He recommends sharing 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 spouse—if their spouse is able to bear the pain of hearing about those kinds of losses.”
Dr. McKelvey met with a psychiatrist for about a year to discuss his feelings about the suicides. “Another thing that's helpful is to continue to do the job and get some more experience under your belt. Gradually, you realize that there is only a limited amount of control you have over what patients do and what happens to them.”
He thinks hospitals should provide pediatric residents with free, confidential counseling. “A lot of physicians are afraid to go see a psychiatrist because they somehow feel that it's going to appear on their record and the medical board will wonder about them,” Dr. McKelvey explained. “If you could have somebody who's paid to be there and is available and can listen, I think that would be very helpful.”
One of the physicians interviewed by Dr. McKelvey said that, ultimately, patients' deaths are not about physicians. “He told me, 'Our goal is to support the patient and his or her family through this. It's important for us to get our own support, but we have to put their needs first and remember whose suffering it really is.' I thought that was a good comment,” Dr. McKelvey said. “On the other hand if you neglect your own needs, you become less available to patients and families and to the other people in your life. You kind of walk a tightrope.”
Overwhelmed by Gratitude
When San Diego-area physicians feel isolated due to a patient's death, many speak with Dr. Charles F. von Gunten, a consultant in hospice and palliative medicine.
“For most doctors, caring for a dying patient feels very lonely, because all the other consultants go away,” said Dr. von Gunten, medical director of the Center for Palliative Studies at San Diego Hospice and Palliative Care. “If I have been involved in the case or am asked to consult and agree that they have done everything that can be done and that they are doing a good job, hearing that from me helps them cope.”
Such support marks one benefit of expanding palliative care and hospice programs, but medicine has yet to devote adequate training to coping with death, said Dr. von Gunten, who also is editor in chief of the Journal of Palliative Medicine. “The loud message from the medical culture is, 'You should have no feelings about death. You move on to the next case who needs your help,'” he said. “Your personal feelings are not germane. The culture of medical training teaches that doctors are not supposed to be upset by this.”
As an oncology fellow, Dr. von Gunten was rattled when his first patient died. He remembered what he'd learned: send a sympathy note and attend the funeral of patients with whom you are close, “to help you grieve, move on, and be emotionally available to other patients.” When Dr. von Gunten arrived at the funeral, the man's family expressed unexpected gratitude. “He'd had a difficult course with difficult symptoms that I hadn't controlled very well, and I couldn't make sense of how grateful the family was. It was only with more maturity that I realized that they were expressing gratitude for the sense that I had cared as a doctor; cared enough to look after him, even though the cancer didn't get better; cared enough to stick with him, even though I didn't get his symptoms under better control; and cared enough to go to the funeral.”
In notes to families of patients that die, he expresses condolences and offers to meet with them. This helps families cope, he said, “because there are frequently questions that come up that the doctor can easily answer.”
It's also plain good care. “If you're interested in family satisfaction with care, they want to know some expression that the doctor cared about the patient as a person,” Dr. von Gunten said. “The chief complaint from patients about their doctors and about their hospitals is, 'As soon as the patient died, all communication stopped. It was as if he was just a case, wasn't an important person.'”