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Dealing with death: doctor-patient dialogue

Consider the following scene: Mrs. Johnson, beloved grandmother of three, lies in a hospital bed, surrounded by her family and hoping for good news from pending medical tests. Having experienced sudden pain, she worries that something may be seriously wrong. Perhaps a broken bone or surgery may be involved? Her physician walks in and delivers bad news, standing at the foot of the bed and reading from the chart. The woman's internal injuries stem from undetected, malignant cancer, and she will die. After citing statistics and standing through an awkward silence, the doctor mutters a word about questions and walks from the room, leaving the patient shocked and her family tearful.

The job of a doctor requires far more compassion than witnessed in the scene above. But physicians spend countless hours knowing disease, and relatively few hours knowing humanity. A physician is, at heart, an ordinary person asked to approach the difficult task of telling a vulnerable patient that death has come. A doctor must wait for the inevitable, emotional storm following comprehension by a patient that nothing more can be medically done to prevent, or even forestall, death.

Patient reactions to death are often mediated by several factors, including a lack of experience with death, if few family members have previously died. Some patients also sustain profound, unrealistic hopes, having failed to reconcile the inevitable loss of material life. Equally important, living people actively push themselves away from the dying in very mechanical ways. Such isolation cannot fail to sadden a person already suffering through the end of life.

Dr. Robert Buckman, MD, has discussed doctor/patient interaction surrounding death extensively in How to Break Bad News: A Guide for Health Care Professionals. Like many psychologists, he critiques the five stage coping method elucidated by Elizabeth Kubler Ross: Denial, Anger, Bargaining, Depression, and Acceptance. Buckman instead advocates a three stage model involving an Initial Stage, when a threat is faced, a Chronic Stage including depression and possible resolution, as well as a Final Stage in which the ability to manage the inevitable death occurs.

While these reactions to death obviously occur among patients, families and physicians must deal with the future loss. Reactions of family members often involve a mixture of grief and aversion, which leads people to encounter guilt, avoidance, and feelings of mourning. In this era, human death often differs from previous centuries because many people know they will die before the event takes place, and understand exactly what reason will bring about their death. Although patients must face this knowledge, the families of patients often begin mourning long before their loved one has died.

Physicians also react to the impending death of their patients with powerful emotions. Doctors often fear losing control in such a situation. By breaking the bad news, the patient may suffer more. Blame for the circumstances might also shift from thoughts about death to an attack on medical competence. At some point, all medical specialists must face the knowledge that nothing more is possible for certain patients. This inadequacy of human ability can produce feelings of helplessness in people. Many students enter medical school understanding that they will gain the resources to make a difference where others cannot. When this reality reaches its limit, many physicians find themselves in an unfamiliar, very uncomfortable situation.

Physicians emotionally manage death in ways that blend their humanity with the experiences of a caregiver, providing space for a number of common reactions. Many doctors face counter-transference, wherein similarity of a patient to someone from the past (liked or disliked) produces a prejudicial approach by the caregiver. Many doctors withdraw from their patients, resulting in the experience of the grandmother above. Others express guilt, and anger at the patient's vulnerability or ignorance of the medical intricacies involved with the painful diagnosis. Although the preceding reactions often lead doctors to disregard their patient's feelings, some physicians cope in the opposite manner - by spending time with the patient, but backing away from the certainty of death. In this latter category, doctors may speak in ways that perpetuate a patient's false hope rather than helping that person to face decisions that will ultimately ease the end of life.

The focus of every person involved in a terminal diagnosis must ultimately sharpen upon key responsibilities to the dying patient. In particular, the physician has the opportunity to act as a leader, helping the patient set an emotional and mental framework to face difficulty ahead with greater ease. This role necessitates an awareness of psychological reactions that will permeate the attitudes of the patient, family, and self. Patients often remain in shock as they face the bad news. A patient's shock may transform into negative coping mechanisms. Anger, denial, and a lengthy refusal to accept death, may in turn cause an avoidance of responsibilities such as a will, Do Not Resuscitate orders, and funeral preparations. Here, a physician can effectively help a patient to make reasonable decisions, and feel calmer.

Dr. Buckman advocates six steps as a guideline for doctor-mediated approaches to breaking bad news. First, a positive encounter must happen between the physician, the patient, and involved support groups. This encounter must be honest. An initial acknowledgement of emotional baggage might be necessary before medical issues can be introduced. The physician must assess a patient's technical knowledge, and dwell on statistics only if the patient's questions involve medical intricacies. Physicians must also think about how much a patient actually does want to know, discuss distinct gaps in the patient's knowledge. Finally, a doctor must advocate thoughts and explore future plans, fulfilling the role of a medical advisor whom the patient will feel comfortable with.

The job of a physician often asks an ordinary being to transcend human feelings to carry out a duty for people in need. Neither doctors nor the medical establishment should assume that medical professionals have innate resources to deliver bad news to patients. Doctors must understand their natural reactions to death and its proximity in their world. By learning to manage these feelings, and assessing common threads of response among patients, an insightful physician can offer guidance to a patient struggling with a life changing moment.

[ Posted by Amit Raghavan at June 1, 2001 09:00 AM | More Opinion articles ]

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