Clinician Grief

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Craig (name changed to protect confidentiality) taught me how tough physicians should grieve. They shouldn’t. Craig and I were about the same age, each with sons at similar ages. Craig suffered from advanced lymphoma, no longer responding to chemotherapy. He knew from his shortness of breath and growing disfiguring tumors on his face and chest that he was dying. He asked me to promise, when his time came, to keep him comfortable. I promised.

Late afternoon on a “call day” his nurse paged me to his room. Call days were rough. Each intern typically “worked up” 8-10 newly admitted patients over a 36 hour period and responded to the changing needs of over 100 other patients. Upon entering his room, I knew from his gurgling, irregular breathing and faraway look that he was dying. I remembered my promise as he weakly squeezed my hand. He died a few minutes later.

Aware that I already had two new patients to evaluate, as well as a long list of other tasks, I left the room and headed for the stairs. Alone in the stairwell, I paused — surprised by a single muffled sob rising from my chest. I shook it off and headed to the next admission and, from there, to many more patients waiting to be seen that evening.

The implicit message, “real doctors don’t feel sadness”, I incorporated from those ahead of me in training. One just moves on.

I did not think about Craig again until several years after my internship. I heard the book “House of God,” presented a raucous and hilarious view of internship. Instead of laughing, I wept as I read the book which triggered a flood of memories and bottled up grief. I cried for Craig. I cried for the four year old who was crushed by a car when he darted out into the street, and I cried for his parents, to whom I had to deliver the unfathomable news. My tears felt cleansing as I cried for the many patients who died during my training.

A  study in the Archives of Internal Medicine (Nature and Impact of Grief over Patient Loss on Oncologists Personal and Professional Lives) tracked 20 oncologists for nine months to determine if they felt grief when a patient died and how they coped with the feeling. In a New York Times article about the study, the lead researcher, Leeat Granek, writes that “not only do doctors experience grief, but the professional taboo on the emotion also has negative consequences for the doctors themselves…More than half of our participants reported feelings of failure, self-doubt, sadness and powerlessness as part of their grief experience, and a third talked about feelings of guilt, loss of sleep and crying.”

To avoid being overwhelmed, some physicians and clinicians maintain an emotional distance to cope with a career where they witness so much illness and death. Many clinicians feel they must stay strong for patients and families who are experiencing their own substantial grief. Other clinicians may be reluctant to show emotion in front of patients or their professional colleagues as they perceive this as a sign of weakness.

The study goes on to say “the theme of balancing emotional boundaries captured the tension between growing close enough to care about the patients but remaining distant enough to avoid the pain of the loss when the patient died…patient loss was a unique affective experience that had a smoke like quality. Like smoke, this grief was intangible and invisible. Nonetheless, it was pervasive, sticking to the physicians’ clothes when they went home after work and slipping under the doors between patient rooms.”

Please use comments below to describe how you deal with grief in your professional life.

Privileged Presence

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The story below, She Sang Him His Life, from the book Privileged Presence:­ Personal Stories of Connections in Health Care, captures my sense of reverence for health care.

Palliative care seems to be a place where anything goes. On our unit, the hours are completely open; people come and go as the need; pets visit. Staff pay attention to so many little details of comfort. There’s a tenderness and kindness on the unit that’s extraordinary. By comparison, when I visit someone on another floor, it’s impersonal, and I feel assaulted by noise, unpleasant smells, and a sense of crowdedness.

One night, I arrived for my regular volunteer shift on the palliative care unit and found the staff in a very emotional state. This was not entirely unusual, but I sensed that something special had happened that day. I was right.
A young man, in his early forties, had been on the unit for several days. His wife had been with him almost constantly. This husband and wife were both from the same tiny village in Newfoundland. They had grown up together, become a couple, gotten married, and lived there all their lives. And now this man, her husband, was dying. She knew that the end was near and asked the nurses if she could get into bed with her husband and snuggle. And the answer was, “Of course you can, dear.”

And then the singing started. It went on for well over an hour. This woman, as she cuddled her dying husband, slowly and gently, sang him his life and their lives together.
When the singing stopped, her husband was still alive. She then sang him permission to leave.

Use comments below about stories giving you a sense of reverence working with patients and families.