By Doug Brunk, San Diego Bureau
Death is not often discussed among physicians, but after Dr. Pauline W. Chen's critically acclaimed book "Final Exam: A Surgeon's Reflections on Mortality" (New York: Knopf, 2007) hit bookstores, many physicians approached her, eager to share their own stories about caring for patients at the end of life.
"I feel the same way," they'd tell her, said Dr. Chen, a transplant surgeon who lives near Boston. "They don't feel so alone in some of their emotions."
The book chronicles Dr. Chen's transformation from a medical student taught to depersonalize death to a transplant surgeon who must be emotionally present for patients and their families during the end of life. "I don't pretend to be an end-of-life care expert," she said. "I'm certainly not perfect, and I continue to struggle to do the best for those I care for; but this is my experience. I hope that being open about my experience helps their efforts."
In one chapter she recalls the challenges of her Aunt Grace's kidney failure. On the one hand, she knew what to expect and was a key person for relatives who wondered, "What happens next? What really happens when someone dies?"
But Dr. Chen became preoccupied with her aunt's physical status and transplant candidacy, and forgot about her as a whole person. Aunt Grace realized this, and 3 weeks before she died, she called her niece on the phone. Part of the conversation involved Dr. Chen's request to include her aunt's story in an article she was writing about organ donation. Aunt Grace granted permission but insisted the article mention the care and support that Dr. Chen's uncle and cousin had provided her. "They have been here for me always; they have listened to me always," Aunt Grace told her. "Your uncle has taken such good care of me, and your cousin has helped him. They have sacrificed so much. … I owe everything to them." That brief conversation reminded Dr. Chen of the importance of caring for the person beyond the symptoms and illness.
Despite the growing popularity of palliative medicine and hospice care, Dr. Chen said that some physicians equate patients' deaths with failure.
"The metaphor for a surgeon is that you've actually got your hand in there affecting the cure, so you really feel tied in with them and personally responsible," she said. "When those deaths occur, it can be devastating for doctors, not only on the relationship levelbecause you form relationships with your patientsbut also, personally, you feel like you failed them and you failed your profession in a way." That sense of responsibility "can hamper our future ability to care for people and to care for ourselves," she said. "I think we only worsen the situation by not doing the small little bit that we can, which is discussing [end-of-life care] with our patients and among ourselves. By talking about itby being present for our patientswe can fulfill those ideals that brought us to medicine in the first place."
No One Is Immune
When two patients of Dr. Robert S. McKelvey committed suicide during his psychiatry residency in the 1970s, he was so devastated that he considered leaving the field. "I took it as an accusation against me that I wasn't doing a good enough job or that I wasn't cut out to be a psychiatrist," recalled Dr. McKelvey, now director of the division of child and adolescent psychiatry at Oregon Health and Science University, Portland. "I've practiced for many years now, so I realize that's part of the profession: you're going to have people die from time to time if you work with severely disturbed patients. But then I was brand new."
Physicians' reactions to death vary, said Dr. McKelvey, author of "When a Child Dies: How Pediatric Physicians and Nurses Cope" (Seattle: University of Washington Press, 2007). Patient deaths tend to affect residents and early-career physicians the most, but no physician is immune. "No matter how experienced you are, there are going to be situations that are really going to affect you, especially if you get a little too attached to a patient or to a patient's family," said Dr. McKelvey, who interviewed about 35 pediatricians, pediatric residents, and pediatric nurses for his book.
In interviewing pediatricians, he discovered many coped with a dying child by focusing their energies on trying to keep the child "comfortable on the one hand and on the other hand trying to make the dying process as good as it can be for the family by explaining what's going on and trying to provide supportbeing emotionally present for them," Dr. McKelvey said. "Not everybody can do that. One of the things about physicians is that there is a certain self-selection; many tend to compartmentalize things. They may be less likely to be open with their feelings than others." One strategy he recommends is to share your feelings about death with someone you can confide in. That's easier said than done, because people not in the medical field "don't want to hear about the death of a child," he said. "Physicians usually find either someone within their own field to talk to, or a professional listener like a psychiatrist or psychologist, or their spouseif their spouse is able to bear the pain of hearing about those kinds of losses."