The Value of Ambivalence & Procrastination for Patients

By Lukas Radbruch, MD
Chair, IAHPC Board of Directors

Some time ago I was visiting a patient with advanced cancer in his home, as part of our specialized palliative home care service here in Germany. When sitting in his living room, with his wife by his side, he told me that he was doing quite well right now. He had recently begun third-line chemotherapy, and said that he had to stay one week in hospital for the chemotherapy course, then had another week suffering from nausea and other treatment-related symptoms, then had a third week feeling pretty well before the next course started the sequence all over again. He told me that he and his wife had made good use of that third week recently by taking a short trip to London. He really enjoyed that trip, and said that they might take another short trip, maybe to Paris, if he experienced another good week after the next chemotherapy course. 

I saw how his face lit up when he talked about this short holiday, and I knew that the oncologists were not at all optimistic about this third-line chemotherapy, which they had offered as a "last chance" option. So I suggested that it might be better to stop chemotherapy, and not have all the treatment-related impairments, so that he could use the time instead to plan a series of short trips—like the one he had enjoyed so much. 

He very kindly listened to me, then replied: “Well, let’s see how the next chemo course will be: maybe we can do another short trip if everything works out like last time.” I thought maybe he had not understood, or I had not explained well enough, so I repeated my explanation, but, again, he responded that he would see how the next course of chemotherapy would work out. I finally understood that he did not want to give up chemotherapy yet. Upon reflection, I realized that continuing chemotherapy gave him twice as many options for action as stopping. 

This made me think about the value of ambivalence for patients with progressive health conditions. 

Maybe just for this week...

I remembered the first patient we had on our new palliative care unit at the University Hospital Bonn many years ago who was feeling much too ill to undergo chemotherapy, but for several weeks declined to break off chemotherapy completely. Instead, she insisted that it be paused just for this week, and could perhaps be continued next week. I thought about other patients who found it much easier to pause treatments rather than stop them once and for all. “I do not want that treatment now, but I may still want it in the future,” seems to be the essence of the ambivalence that many patients express.

I also noticed that the palliative care team lacked understanding for this ambivalence, and grew more impatient as it persisted. “She needs to decide what she wants, chemotherapy or hospice care” was a typical statement in team meetings. For the team, ambivalence is often viewed as a lack of decision that prevents the organization of care and discharge from the palliative care unit.

Sometimes I feel that it is the care team that wants a clear decision, whereas patients prefer to keep all options open, and not make irreversible decisions. From the patient perspective, ambivalence seems to have a significant value, whereas from the caregiver perspective it feels like procrastination of the inevitable. 

Research typecasts ambivalence as an obstacle

Palliative care research has dealt with ambivalence, but mostly in connection with the wish for hastened death. Palliative care patients describe the ambivalence between the wish to die and a concurrent wish to live. This ambivalence is a major factor in the very cautious approach that many palliative care professionals have toward a wish for hastened death.^1,2 Ambivalence and hesitation has also been discussed in the context of advance care planning.³

Ambivalence seems to be a frequent phenomenon with decision-making: it has been described in 82% of all patient encounters. However, in most publications it is perceived as an obstacle that must be overcome by the health care professionals, as it procrastinates decisions that patients need to make.⁴ There has been an effort for a more refined taxonomy, differentiating between a lack of adequate information, the slow evolution of patient preferences, indecisiveness, vacillation, conflict avoidance, the desire to disagree with others, apathy, indifference, and “true” ambivalence, where the patient is in a “both” or “neither” state of preferences, endorsing multiple but incompatible options.⁵  The authors list strategies for addressing these different types of (true or false) ambivalence, but also describe some practical and epistemic value of ambivalence. For example, it could be evidence that the patient is truly engaging and reflecting on the available options. Or ambivalence could be a natural part of the process of meaning-making.

Other ways to view it

Other authors have confirmed this positive view of ambivalence. Ohnsorge et al. commented that the focus of health care professionals should not be on resolving ambivalence, but rather being aware of the fundamental tensions involved in existential crises by listening to patients’ stories.⁶  Arnold described ambivalence and ambiguity as part of Western culture when dealing with death and dying.⁷ Patients want to live as long as possible, but do not want to waste valuable life time with futile treatments. This leaves patients with the central questions whether now is the time to stop interventions, and how to maintain hope for the future. Arnold summarizes that both patients and their health care providers want "a good death," but not a minute too soon.

Ambivalence is closely related to other concepts. In a joint research group with medical and social sciences and humanities we have worked on an interdisciplinary understanding of resilience.^8,9 The model of resilience we discussed included ambivalence, together with hope and struggling with destructivity, as dynamic basic phenomena of resilience that complement the coping strategies and interactions that are more visible proponents of resilience. 

Ambivalence & ambiguity differ

There is also a relationship between ambivalence (having mixed feelings or internal conflict) and ambiguity (unclear situations or options). Ambiguity depends more on external factors than on internal priorities and values. Tolerance for ambiguity is a major resource for patients in those phases of the illness trajectory where no clear care and treatment pathways have yet emerged, for example, immediately following the diagnosis of a life-threatening disease. 

Questions to ask ourselves

In summary, I would postulate that palliative care professionals need to understand ambivalence not as an obstacle to overcome, but as a resource that patients use in order to expand their range of options. We should respect ambivalence in our patients, while recognizing that we become impatient because we want to proceed and think that we know what the right decision pathway is for the patient. My standard question in team meetings for this kind of situation is, “So who is having this problem? Is this a problem for the patient, for his family caregivers, or for us, the health care providers?” 

Quite often we then realize that we feel the urge for action, but that ambivalence and procrastination may be most appropriate from the patient’s point of view. From the patient perspective, resilience does not always mean that the patient needs to plow ahead against all adversities, but sometimes is best served by keeping all options open by not making any final decisions just yet. 

References

1. De Lima L, Woodruff R, Pettus K, Downing J, Buitrago R, Munyoro E, Venkateswaran C, Bhatnagar S, Radbruch L. International Association for Hospice and Palliative Care Position Statement: Euthanasia and Physician-Assisted Suicide. J Palliat Med 2017; 20: 8-14.
2. Radbruch L, Leget C, Bahr P, Muller-Busch C, Ellershaw J, de Conno F, Berghe PV, Epac. Euthanasia and Physician-Assisted Suicide: A white paper from the European Association for Palliative Care. Palliat Med 2016; 30: 104-116.
3. van Wijngaarden E. Embracing Ambivalence and Hesitation: A Ricoeurian perspective on anticipatory choice processes at the end of life. Med Health Care Philos 2024; 27: 555-566.
4. Gupta MND, Hantzmon SV, Kutner JS, Arnold RM, Duck V, Mahoney H, Willis E, Pollak KI. Patient and Caregiver Expression of Reluctance and Ambivalence During Palliative Care Encounters. J Palliat Med 2023; 26: 1391-1394.
5. Moore B, Nelson RH, Ubel PA, Blumenthal-Barby J. Two Minds, One Patient: Clearing up confusion about "ambivalence". Am J Bioeth 2022; 22: 37-47.
6. Ohnsorge K, Widdershoven G, Gudat H, Rehmann-Sutter C. Ambivalence: The patient's perspective counts. Am J Bioeth 2022; 22: 55-57.
7. Arnold R. Ambivalence and Ambiguity in Hospitalized, Critically Ill Patients and Its Relevance for Palliative Care. J Palliat Med 2000; 3: 17-22.
8. Maus K, Peusquens F, Kriegsmann-Rabe M, Matthias JK, Ates G, Jaspers B, Geiser F, Radbruch L. 'Not a Panacea' - Expert perspectives on the concept of resilience and its potential for palliative care. Palliat Care Soc Pract 2024; 18: 26323524241254839.
9. Peusquens F, Maus K, Geiser F, Jaspers B, Radbruch L. [Who is afraid of Ockham's razor? : A discourse analysis on resilience in palliative care (2000-2021)]. Schmerz. 2023; 37: 107-115.

Read Dr. Lukas Radbruch's bio.

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