Existential Analysis 17.1: January 2006
Death and the Doctor Elaine Kasket Abstract Review of the academic literature and popular press suggests that physicians have considerable difficulty with issues of death and dying. This is often reductionistically attributed to such factors as insufficient training in communication skills, but death denial, death anxiety, and the emotion-management rules of the profession all play their part.
The Denial of Death The knowledge and anticipation of death has always been a tricky area for humans, theoretically the only animals with the ability to contemplate their own demise (Becker, 1973). Most of the terrors that the world holds for us are intimately connected to our fear of death (Keen, in Becker, 1973), of the near-inconceivable end to our being. The defenses that we construct against this perceived horror underpin most neuroses, psychoses, and other maladaptive ways of interacting with the others and the world (Yalom, 1980). Yalom reminded us, as did Tillich, Heidegger, Sartre, Frankl, and others before him (van Deurzen-Smith, 1997), that facing death can enrich our lives by allowing us to live more purposefully and to appreciate what life we have more deeply – Heidegger termed it “Being-towards-death” and argued that it was the key to an authentic existence (Heidegger, 1926/1962). The idea of facing death head-on, however, is too difficult for many of us, particularly when it is our own death that we confront; we defend against our anxiety through various forms of denial, sometimes half-realizing what we do and overtly asserting that this is the only way to have a comfortable life. This denial of death is not a new phenomenon. However, what may be new is the modern experience of dying, which is different and perhaps more difficult than it was even a generation or two ago. The increased involvement of science, machines, and general technology in the medical realm makes the field a different world today than it was not long ago (Kübler-Ross, 1969; Thompson, 1988). It was once the case that doctors and priests inhabited nearly the same sphere: the priest attended the soul, the doctor the body, both of them knowing and accepting the power of their common, faceless enemy, both of them operating against the frightening backdrop of impending death. With the modern decline of religion and elevation of science and technology, the the fight against death is a war, with the charge led by the physician. 137
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Society and patients cast physicians in a highly pressurized role that is both potentially rewarding and potentially awkward. Irvin Yalom (1980) described an often-employed system of denying death that he terms “the belief in a personal ultimate rescuer.” This comforting delusion consists of the belief that somehow one will be snatched from the brink of the grave, that someone will intervene, that death will never really befall one. In the context of childhood, if the child has been well cared for, the all-powerful protector and ultimate rescuers are the parents, who reassure the child that there is no reason to fear (Becker, 1973). In the context of spiritual or religious belief, the ultimate rescuer is God or some kind of higher power, who either will not allow one to die or will ensure that one will have a better life after death or will be born again (Yalom, 1980). In the context of fatal illness, the ultimate rescuer is the physician, the force who, in our society, has symbolic and perceived actual control over death (McQuade, 1992; Salander et al., 1999). This is a role that is imposed upon the physician because the patient wishes to believe in the physician’s ability to save him or her; however, the role is often eagerly accepted by the physician, “because playing God is the physician’s method of augmenting his belief in his personal specialness” [another of Yalom’s systems of death denial] (Yalom, 1980, p. 132). The physician’s desire to accept and succeed at the “Ultimate Rescuer” role is augmented by the difficulty of dealing with the patient’s reactions when efforts fail. Physicians’ denial and avoidance of death is something that many researchers, including Elisabeth Kübler-Ross and Herman Feifel, have run up against in their research on death and dying (Kaspar, 1959; KüblerRoss, 1969; McQuade, 1992). Kübler-Ross found that doctors were resistant to and angry about her efforts to get access to their dying patients, sometimes flatly denying that they had any terminally ill patients on their caseload (Kübler-Ross, 1969). One of the most critical of these fears may be physicians’ own fear of death, so that when patients implore their physician to save them from death, their pressure may be adding weight to another, more internal concern. It has been suggested that those who enter the medical field may be partly motivated by a personal need to overcome death anxiety – if indeed it can be completely overcome, for although their powerful role in curing or saving patients from death may assuage their more conscious fears about death, the deeper, more primal fears that pushed them into the profession may still exist (McQuade, 1992; Yalom, making reference to Herman Feifel, 1980). These deeply-felt anxieties can be a powerful impetus to enter and succeed in the profession: “Here we glimpse part of the psychological motivation of the doctor: to cure himself, to live forever. We all work to live, but the doctor has a bonus incentive: he works directly against Man’s adversary, Death” (Kaspar, 1959, p. 260). 138
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An Education in Emotion Management Everyone engages in emotion management. In a competitive, not-alwaysfriendly world, social survival-of-the-fittest involves learning to protect oneself by being relatively emotionally invulnerable, by not showing one’s feelings. When this emotional suit of armor is worn for too long in too many situations, however, a person may become unaware of the true nature of his or her own feelings. “Instead, there may be a vague feeling of discomfort or unhappiness that the person can’t easily pinpoint” (Aronson, 1996, p. 401). Being divided from one’s own feelings makes it difficult to either understand them oneself or to articulate them to others, which contributes to deficient communication skills – a problem that is often identified in physicians who are trying to communicate about death and dying (McQuade, 1992). Aronson assured us that these skills – being in touch with your emotions, communicating them to other people – can be learned, but that they are better absorbed from experience than from textbookreading. He suggested that such learning will be most effective “if it takes place in a relatively safe, protected social environment where people can practice straight talk without fear that others will take advantage of their situation” (Aronson, 1996, p. 401). Medical students, encountering mortality up-close-and-personal for perhaps the first time in their young lives, need to learn how to cope emotionally, as well as practically, with the fact of death (Cowell, Farrell, Campbell and Canady, 2002). The question is: Is medical school the kind of safe, protected environment where experiential learning of this type can take place? In The Managed Heart (1983), Hochschild described the features of those professions that involve “emotional labor.” Workers in emotionally laborious jobs are required to produce certain emotional states in others, such as fear, gratitude, happiness, comfort, or relief. These jobs “allow the employer, through training and supervision, to exercise a degree of control over the emotional activities of employees” (Hochschild, 1983, p. 147). Hochschild identified medicine as emotional labor but noted that physicians “do not work with an emotion supervisor immediately on hand. Rather, they supervise their own emotional labor by considering informal professional norms and client expectations” (p. 153). It seems that “informal professional norms” may be interpreted to mean, in part, the expectations of one’s colleagues and superiors, as well as the doctor’s selfperception of how well he or she conforms to what is seen as “proper” behavior for a physician. Certainly, although an “emotional supervisor” might not be overtly present, awareness of professional norms and of expectations from all sides might certainly make a physician feel that emotional faux pas will be noticed and disapproved of by someone.
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As noted above, it has been suggested that those who choose to enter the medical profession may do so in part to work out their own death-related concerns, and it seems that changes in death-anxiety levels and in styles of coping may begin to occur even before medical school commences. In an investigation of the relationships among death anxiety, apprehensiveness about communicating with the dying, and empathy in U.S. undergraduate pre-medical students, it was discovered that seniors were less apprehensive than were freshmen about communicating with a dying person; however, over the four years of their pre-med education, their degree of empathy dropped (Servaty, Krejci, and Hayslip, 1996). It is when medical school begins, however, that the real education in emotion management begins. The first 3 years are a crucial time for medical students – it is during this period that they gain basic knowledge, develop skills and attitudes, and begin to develop their professional identity (Barnard et al., 1999). When emotional expression is discouraged or not allowed space, when faculty members do not ask about students’ affective responses, when it is explicitly stated that too much emotional involvement will interfere with good patient care, and when hard work and academic pressures are so strong as to cause emotional blunting, medical students get the message that negative emotions and their management are a private matter and their own “problem,” to be dealt with by themselves (Smith and Kleinman, 2001), and not part of their professional development (Barnard et al., 1999) . Bertman (1997) told the story of one medical student who admitted, apologetically, that “non-medically-oriented” issues kept coming up for him – by which he meant his own grief, his own emotional difficulty in dealing with death and dying. His sheepishness at this confession and the vocabulary he used (“non-medical issues”) shows how well he had been taught that his own feeling responses should remain outside the realm of his practice of medicine. These lessons in emotion management and the feeling rules of the profession are sometimes referred to as medical school’s “hidden curriculum” (Barnard et al., 1999; McQuade, 1992; Smith and Kleinman, 2001). The syllabus of the hidden curriculum comprises “the everyday routines, assumptions, and experiences students encounter from their very first day that communicate what the ‘real’ priorities and values of medicine are” (Barnard et al., 1999, p. 503). In these initial years of medical school, dealing with death face to face is not usually an issue for some time. Contact with living, breathing patients constitutes less than 3% of medical students’ school time over their first 3 years (Smith and Kleinman, 2001). The medical student’s first “patient” is one that would naturally bring up many thoughts and feelings about death and dying – one of the first tasks of the newly matriculated 1st-year medical student is to dissect a human cadaver (Bertman, 1997). These emotional responses are quickly blunted, however, and students “clearly 140
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demonstrat[e] the rapid acquisition of coping mechanisms to death” (Charlton, Dovey, Jones and Blunt, 1994, p. 294). The primary coping mechanism taught and absorbed during this time period, one which seems to serve physicians well throughout their subsequent professional lives, is the detachment-provoking defense of intellectualization, a coping response that is not only effective, but is valued and rewarded in medical academia and practice. To dissect a cadaver is not simply a neutral, technical exercise, but raises questions about the relationship between human biology and human dignity, mortality, grief, and how to deal with emotions experienced by both patients and doctors. The natural tendency of the… student faced with the dissection of a human body is to intellectualize, as this accelerates coping with the stressful situation (Charlton et al., 1994). Many physicians can recall the gradual emotional detachment that they experienced as cadaver dissection progressed and no mention was made about the cadaver’s having been a person, no questions asked about the students’ emotional responses (Bertman, 1997). The cadaver is viewed as something not quite human, but rather a dead animal, an object, a complicated machine, an engine to take apart (Smith and Kleinman, 2001). The response that is encouraged is not an emotional, caring one; such an approach will not allow the student to complete the task at hand, to make the grade. “The absence of discussion of reactions to dissection in the anatomy lab… gives a strong message about how ‘professionals’ are ‘supposed’ to handle such experiences” (Barnard et al., 1999, p. 503). The preferred approach is a mechanical, analytic one. This so called “analytic transformation” of the potentially meaningful and emotion-provoking realm of human bodies becomes the medical student’s primary method of managing emotions (Smith and Kleinman, 2001). During this time period, early in medical school, students develop additional techniques of coping and emotion management that may stay with them through the remainder of their careers. They learn and adopt scientific, technical language, which can transform a person into a case report, a collection of clinical information (Smith and Kleinman, 2001). They analyze “cases” rather than people, the effect of which Bertman described as the evaporation of a human response to human suffering – just as poetry evaporates when it is translated into another language. They use humor, often black humor, around the dissecting table – this is one way to talk about their feelings without really having to reveal their weaknesses in an academically competitive environment (Smith & Kleinman, 2001). They put the lid on their emotional responses; 21% of one surveyed group admitted to deliberate suppression of feelings so that they might remain 141
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“objective” (Penney, 1985, cited in Charlton et al., 1994). They keep their feelings to themselves. Considering that emotional awareness is linked with effective communication skills (Aronson, 1996), it is little wonder that medical training is associated with a reduction in communication skills (Charlton et al., 1994; Helfer, 1970). Death-anxious medical students who avoided death-and-dying electives in their preclinical years may find that their avoidance becomes more pronounced in the clinical years, when they begin seeing real-life patients. Students may cut short the kinds of contact that give rise to uncomfortable feelings, sometimes eliminating that contact altogether. The extreme of this avoidance is choosing specialties in which they are unlikely to be confronted by death as a major part of their work - psychiatry, cosmetic surgery, or pathology, for example (McQuade, 1992). Other emotion management strategies are empathy, on the surface of it a valuable quality, to deflect attention away from their own feelings by focusing upon the patients’; blaming the patient, making the patient responsible for their (the doctor’s) own feelings; and projecting their own emotions onto the patient (Smith and Kleinman, 2001). Emotions may, in any case, be considerably blunted under the weight of fatigue and stress brought on by punishing work schedules, the new level of awesome responsibility for others’ lives, and the considerable academic pressure that are all hallmark features of the clinical years (Smith and Kleinman, 2001). When medical students have not been encouraged in their preclinical years to do self-reflection, to monitor their responses, or to notice their emerging defense mechanisms in the face of stress, they are perhaps less prepared to identify, to deal with, and to recognize the effects of these responses and defenses when they arise in practice. By the time a medical training is complete, and the newly qualified physician is launched into the rest of his or her career, considerably more than the technical, knowledge-based aspects of medical care has been learned. An acculturation has occurred, a personal system of dealing with death has developed, defenses have been erected, and coping mechanisms have been put in place - some beneficial, but some potentially detrimental to both doctor and patient.
The Emotional and Psychological World of the Practicing Physician The jury is still out on whether education about death and dying in medical school affects how physicians will react and respond to patient death. With the apparent deficits in that education, it would not be surprising if the lasting effects were negligible. Indeed, in a study of 1186 physicians 10 years after their graduation from medical school, the results showed that thanatology courses in medical school did not seem to make a major 142
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difference in attitudes toward death and terminally ill patients and their families (Dickinson, Sumner, and Durand, 1992). However, those physicians who had taken a course reported thinking about death more, were less likely to avoid telling a patient that he or she is dying, and were more likely to believe that physicians refer terminal patients to other doctors more often than nonterminal patients, in order to avoid having to deal with their eventual death. These results seem to indicate that, among those who had had coursework, there was a greater awareness level of both death and some of physicians’ responses to it. Another study indicated that doctors who had taken death-and-dying coursework scored lower on deathanxiety measures, appeared to be more comfortable interacting with dying patients, and were less likely to believe that patients should, in all cases, be informed of diagnosis and prognosis (Cochrane, Levy, Fryer, and Oglesby, 1990). Regardless of what was and was not taught in medical school, the fact remains that newly qualified doctors find themselves in a line of work where death is probably faced more often than in any other profession (Behnke, Reiss, Neimeyer, & Bandstra, 1987; McQuade, 1992). Oncologists deliver bad (i.e., about terminal illness) news to patients 35 times a month on average (Groopman, 2002). The stress of these types of experiences is significant and powerful. When 1435 newly qualified doctors were asked an open-ended question – to describe a stressful situation at work – almost all the incidents were strongly related to severe disease and death. Even when death did not constitute the main theme of the story, it lurked in the periphery, mentioned in an incidental fashion (Paice, Rutter, Wetherell, Winder, and McManus, 2002). Despite the constant presence of the stressors connected with death and dying, physicians are expected to maintain “affective neutrality,” one of the most highly valued aspects of a physician’s professional identity, as it is associated with power, knowledge, and being above challenge (Smith and Kleinman, 2001). A physician’s professional and sometimes personal sense of self is tied to being an affectively neutral technician (McQuade, 1992; Thompson, 1988), a cool-headed surgeon or A&E doctor, the person in control. They have taught and retaught, in myriad overt and subtle ways, that an effective physician should never become personally involved and hence emotionally involved with patients (Kasper, 1959). It is the signature feeling rule of the profession (Hochschild, 1983). There has not been a great deal of literature addressing the grief and coping mechanisms of physicians (Kalra, Rosner, and Shapiro, 1987; McQuade, 1992); perhaps this is because doctors have done such a good job of turning the face of affective neutrality to their colleagues and to the public, so that their patients (and increasingly, their patients’ lawyers) might always feel assured that the patient is safe in the physician’s cool and capable hands. It is believed that in order to stay effective, doctors should not experience 143
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grief, sadness, anger, anxiety, or depression in the face of patients’ deaths. And yet they do. In responding to safely anonymous questionnaires, doctors report a pattern of reactions to patient death that is similar to that usually associated with losing a friend, or a family member – a typical bereavement depression. They report appetite changes, sleep pattern changes, nightmares, body aches, energy loss, fatigue, recurring thoughts of the dead patient, guilt, irritability, anger, despair, emptiness, poor concentration, disturbances in the sense of time, feelings of unreality and of being shocked or numb, and loss of interest in sex, and feelings of futility, hopelessness and helplessness (Behnke et al., 1987; Groopman, 2002; Hamama-Raz et al., 2002; Kalra et al., 1987; Kasper, 1959; Pasnau, Fawzy, and Fawzy, 1987). Crises of identity or self-concept are frequently reported and observed in studies of physician responses to patient death. The dying patient challenges physicians’ carefully constructed and reinforced view of themselves that they are experts, who know what is wrong and who know what needs to be done to cure the patient. Not being able to effect that cure can lead to identity confusion (Severino et al., 1986), feelings of personal failure (Hamama-Raz et al., 2000) and self-esteem crises (Kalra et al., 1987). When doctors are asked about their vision of the ideal physician, results have shown that the perfect doctor is imagined to be less preoccupied with thoughts of the death, more likely to pour energy into reviewing the records for the cause of death, and more likely to seek professional help. When doctors find their own reactions and responses to be at odds with those they imagine the ideal doctor would have, they experience cognitive dissonance and inner turmoil (Behnke et al., 1987). After a death, physicians are left doubting themselves: Did they do something wrong? Could something more have been done to prevent the death? Is their grief reaction abnormal? Will it interfere with their work? (Cochrane et al., 1990). Death anxiety is yet another response to patient death. Physicians may experience patient death as a reminder of their own mortality, especially when they identify with the patient in some way (e.g., they were the same age, they had similar interests, or worst of all, the patient was a doctor). Death anxiety is also especially evoked when the patient reminds them of someone close to them who has died, rekindling their own past suffering, and perhaps unresolved grief issues (McQuade, 1992; Paice et al., 2002; Severino et al., 1986). Levels of death anxiety seem to vary according to the physician’s medical specialty. Those who have less contact with death report higher death anxiety, so that psychiatrists will be more anxious about death than surgeons. The reasons for this are not clearly understood: It could be that surgeons are more skilled at repression, or it could be that psychiatrists are more comfortable with talking about emotions and are 144
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more willing to confess to death anxiety on self-report measures (Viswanathan, 1996). Physicians also experience tremendous uncertainty in the face of death and dying – uncertainty about diagnosis, about treatment. Ambiguous medical situations or diagnostic mysteries provoke a terror of making a mistake, the kind of mistake that could result in death and that could not only shatter their own self-esteem or provoke a crisis of identity, but which could also have important consequences legally, professionally, and in how they are perceived by their patients and their colleagues (McQuade, 1992). Their anxiety and other emotional responses are understandable, for death is perhaps the most anxiety-provoking stimulus known to humankind. For physicians in specialties that deal with death on a regular basis, the build-up of stress over the long term results in lower feelings of mastery and more feelings of stress (Cochrane et al., 1990), and with that stress come more entrenched defense mechanisms. As has been noted previously, physicians are socialized to use analytical and rational ways of responding to threatening situations (Hamama-Raz et al., 2000). They intellectualise; they flee into the scientific paradigm (Thompson, 1988); they “take [their] own fears, put them as intellectual questions, and try to answer them for other people” (Kasper, 1959, p. 263). In responding in this way, they may be emulating the intellectual- and technical-oriented reactions of their perceived ideal physician (Behnke et al., 1987). In terms of behavioral coping strategies, it seems that more contact with dying patients is one coping mechanism that considerably affects levels of depression and death anxiety. For those physicians who have a high probability of contact with dying patients, there is less ruminating about whether something else could have been done and there is less discomfort in interacting with dying patients. Those physicians whose probability of contacting dying patients is low are more likely to report that death was the most unpleasant aspect of their work; they are more likely to avoid telling patients directly about their impending death; they are more likely to attend the funeral; and they find it harder to deal emotionally with the death. Overall, the more contact, the higher the comfort level – but whether this is through lessened death anxiety or more repression is difficult to say (Dickinson et al., 1992). Seeking out more death and dying experiences, however, is not a particularly common behavioral coping strategy for dealing with mortality; the most common methods are social-supportseeking (e.g., talking to someone about how they are feeling or accepting sympathy from a medical colleague), problem-focused self-talk (e.g., telling themselves that they will come out of the situation better than when they went in), avoidance (e.g., feeling bad that they could not avoid the problem), and wishful thinking (e.g., wishing that they could change what happened) (Paice et al., 2002). 145
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All of these internal emotional reactions and coping strategies have a significant impact upon professional behaviour. Generally, doctors seem to keep their emotional reactions to themselves. This reluctance to discuss emotional or psychological issues with colleagues seems to be a product of the “latent curriculum” of medical school, which continues on into the workplace and may be specific to physicians (Smith and Kleinman, 2001). Only a few doctors in Behnke et al.’s (1987) study discussed their reactions with colleagues, as opposed to nurses, for example, who use talking things over with colleagues as their primary way of combating stress (Alexander, 1990). The list of behavioral responses of 25 pediatric house officers in Behnke et al.’s (1987) study included lashing out at others, taking alcohol or drugs, blaming themselves, blaming others, doing physical exercise, shaking it off, reviewing the medical records (intellectualization), throwing themselves into work (avoidance), remaining unaffected by the death (avoidance), and crying. Often they simply cannot take the time to reflect or have a private emotional moment, and they may be emotionally numbed by fatigue anyway: “In the 17 hours to come [after a patient death], I slept only two hours and saw 40 patients” (Kasman, 1994, p. 433). Certain behavioral responses to death may come to form part of physicians’ overall approach to their medical practice. They may tend towards heroic attempts to sustain life, even when it is not appropriate, may favour resuscitation at any cost, may order a plethora of unnecessary tests for a patient who is clearly dying, or may use the prescribing of medications as an intellectual or academic defense against death anxiety (Kalra et al., 1987; McQuade, 1992). It is thought that this tendency towards heroic efforts at the end of life is one reason why health care costs are skyrocketing (Groopman, 2002). All of these behaviors and defenses have a significant effect on dying patients and their families (Severino et al., 1986), who often can sense the doctor’s emotions clearly (Kasper, 1959). If death anxiety is too low or is too repressed, the physician may demonstrate little empathy and be impaired in his or her ability to communicate (Viswanathan, 1996). Communicating such bad news is, physicians report, a major area of stress for them (Ptacek et al., 2001). Once the bad news is delivered, communication may cease entirely. Some doctors avoid the deathbed by handing over responsibility for the care of the dying patient to other people – nurses, social workers, relatives, and hospice workers (Kalra et al., 1987), leaving the patient feeling abandoned, fearful, and isolated as the end approaches (Patterson, 1989). Although there have been pleas for senior hospital staff and medical schools to be aware of sources of stress for medical students and doctors, and to be responsive to their need for support when they witness a lot of suffering and death, there is little evidence that this is happening. Junior doctors may build up an informal support network, centered on the 146
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doctor’s lounge (Lloyd-Williams, 2002), and physicians may seek the support of friends, families, or peers – but the nature of support, especially, from peers, is perhaps not what is most needed. Kasman may have described it best: Yes, I talked about the boy’s death. I shared it with other residents and with faculty. In the even light of day, we discussed how the boy was already dead and how I had done all that was possible. We reviewed the steps to have taken if the boy had had a pulse; how to intubate him and how to protect his spine. We learned the procedure for defibrillating a child and how to start an interosseous IV when indicated. Everyone said I had managed the situation well. They gave me their best support. But no one asked me how I felt. (Kasman, 1994)
Final Word The recitation of the Hippocratic Oath is a physician’s rite of passage, a doctor’s vow to uphold the ideals and aims of the medicine. Contained within that oath is the following passage: I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug… Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. (Lasagna, 1964) The word “frailty” could mean a number of things, and one could interpret “playing at God” in several ways. A new physician taking the Hippocratic Oath might see “frailty” as meaning “capable of making treatment mistakes”; he or she might take “playing at God” to refer to making decisions to cease someone’s life support, to assist a suicide, or something similar. The reminder about frailty and the warning not to play God, however, could assume a different meaning and contain an additional caveat for the physician: You are mortal. In doctors’ vulnerability to death, and in their primal fear of it, they are on par with any other humans, and yet we tend to treat them like gods or robots. It is only natural for their vision of themselves to fall into line with others’ persistent assumptions about them. As long as medical schools, training programs, hospitals, and society treat physicians as though they are immune to the grief and trauma provoked by
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patient death, physicians will continue to assume a mantle of invulnerability – one that hangs heavily about their shoulders. Elaine Kasket is the co-director of American Psychotherapy Associates, a private practice in central London. She received her MA in Psychotherapy and Counselling from Regent's College and completed her doctorate in Clinical Psychology in the United States. This paper is drawn from her doctoral dissertation, a phenomenological investigation into how physicians cope with patient death. Comments and responses can be emailed to
[email protected].
References Alexander, D.A. (1990). ‘Stressors’ and difficulties in dealing with the terminal patient. Journal of Palliative Care, 6(3), 28-33. Barnard, D., Quill, T., Hafferty, F.W., Arnold, R., Plumb, J., Bulger, R., et al. (1999). Preparing the ground: Contributions of the preclinical years to medical education for care near the end of life. Academic Medicine, 74(5), 499-505. Becker, E. (1974). The denial of death. New York: Free Press Paperbacks. Behnke, M., Reiss, J., Neimeyer, G., and Bandstra, E.S. (1987). Grief responses of house officers to a patient’s death. Death Studies, 11, 167176. Bertman, S.L. (1997). From the very first patient to the very last: Soul pain, aesthetic distance, and the training of physicians. In Strack, S. (ed) Death and the Quest for Meaning: Essays in Honor of Herman Feifel. (pp. 161-189). London: Jason Aronson, Inc. Charlton, R., Dovey, S.M., Jones, D.G., and Blunt, A. (1994). Effects of cadaver dissection on the attitudes of medical students. Medical Education, 28, 290-295. Cochrane, J.B., Levy, M.R., Fryer, J.E., and Oglesby, C.A. (1990). Death anxiety, disclosure behaviors, and attitudes of oncologists toward terminal care. Omega, 22(1), 1-12. de Montaigne, M. (trans. 1991). To philosophise is to learn how to die. In Trans. Screech, M.A. The Complete Essays (pp. 90-108). New York: Penguin Classics. Dickinson, G.E., Sumner, E.D., and Durand, R.P. (1992). Physicians’ attitudes toward death and terminally ill patients: A decade after graduation from medical school. Loss, Grief & Care, 6(2-3), 97-108. Groopman, J. (2002, October 28). Dying words: How should doctors deliver bad news? The New Yorker, pp. 62-70. Hamama-Raz, Y., Solomon, Z., and Ohry, A. (2000). Fear of personal death among physicians. Omega, 41(2), 139-149.
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Heidegger, M. (1962). Being and Time. Trans. Macquarrie, J. & Robinson, E. Oxford: Blackwell Publishers, Ltd. (Original work published 1926). Hochschild, A.R. (2003). The Managed Heart: Commercialization of Human Feeling (20th anniversary ed.). Berkeley, CA: University of California Press. Kalra, J., Rosner, F., and Shapiro, S. (1987). Emotional strain on physicians caring for cancer patients. Loss, Grief & Care, 1(3-4), 19-24. Kübler-Ross, E. (1970). On death and dying. London: Routledge. Lasagna, L. (1964). The Hippocratic Oath. Retrieved 7 March, 2004, from http://www.pbs.org/wgbh/nova/doctors/oath_modern.html. Lloyd-Williams, M. (2002). Senior house officers’ experience of a six month post in a hospice. Medical Education, 36, 45-48. McQuade, J. (1992). Physicians and death. Loss, Grief & Care, 6(2-3), 3975. Paice, E., Rutter, H., Wetherell, M., Winder, B., and McManus, I.C. (2002). Stressful incidents, stress and coping strategies in the preregistration house officer year. Medical Education, 36, 56-65. Pasnau, R.O., Fawzy, I., and Fawzy, N. (1987). Role of the physician in bereavement. Psychiatric Clinics of North America, 10(1), 109-120. Patterson, P.R. (1989). The pediatrician coping with the dying child. Loss, Grief and Care, 3(3-4), 191-198. Ptacek, J.T., Ptacek, J.J., and Ellison, N.M. (2001). “I’m sorry to tell you…”: Physicians’ reports of breaking bad news. Journal of Behavioral Medicine, 24(2), 205-217. Salander, P., Bergenheim, A., Bergstroem, P., and Henriksson, R. (1999). How to tell cancer patients: A contribution to a theory of communicating the diagnosis. Journal of Psychosocial Oncology, 16(2), 79-93. Servaty, H.L., Krejci, M.J., and Hayslip, B. (1996). Relationships among death anxiety, communication apprehension with the dying, and empathy in those seeking occupations as nurses and physicians. Death Studies, 20, 149-161. Severino, S.K., Friedman, R., and Moore, P. (1986). The dying patient: Physician’s suffering. In R. DeBellis, E. Marcus, A. H. Kutscher, C. Smith Torres, B. Barrett, & M. Siegel (Eds.), Suffering: Psychological and social aspects in loss, grief, and care (pp. 25-29). New York: The Haworth Press. Smith, A.C. & Kleinman, S. (2001). Managing emotions in medical school. In Cahill, S.E. (ed) Inside Social Life: Readings in Sociological Psychology and Microsociology (3rd ed.; pp. 61-71). Los Angeles: Roxbury Publishing Company. Thompson, L.M. (1988). Educating allied health personnel: Seeing the dying patient as a person. Loss, Grief & Care, 2(1-2), 39-47. van Deurzen-Smith, E. (1997). Everyday mysteries: Existential dimensions of psychotherapy. London: Routledge. 149
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Viswanathan, R. (1996). Death anxiety, locus of control, and purpose in life of physicians: Their relationship to patient death notification. Psychosomatics, 37(4), 339-345. Yalom, I. (1980). Existential psychotherapy. New York: Basic Books.
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