The Situation of the Terminal Cancer Patient I do not know how many of you here today have had a primary exposure to someone whom you knew well and intimately who was dying of cancer, but at best this is a grim situation. What do we usually find happening? In my work with such patients I have become keenly aware of the fear, depression, anxiety, loneliness, and suffering which are usually present. There is a certain degree of underlying fear on the part of everyone involved—not only the patient himself, but also his family and friends, the nurses, and even the doctors. This fear manifests itself in many ways, both consciously and unconsciously, and is basically a fear of the unknown. No matter how much we have been told about death, its implications for life, or what might follow afterwards, down deep we all know that some day each one of us must face this experience as an individual at the end of his own life. This is a very personal thing, and one that can stir deep emotions in any person who is involved even as an observer. Thus, it is not surprising that frequently in this situation the fear is expressed by an avoidance of the issue in many ways, some subtle and some not so subtle. There is hesitation to tell the dying person the gravity of the condition, especially if his diagnosis is cancer. Doctors many times advise the distraught family not to tell. The implication is that the patient psychologically could not take such ominous news and would disintegrate under the stress. A common rationalization is that hope would be taken away and the patient plunged into a deep depression. The assumption is made for the patient that if he knew the truth, a bad situation would automatically be made worse. By this line of reasoning, any show of powerful emotions, even though genuine, is to be avoided at all costs because the patient cannot take it. But what the family really means is that they themselves are afraid to face the fact of death. Undoubtedly, such a course of action, though admittedly dishonest, seems justified by the situation "for the patient's own good" and is many times the easiest thing to do at first. The patient's direct questions, if any, are parried with cheerful reassurance or adroitly avoided by changing the subject or avowing ignorance. Nurses can do the same or, if cornered, can refer the patient to his doctor, who can fill the time spent with the patient during medical rounds with questions about details of bowel function, appetite, and pain control. But what does the patient think and feel about these happenings? At first he may believe everything he is told, especially because it is what he would like to think, but as his condition worsens into a progressively downhill course, he may realize more and more that something more serious is occurring. In spite of the natural defense of denial, which can sustain some patients for a while, he will begin to wonder if he is being told the truth. If the pretense is continued, and sometimes at this point it is even intensified, the patient will be getting a powerful nonverbal message to avoid the issue. The fears of the family will also be communicated and will reinforce the patient's own private anxiety. Picking up the emotional turmoil of the family in spite of attempts to hide it, the patient wonders what they really know, but out of concern for them chooses not to bring up issues which they are obviously avoiding. Each side then attempts the heroic posture of protecting the other from what is imagined to be too difficult to bear. The more this dishonesty is perpetuated, the more difficult it is to face the issues, and the more desperate the situation becomes. Family members wonder what the patient will think of them if he finally finds out that such vital information has been withheld. It is almost as if the participants really believed that not talking about something unpleasant would make it magically disappear. Perhaps the most devastating effect of such deception, even when done with the honest intention of trying to make the patient's burden lighter, is to increase the patient's psychological isolation. At the very time when the welfare and support of those closest to him could help him the most he feels cut off at a basic level because his trust is undermined. He cannot even talk about the things which concern him deeply. In actuality the emotional pressure is increased for both patient and family at this deadly game of pretense is played out. It is no wonder that under such circumstances most patients become depressed. With cancer patients the usual downhill course also involves an increase in pain and suffering. When this is treated with increasing doses of narcotic pain-killing drugs, there is increased clouding of consciousness. Aldous Huxley in his last novel, Island, describes the all too common situation for the dying cancer patient as increasing pain, increasing anxiety, increasing morphine, increasing addiction, increasing demandingness, with the ultimate disintegration of personality and loss of the opportunity to die with dignity. To this list I would add psychological isolation, withdrawal, and depression. The LSD research in which I have engaged for the last few years has been an attempt to alter this dehumanization in the course of events prior to death. How, you may ask, can the use of LSD, a powerful and sometimes dangerous psychoactive drug, be of any value to a person who may soon be dead? Don't these poor patients have enough drugs already—anti-cancer medicines, pain-killing narcotics, tranquilizers, and anti-depressants, to mention only a few?