Why is it so difficult for doctors to confront the truth when a patient is dying and almost impossible for most to talk about it openly with the patient and loved ones?
Last week I shared a hunch. A journalist asked me the question, "Why do doctors find these conversations so hard?" I said I could only speculate. But I would base my guess on decades of practice as a nurse and physician assistant and watching doctors from the vantage points of those allied professions.
My guess was that doctors are among the people in our society most frightened by death. Their fear reinforces our society's death taboo. They have not yet learned to live in harmony with mortality, and they don't know how to grieve. Every dying patient presents another opportunity to deny the inherent role of loss and sadness in every human being's life story. They act as though awareness of our transience does not define human consciousness nor form the basis of our common shared humanity. In this way doctors are a bit "inhuman."
The reporter said, "Wow, that's really interesting." Then the conversation ended.
This week comes news that science corroborates my hunch. The scientific study feels like synchronicity, coming so close on the heels of my flight of ideas.
Sunday's New York Times carried Dr. Leeat Granek's description of research into whether oncologists grieve when their patients die. She reports her central finding that, "Not only do doctors experience grief, but the professional taboo on the emotion also has negative consequences for the doctors themselves, as well as for the quality of care they provide."
Dr. Granek's study reveals that most oncologists suffer from unacknowledged grief, and they experience their sadness all mixed up with feelings of guilt, self-doubt, failure and powerlessness. They keep these feelings to themselves because that is the professional code. As an aside, I'll mention here that professional approval of suppressed grief almost went to the extreme of labeling demonstrable grief a mental illness. But the panel of psychiatrists updating the DSM (Diagnostic and Statistical Manual of Mental Disorders -- the bible of mental illness and its billing codes) bowed to public criticism and reverted to a two-month exception for bereavement in its definition of depression.
Granek's work found that doctors' unacknowledged grief comes out in impatience, irritability, emotional exhaustion and inattentiveness. Half the study participants admitted their thwarted grief affects the care of subsequent patients. It motivates them to continue aggressive, fruitless treatments long after palliative care would be more appropriate and to distance themselves from patients as death approaches.
We must draw the stunning and unavoidable conclusion that doctors' averted grief constitutes an important cause of the deplorable end-of-life care that is America's norm. Patients receive warrantless treatment through repeated hospitalizations and suffer the inevitable pain, bodily invasion, isolation and loneliness it brings. Perhaps instead of calling for more medical education, we should call for guidance in grief resolution and support for its expression.
When he was 82 my father suffered a fatal heart attack during a minor surgical procedure. After he died, my sister and I brought my mother to the hospital. I have always admired the doctor who came to us in the visitation room, crouched next to my mother's chair, and wept. He gave my mother a great gift, and even through her creeping dementia, she never forgot it. He didn't know my father well, but he was willing to feel and reveal his unity with the universal tragedy of losing one who is most dear. "You are not alone," his tears said to her. "You and I and all human beings who love deeply must also someday bear the pain of loss."
Grieving openly serves the important function of assuring ourselves and others that it is normal, and temporary, and part of a full and authentic life. Only suppressed grief threatens one's mental health.
With training and practice, I believe doctors could learn to experience the sadness of a patient's death, acknowledge it, decouple it from feelings of guilt or inadequacy, and move to the other side of grief. As poet Mary Oliver reminds us, though we must journey through black rivers of loss, the other side is salvation.
Doctors would do well to heed Oliver's advice:
To live in this world
you must be able
to do three things:
to love what is mortal;
to hold it
against your bones knowing
your own life depends on it;
and, when the time comes to let it go,
to let it go.
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