Difficult Patient Loss and Physician Culture for Oncologists Grieving Patient Loss

Abstract

Background:

While caring for critically ill and terminal patients can elicit grief symptoms in health care professionals, few studies have examined oncologists' grief over patient loss using a qualitative approach to inquiry.

Objectives:

To explore what makes patient loss difficult for oncologists and to explore the context in which these losses were occurring.

Method:

Twenty oncologists were interviewed at three oncology centers in Canada about their experiences of grief over patient loss. Exclusion criteria included never having lost a patient in their care and being unable to speak English. Data was analyzed using the grounded theory method.

Results:

Oncologists found patient loss particularly difficult for relational reasons including instances where they felt close to patients and their families, when they had a transference to the patient, when patients died young, when they had long-term patients, and when deaths were unexpected. Contextual reasons included when patients and their families were unprepared for death, had unrealistic expectations about cure, when excessive treatments were perceived to be used, when physicians were blamed for the loss, or when families were chaotic or had high needs. Findings further revealed that these losses were occurring within a physician culture that had a stigma around death and dying, viewed emotion as weakness, was focused on cure, and was gendered.

Conclusions:

Effective interventions to help oncologists cope with grief must identify the expectation gaps between physicians and patients when it comes to end-of-life care.

Introduction

The emotional life of physicians is a fairly new field of inquiry.^1–4 While it has been documented that caring for critically ill and terminal patients can elicit grief symptoms in health care professionals (HCPs)^3,5–8 few studies have examined oncologists' grief over patient loss. Reports have indicated that physicians may feel grief over the deaths of patients to whom they felt close to, patients who failed to be cured by standard treatment interventions, and by deaths of younger patients.^7,8 One qualitative study of physicians in a range of specialties that included oncologists found that HCPs reported powerful emotional experiences as a result of patient loss.⁹ Some reports have suggested that HCPs consider grieving over patients unprofessional and a personal and professional failure.^3,6,10 Moreover, the research suggests that unmanaged and unacknowledged emotion in HCPs can lead to stress, burnout, and alcohol and substance addiction;^3,5,11–15 high turnover in work settings;⁵ professional loneliness, cynicism, hopelessness, and a sense of frustration;³ and clinical distress such as anxiety and difficulty concentrating.^3,6,13,16

Despite the evidence that grief over patient loss is a part of the oncology setting, few qualitative research studies have explored how oncologists deal with the grief of continually losing patients and more specifically, what makes some losses more difficult than others in the oncology context. The purpose of this analysis, which was part of a larger study examining oncologists' experiences of patient loss, was to explore what intensifies grief over patient loss for oncologists and the workplace context in which these losses occur.

Methods

Study design and participants

The grounded theory method was used.¹⁷ Twenty oncologists were recruited and interviewed between November 2010 and July 2011 from three adult oncology centers in Ontario, Canada. Purposive sampling was used to target three groups of oncologists who were at different stages of their career trajectory (e.g., oncology fellows; junior oncologists with less than 10 years experience; and senior oncologists with more than 10 years experience, and who varied in their subspecialties, gender, and ethnicities [see Table 1 for participant demographics]). Exclusion criteria were the inability to speak English and never having had a patient die in their care.

Table 1.

Participant Demographics

Characteristic	N (%) 20
Gender
Male	11 (55)
Female	9 (45)
Age (range; mean)	30–65; 47
Living situation
Married	16 (80)
Single	4 (20)
Children	14 (70)
Religious background
Jewish	1 (5)
Catholic	4 (20)
Christian	8 (40)
Hindu	1 (5)
Sikh	1 (5)
No affiliation	4 (20)
Ethnicity
Caucasian	14 (70)
Indian	3 (15)
Asian	3 (15)
Years in practice (range; mean)	1.5–31; 13
Fellowship training	3 (15)
Working 10 years or less	11 (55)
Working 10–20 years	2 (10)
Working 20 or more years	7 (35)
Disease site specialty
Breast	6 (30)
Gastrointestinal	5 (25)
Genitourinary	5 (25)
Head and neck	1 (5)
Hematology	2 (15)
Lung	1 (5)
Melanoma	2 (10)
Patients seen monthly (range; mean)	44–360; 176
Length of relationship with patient	4 weeks–25 years
Patient deaths per month (range; mean)	1–10; 4

Procedure

Research ethics board approvals were obtained at each participating health care center prior to beginning the study. Participants were approached by the oncologist co-investigators (MK, PM, and RT) at their respective study sites via email and were asked if they could be contacted to hear more about the study. If the oncologist agreed to be contacted, LG, the principal investigator, who is a psychologist and who did not work with or know any of the participants, followed up with a telephone call to describe the study and schedule an interview. An email was sent out to approximately 65 oncologists in the first wave at all three study sites. Fifteen oncologists responded to the recruitment email and agreed to be interviewed. After conducting and analyzing 15 interviews, participants who were not represented in the sample were targeted. An additional email was sent out to 5 oncologists and all 5 responded to the second email and were subsequently interviewed. During the initial contact with the oncologist, LG described the purpose of the project as well as the interview structure and time commitment. All interviews were conducted by LG, an experienced qualitative researcher, and informed consent and participants' agreement to the interview being audiorecorded were confirmed at the beginning of each interview. We used a semistructured interview guide with questions designed to encourage oncologists to discuss their experiences in depth. This interview guide was revised throughout the process of data collection and analysis. (See Appendix A.) All interviews were recorded and transcribed and all identifiable information was removed from the transcripts. Each transcript was assigned a participant numerical ID number.

Data analysis

We used the grounded theory method for coding and analyzing our data.¹⁷ LG and a research assistant separately coded the first five transcripts; this was followed by several team discussions with the research team on the developing coding scheme to ensure consistency between coders and validity of the emerging findings. Data collection and analysis took place concurrently and line-by-line coding was used. The process involved separating sections of text that carried a uniform meaning into codes that were labeled descriptively to capture the meaning of the text. As the analysis continued, the descriptive codes were further distilled to capture the themes and subthemes emerging from the text.

The coding scheme was revised throughout the process of data analysis and was developed through ongoing discussions with members of the research team. Data collection stopped when the team determined that we had reached saturation and that no more new codes were created. NVivo 8 computer software was used to organize, code, and store the data.

Findings

In Table 2 we present the findings and outline the descriptive categories, the themes, subthemes, and supporting quotations that illustrate each finding from our analysis.

Table 2.

Results from Data Analysis: Categories, Themes, Subthemes, and Supporting Quotations

Category	Themes and subthemes	Supporting quotation
Difficult patient loss	Relational Close patients and families	“I became very close to the whole family unit…. When we went to the funeral it was to pay respect to that patient but mostly to offer support to the wife and son that we had become close to.”
	Patient transference/ identifying with patient	“The ones that are always challenging…that I can identify with…close to my age, demographics, those sorts of things. I think it's that issue of that transference…. You could put yourself in their spot.”
	Young patients	“It was just the fact that he was young, very young, and the things that he would say would just really tear at you. Tear your heart out when a young patient's telling you, ‘Doctor, you have to help me, I want to live,’ you know. Those sorts of things just stick in your mind.”
	Long-term patients	“I think emotionally it's very exhausting, you get attached to patients–there's just no way you can't…. With some of my patients…you see them like once a week, their parents, their boyfriends, their girlfriends; it's just a very high intensity sort of relationship for sometimes very long period of time, depending on how sick they are and how well they're doing.”
	Unexpected deaths	“He died suddenly…. My level of grief was much worse after he died. It was that he was very young, and that he had a very bad cancer and that he died very unexpectedly.”
	ContextualUnprepared families and patients	“[Loss is difficult when] the family or the patient not really coming to grips with their diagnosis and what it means and the stresses.”
	Unrealistic expectations	“That seems to be the hardest thing—when the patient doesn't accept, even when the writing's on the wall, and even when they've been told that they're dying. That's very hard. Because then, the focus is so much on, in their minds, on cure—they won't accept painkillers, they won't accept anything that would make their quality of life better. Because they're so focused on chemo. It's very hard to deal with that.”
	Perceived excessive treatments	“Sometimes we see it as a type of assault, the patients are in their last twenty-four, forty-eight hours and they're still being poked, prodded, having all these things done to them that are completely medically futile. And not just medically futile but really putting the patients through discomfort.”
	Physician blame	“That keeps me from sleeping. That really is very hard. And the worst is when they blame you and you haven't done anything wrong. You happened to be the convenient scapegoat. That's terribly hard.”
Physician culture	Stigma around death and dying	“There's a stigma associated with dying in our society…. There shouldn't be one in the discipline we practice in. It's such a day-to-day part of what we do. Every day patients die on our ward…. Every week, for sure, there are multiple patients dying on our ward, so there shouldn't be, but there is in society and some of that just kind of flows over to where we practice.”
	Affect as weakness	“Very few people would actually go to see [an] oncologist because you don't want to be—and maybe it's just me, but I honestly think it's everybody—but you don't want to be viewed as having weaknesses as a physician.…The weakness is that you can't deal with patient loss, maybe you don't have the coping skills, or ‘Why is it affecting this one person and nobody else is being affected or at least bringing it up?’…. And then, that person's perception of you may be altered so, oh this person's very sensitive, I'm really going to have to keep an eye on him.”“I had a struggle with depression several years ago and I was trying to hide it from work because medical professionals are not supposed to have any problems like that…you're weak if that happens…We are on the healthy side of the doctor's desk; we're not supposed to have any health issues ourselves.”
	Culture of cure	“There's signs all over—“Conquer cancer this, conquer cancer that.” So I think that as a society, as a medical society, for obvious reasons for example like fundraising and such we send one message that it can be beaten, that the cure is just around the corner.”“Well, when you're looking for a cure, you have control. When you're looking at dealing with death, you have to accept that you do not have control.…I mean, I can tell you that dealing with death and dying was not part of my training as a medical oncologist.”
	Gendered	“If I heard about one of my male colleagues crying over a death I would say, ‘Wow I've never heard of that happening before….’ That's [unusual]. I would say it's unheard of, or it's…not spoken of.…So I think there is a gender bias there.”

Difficult patient loss

The majority of oncologists in our study reported seeing between 40 and 90 patients a week. Many were experiencing several deaths in their practices, sometimes as many as three a week. When asked to reflect on what made patient death difficult, physicians talked about a number of relational factors including being close to the patients and their families; dealing with patients who had children; dealing with patients with whom physicians felt a ‘transference’ or an identification; dealing with long-term patients; and deaths that occurred unexpectedly. Contextual reasons were also named as making patient deaths challenging and thus exacerbating a physician's grief. By contextual reasons we mean factors that oncologists considered outside of their control and that did not pertain to their emotional or relational attachment to their patients. These included instances where the families and patients were unprepared or ‘in denial’ about what was happening; where patients were perceived to be given excessive treatments; when physicians were blamed for deaths or negligence; when families had unrealistic expectations; and/or when families were particularly chaotic or perceived as high-need.

Relational factors

Close patients and families

Oncologists reported having a harder time with patient loss when they were close to the deceased and their families. Patients who had an extended, close family and who the oncologists knew well made the loss more emotionally challenging, because the oncologists could see the impact of the loss on relatives and the patients' community.

Patient transference

Identification with the patient meant he or she either was close to the physician's own age, was from the same ethnic or religious background, had children who were the same age as the physician, or simply resembled someone the physician knew. In other instances the patient reminded them of their own family members (e.g., siblings or parents) and thus elicited a stronger attachment in the oncologist and subsequently more intense grief when the patient died. The more the oncologist was able to identify with the patient, the more he or she was able to empathize and imagine being in the patient's shoes.

Young patients

The deaths of younger patients were particularly emotionally draining and elicited feelings of grief in oncologists. There was a sense among physicians of injustice around these losses since they had not lived out their life goals yet.

Long-term relationships

Depending on their specialties, oncologists could follow patients and their families for as little as three months to as long as 25 years. The longer the patient was in the practice, the more oncologists got to know them and their families and this made the loss more difficult.

Unexpected deaths

When a patient was doing well and suddenly deteriorated or died unexpectedly, oncologists were taken off guard and experienced grief over that loss. The more hope there was for the patient's recovery, the harder the death was to accept, and the more grief they reported experiencing because they had expected that patient to survive and be cured, and were not anticipating this loss.

Contextual factors

In all of the contextual instances, the oncologist was experiencing grief because of factors considered to be outside his or her control, but that nonetheless were impacting the oncologist because the patient was suffering, which in turn caused the oncologist to suffer as well.

Unprepared families and patients

Families and patients that were not well informed or who did not know their family member was terminal were particularly hard patient deaths for the oncologists. These cases might involve a patient being referred to palliative care later than desirable because the family was reluctant to accept that the patient was dying.

Unrealistic expectations

As with families being unprepared, oncologists noted that when families and patients had unrealistic expectations for cure or were focused too much on keeping the patient alive, the patients suffered emotionally and physically, which in turn, caused stress for the oncologist and exacerbated his or her grief when that patient died.

Excessive treatments

When oncologists perceived that excessive treatments such as chemotherapy, clinical trials, or surgery that had no curative or palliative purpose were being offered to please the patient's family or to avoid the conversation on the patient's death, it made the loss harder. This was especially marked when oncologists worked on a health care team in the hospital setting and were not solely responsible for making treatment decisions for their patients. In other instances, oncologists spoke about feeling pressured by the family or the patient to provide more treatment than they felt was necessary because the patient or family did not want to give up active treatment.

Physician blame/negligence

In instances where oncologists felt that their patient's demise was due to another physician's negligence or in cases where the patients or their families had blamed the oncologist for their deterioration, the loss was described as particularly stressful and eliciting grief.

Chaotic, high-needs families

Another frequently named source of difficult patient loss had to do with the stability of the patient's family and how chaotic and/or needy family members were when they reached the patient's end of life.

Physician culture

Our analysis revealed that some of the factors that made patient loss difficult were the more elusive cultural undercurrents around what oncologists felt was acceptable to talk about, experience, and acknowledge in themselves. Several themes emerged in this category including stigma around death and dying, viewing affect as weakness, the “culture of cure,” and the gendered aspects of showing emotion in the oncology setting.

Stigma around death and dying

Throughout the interviews the oncologists noted that talking about death and dying is a stigma in society at large and that physicians are not extinct from this culture. Although they were immersed in and surrounded by death on a daily basis, they were not immune to the cultural messages about avoiding it, or their grief.

Affect as weakness

There was also a stigma in physician culture about emotion in general. Since showing emotion was considered weak, acknowledging or showing grief or experiencing sadness over patient loss was also stigmatized as unprofessional.

Culture of cure

As was the case for some of the patients and their families, some oncologists noted that the discourse around oncology is focused on cure as opposed to death, dying, and end-of-life care. This culture of cure or what one physician called “the death defying mode” was one in which the focus and the training was almost entirely on curing and controlling the disease, thereby making it hard to acknowledge one's grief when the patient died.

Gendered

This stigma around showing emotion in the workplace affected how oncologists thought about grief. Female oncologists reported that it was more acceptable for them to speak openly about their grief over patient loss in the workplace and at home. Male physicians reported that they were more likely to talk to female colleagues than male colleagues about their feelings, or that it was more common and acceptable for women to acknowledge and express their grief than for men, even if it was having an impact on both genders.

Discussion

In this study we explored the factors that make patient loss particularly difficulty for oncologists. Our participants spoke about both relational and contextual factors as exacerbating their grief when patients died. The analysis also identified a physician culture in which these losses were occurring that added another layer of complexity in dealing with grief over patient loss in the oncology setting. As reflected in the physicians' thoughtful quotations (Table 2), the relationships physicians developed with their patients and their families were braided with affection, attachment, and closeness; it was a benefit of the job, but also what made it challenging when patients died. The literature in the field supports the notion that the patient-physician relationship is one of the most gratifying aspects of practicing medicine but can also be the most stressful.^18,19 This is particularly true for physicians who deal with patients at the end of life and has been associated with burnout in some oncologists.^15,20

Some of these difficulties were caused by relational factors and had to do with identification with the patient, closeness with the families, and the nature of these long-term relationships.^3,9,20–22 Others had to do with contextual reasons considered outside of the oncologists control such as unprepared families and patients, unrealistic expectations on the part of patients and families, physician blame, and high-needs families.^3,9 Wallace and Lemaire⁴ found that in a sample of 182 physicians, the emotional demands of their work including coping with suffering and death were reported as more detrimental to physician well-being than any other challenge they faced, including working long hours and juggling work-life demands.⁴

What this research indicates in the context of our own is that emotional difficulties including grief are a part of the oncology setting, and yet these experiences are occurring within a culture that does not allow for free expression of this affect. As with North American culture where death, grief, and loss are stigmatized topics,²³ we found that there was also a reluctance to talk about death and dying in the oncology context, and physicians associated affect, especially grief, with weakness and vulnerability.^24,25 The focus on cure within the culture of oncology and the norms around curbing emotions were salient and made speaking about grief and loss difficult for oncologists. While there has been some literature published on a physician's reluctance to seek help when facing emotional distress in general¹⁸ and some literature on physicians' emotional reactions to patient death,⁹ to our knowledge no other study has revealed the intricacies of physician culture within the oncology setting when it comes to the expression of grief over patient loss using a qualitative approach to inquiry.

Implications for practice

In one of the few papers on the inner life of physicians in coping with end of life, Meier and colleagues suggest that developing self-awareness and encouraging physicians to acknowledge their emotions when caring for patients at end of life is a key intervention to avoid unintended negative consequences for patients.³ They further suggest that this self-awareness may be beneficial to physicians and can help with difficult aspects of the job such as professional loneliness, frustration, burnout, and depression. They lay out a four-step process that involves naming the feeling, accepting it as a normal emotion, reflecting on the possible consequences, and consulting with a trusted colleague about what steps to take next.³

Similarly, Kearney and colleagues recommend “self-awareness to enhance self-care” in physicians.²⁶ As with Meier, Back, and Morrison,³ they conclude, “self-awareness may both enhance self-care and satisfaction.”²⁶ Their proposed methods in developing self-awareness include mindfulness meditation, reflective writing exercises, and self-care. While these are promising entry points in dealing with the emotional stresses of oncologists, they do not go far enough. Our qualitative, contextual analysis revealed that the issue is more layered and complicated than it first appears.

Oncologists in our study did not suffer from a lack of self-awareness about their emotions. Indeed, they were not only able to identify their grief over patient loss, they were also able to name which factors caused them the most distress when it came to their grief, and furthermore, to situate these difficulties in the context of an emotionally constricting work culture. The issue was less about self-awareness than about the acceptability of expressing this grief in the workplace given the physician culture they were immersed in and socialized in. The question becomes, how and in what capacity do interventions get incorporated given the stigma around death and dying and the emotional and professional struggles the oncologists are facing in the context of patient loss?

Identifying the gaps

In designing effective interventions to help oncologists cope with their grief, we identified several gaps that need to be addressed. The first has to do with the expectation gaps of physicians and patients. From the physician side, we found that oncologists were experiencing grief over patient loss, but expressing this grief was stigmatized. Normalizing and acknowledging this grief as an expected part of the oncology setting, as opposed to a private burden on the oncologists, would be one important entry point.^27,28 In addition to focusing on self-awareness, normalizing and acknowledging the affect as suggested by Meier and colleagues³ would make room for these feelings as an expected part of the workplace and in the process make it more acceptable to speak these difficulties out loud.

While this study was not about the patient perspective, our analysis pointed to the fact that it would aid oncologists if patients and their families had realistic expectations about cure versus management of disease. As the physicians noted, the discourse around the culture of cancer is primary focused on cure. That, in combination with the cultural context around avoiding death, was making oncologists' work particularly challenging and may be the crossroads where oncologists were facing pressure to give what they perceived to be excessive treatments. For example, one qualitative study conducted in a general physician population corroborates our point about grief and “overtreatment.” In a sample of physicians the authors noted, “care of overtreated patients was frequently described in terms of conflict that interfered with emotional closure and resulted in long-lasting anger and frustration.”⁹ As with our study, perceived “excessive treatment” deaths were particularly disturbing to the physicians and the conflict over treatment could occur within the medical team or between the medical team and the family members of the patient.⁹

In closing, we note a few limitations to our study. First, we recognize that addressing and identifying the gaps is the theoretical first step to designing more practical interventions for oncologists coping with grief over patient loss. Further research on what types of interventions oncologists desire is needed.^29–31 Second, we acknowledge that our sample was limited to academic cancer centers within the Canadian context. The physician culture described in our findings is situated within the larger North American cultural context in which death, dying, and grief is stigmatized,²³ and this had an effect on the way the physicians in our study understood (and allowed for) their own grief to be expressed. Further cross cultural research on the topic is highly desired and needed.

Footnotes

Acknowledgments

This work was supported by the Juravinski Cancer Centre Foundation, Hamilton, Ontario, Canada.

Author Disclosure Statement

The authors have declared no conflicts of interest.

Appendix A: Selected Questions from the Semistructured Interview Guide

References

Farber

, Novack

, O'Brien

. Love, boundaries, and the patient-physician relationship. Arch Intern Med, 1997; 157:2291–2294.

Kushnir

, Kushnir

, Sarel

, Cohen

. Exploring physician perceptions of the impact of emotions on behavior during interactions with patients. Fam Pract, 2011; 28:75–81.

Meier

, Back

, Morrison

. The inner life of physicians and care of the seriously ill. JAMA, 2002; 286:3007–3014.

Wallace

, Lemaire

. On physician well being: You'll get by with a little help from your friends. Soc Sci Med, 2007; 64:2565–2577.

Feldstein

, Gemma

. Oncology nurses and chronic compounded grief. Cancer Nurs, 1995; 18:228–236.

Lenart

, Bauer

, Brighton

, Johnson

, Stringer

. Grief support for nursing staff in the ICU. J Nurses Staff Dev, 1998; 14:293–296.

Redinbaugh

, Schuerger

, Weiss

, Brufsky

, Arnold

. Health care professionals' grief: A model based on occupational style and coping. Psychooncology, 2001; 10:187–198.

Shanafelt

, Adjei

, Meyskens

. When your favorite patient relapses: Physician grief and well-being in the practice of oncology. J Clin Oncol, 2003; 21:2616–2619.

Jackson

, Sullivan

, Gadmer

, Seltzer

, Mitchell

, Lakoma

, Arnold

, Block

. “It was haunting…”: Physicians' descriptions of emotionally powerful patient deaths. Acad Med, 2005; 80:648–656.

10.

Flaming

. Improve care and comfort: Use the label “dying.” J Palliat Care, 2000; 16:30–36.

11.

Fields

, Cuerdon

, Brasseux

, Getson

, Thompson

, Orlowski

et al. Physician burnout in pediatric critical care medicine. Crit Care Med, 1995; 23:1425–1429.

12.

Kuerer

, Eberlein

, Pollock

, Huschka

, Baile

, Morrow

et al. Career satisfaction, practice patterns and burnout among surgical oncologists: Report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol, 2007; 14:3043–3053.

13.

Lyckholm

. Dealing with stress, burnout, and grief in the practice of oncology. Lancet Oncol, 2001; 2:750–755.

14.

Marino

. The effects of cumulative grief in the nurse. J Intraven Nurs, 1998; 21:101–104.

15.

Whippen

, Canellos

. Burnout syndrome in the practice of oncology: Results of a random survey of 1,000 oncologists. J Clin Oncol, 1991; 9:1916–1920.

16.

Ramirez

, Graham

, Richards

, Cull

, Gregory

, Leaning

et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer, 1995; 71:1263–1269.

17.

Glaser

, Strauss

. The discovery of grounded theory: Strategies for qualitative research. Chicago, IL: Aldine, 1967.

18.

Arnetz

. Psychosocial challenges facing physicians today. Soc Sci Med, 2001; 52:203–213.

19.

McMurray

, Williams

, Schwartz

, Douglas

, Van Kirk

, Konrad

et al. Physician job satisfaction: Developing a model using qualitative data. J Gen Intern Med, 1997; 12:711–714.

20.

Wolpin

, Chabner

, Lynch

, Penson

. Update: Learning to cope: How far is too close? Oncologist, 2005; 10:449–456.

21.

Saunderson

, Ridsdale

. General practitioners beliefs and attitudes about how to respond to death and bereavement: A qualitative study. Br Med J, 1993; 219:293–296.

22.

Jackson

, Mack

, Matsuma

, Lakoma

, Sullivan

, Arnold

, Weeks

, Block

. A qualitative study of oncologists' approaches to end-of-life-care. JPM, 2008; 11:893–906.

23.

Granek

. Grief as pathology: The evolution of grief theory in psychology from Freud to the present. Hist Psychol, 2010; 13:46–73.

24.

Berry

. The absence of sadness: Darker reflections on the doctor-patient relationship. J Med Ethics, 2007; 33,5:266–268.

25.

Berry

. Just say die. J Clin Oncol, 2008; 26:157–159.

26.

Kearney

, Weininger

, Vachon

, Harrison

, Mount

. Self-care of physicians caring for patients at the end of life. JAMA, 2009; 11:1155–1165.

27.

Granek

, Tozer

, Mazzotta

, Ramjaum

, Krzyzanowska

. Nature and impact of grief over patient loss on oncologists' personal and professional lives. Arch Intern Med, 2012; 172:964–966.

28.

Granek

, Mazzotta

, Tozer

, Krzyzanowska

. Oncologists' protocol, coping strategies in dealing with patient loss. Death Stud (in press).

29.

Kissane

, Bylund

, Banerjee

, Bialer

, Levin

, Malney

, D'Agostino

. Communication skills training for oncology professionals. J Clin Oncol, 2012; 11:1242–1247.

30.

Shayne

, Quill

. Invited commentary. Arch Intern Med, 2012; 173:10.

31.

Granek

, Mazzotta

, Tozer

, Krzyzanowska

. What do oncologists want? Suggestions from oncologists on how their institutions can help them deal with grief over patient loss. Support Care Cancer, 2012; 20:2627–2632.