally assuring to the family who often feel terrible impotent in such moments. They greatly depend on verbal or nonverbal reassurances from the doctor.

They are encouraged to know that everything possible will be done, if not to prolong life at least to diminish suffering.

If a patient comes with a lump in the breast, a considerate doctor will prepare her with the possibility of a malignancy and tell her that a biopsy, for example, will reveal the true nature of the tumor.

He will also tell her ahead of time that a more extensive surgery will be required if a malignancy is found.

Such a patient has more time to prepare herself for the possibility of cancer and will be better prepared to accept more extensive surgery should it be necessary.

Another patient's response may be, "Oh, doctor, how terrible, how long do I have to live?" the doctor may then tell her how much have been achieved in recent years in terms of extending the life span of such patients, and about the possibility of additional surgery, which has shown good results; he may tell her frankly that nobody knows how long she can live. I think it is the worst possible management of any patient, no matter how strong, to give him or a concrete number of months or years. Since such information can be wrong too, and exceptions in both directions are the rule, I see no reason why we even consider such information.

I think different patients react differently to such news depending on their personality makeup and the style and manner they used in their past life. People who use denial as a main defense will use denial much more extensively then others. Patients who faced past stressful situations with open confrontations will do so similarly in the present situation. It is therefore, very helpful to get acquainted with a new patient, in order to elicit his strengths and weaknesses.