Abstract
Today I learned that one of my patients, let's call her Leslie, had died. Leslie was one of those patients whose death is both expected and a surprise. When I saw her two weeks ago she was, as we say, “stable,” having recovered from her most recent health crisis. She did not have cancer and was not enrolled in hospice. She had, however, surpassed all expectations of longevity. She had lived with progressive heart failure, coronary artery disease, and pulmonary fibrosis for years. She had diabetes, hypertension, and a history of breast cancer. Her survival was a testament to the wonders of modern medicine (she was on 11 different prescription medications) and to her remarkably resilient and optimistic spirit.
Although a doctor's reaction to the death of a patient should barely register with the patient's family, it is a topic that doctors probably do not discuss enough, either among themselves or with trainees. For those of us who care for older patients, or critically ill ones, the death of a patient is not infrequent.
My reaction to Leslie's death did not surprise me. Instead of the Kübler-Ross stages of grief, unfolding over months, my reaction to her death was sudden and predictable. In place of denial, anger, bargaining, depression, and acceptance, I reacted with sorrow, guilt, anxiety, and relief. Although the relative intensity of these emotions, and the order in which I experience them, varies with each death, I can expect to experience all of them.
Anyone would find my sorrow predictable. As a patient approaches death, the doctor–patient relationship intensifies. I will see the patient more frequently and her increasing reliance on me reflexively increases my attachment to her. The sorrow is often compounded if I have become close with the patient's family. Witnessing a family's grief magnifies my own and the death of a patient often means that I lose contact with the patient's family.
Sometimes, I continue to care for the family members of my deceased patient. For many patients (and for me) these visits are therapeutic. We discuss loss and the experience of illness. My patients often relish being able to talk to someone who not only knew their spouse/partner/friend/relative but who was also deeply involved in the intricacies of a life's end. We talk about feelings without having to tiptoe around details. Some patients find these visits, with the doctor who presided over the death of a loved one, intolerable. My own mother had to change her route home from her subway station so as to no longer pass my father's oncologist's office.
Guilt is an emotion that is certainly stronger in some situations than others. There is seldom a case in which I cannot come up with something that I could have done better. Was there a medication I should have prescribed? Should I have been more aggressive in an evaluation? Should I have called a consultation earlier? In cases that I cannot find something to criticize in the care I delivered, I can always find fault in the way things ended. I should have advocated more forcefully for hospice. I should have seen her in the hospital one more time before she died.
Anxiety is the emotion that I often feel first and of which I remain most surprised. I have been in practice for more than 20 years and I should have outgrown this one by now. The anxiety is rooted in a feeling that I will be “found out” for having done something wrong or for not having done enough. Maybe it is part of the imposter syndrome from which most of us suffer. Maybe it originated in medical school when professors felt the need to use the threat of malpractice suits as a way of getting the attention of students. “The internist who treats iron deficiency without pursuing a colonoscopy will be sued.”
Relief comes in two forms. One is professionally acceptable, the other less so. Despite our efforts to craft a “good death” for our patients, many patients go through hell in their final weeks. Whether it is pain or the horrors of the 21st century health care, death can be hard. I am often relieved to hear that the suffering, natural or iatrogenic, has ended.
The other type of relief? Caring for patients is hard work and caring for dying patients is the hardest. When a patient dies, this work ends. I am relieved to know that I no longer have to cut short a breakfast with my family to see a dying patient in the hospital or will no longer be paged out of rooms during clinic sessions to discuss pain regimens with a hospice nurse.
When Leslie died, I felt great sorrow, she was a patient with whom I was very close. There was a bit of relief, her last year had been a tough one for her, she really had lost that fire that I loved in her. There was some guilt, I had seen her so recently that I wondered whether I had missed something. There was very little anxiety, I was close to her daughter who saw me as a member of a small team who was committed to her mom.
I am sure that I am not alone in experiencing these emotions. I am also sure there are other emotions that other physicians expect with every death. I am sure that mindfulness regarding these reactions is beneficial for me in my practice. I have found myself preparing for the sorrow and guilt that I expect to feel, reassuring myself that my anxiety is normal but probably unnecessary, and accepting that my relief at a patient's death does not mean that I did not care.