Death is a universal concept, however there are a variety of emotional and professional reactions to the death of a patient. In order to understand how doctors in the United States confront the death of their patients and improve medical practices, it is important to discern how other countries around the world deal with the death of their patients. However, it is equally as important to identify how traumatic circumstances may affect the emotional complex of physicians. Every doctor works in a different environment and encounters patient death in a variety of ways, whether it be after a prolonged relationship or a momentary consultation, but the effect of death is felt by all. By identifying different coping strategies that doctors use to appropriately grieve and remember their patients, it can improve their medical practice moving forwards[i].

Throughout their careers, physicians are subject to a variety of situations that can result in different reactions by the body. Stress is a physical response caused by our body in reaction to an external stimuli. These external stimuli, or stressors, vary in the ways that they can affect the human body. In most cases, the body produces hormones, such as cortisol, in response to these stimuli which then results in stress. Indeed, life is full of stressors ranging from minor situations to high-impact instances that can change a life. These stressors are present in an excess amount of situations that doctors, nurses and hospital staff members deal with. Thus, doctors are constantly dealing with stress. The symptoms of stress can affect our body in numerous ways and in many different areas, as well. According to Mayo Clinic, the effects of stress can range from differences in your body, mood and behavior. Some examples of physical changes include headaches, muscle pain/tension, fatigue and insomnia. Mood changes that potentially result from stress are anxiety, restlessness, anger or depression. Finally, changes to your behavior include under or overeating, drug or alcohol misuse, and social withdrawal[ii].The combination of these   effects often lead to the deterioration of an individual if they are not properly treated.

Portrayed here is the anatomy of the brain including the Cerebral cortex, the Amygdala and the Hypothalamus. The amygdala is partially responsible in inducing symptoms of stress and stress-related disorders, as it is one of the regions that regulates emotions and fears.[iii]

 

The determination of the emotional composition of a physician after the death of a patient is partially reliant on the manner by which a patient receives care as a precursor to the time of death, as well as, the timeline in which a patient is notified of a terminal diagnosis. Often ingrained in the blurred line between personal and professional relations of the physician, it is apparent that the ethicality of treatment may deviate from the expected protocol of professionality as an emotional response to grief or end of life care for a patient.

To serve as a look into the variance of the emotional response of grief and continued medical treatment to patients after another patient’s death, it is clear that the judgement of the physician may be impaired by unidentified or suppressed feelings of grief with particular emphasis on inattentiveness, impatience, and irritability following the death of a patient. The continued response of grieving physicians can further be enhanced by stress or burnout, which could trigger a response of more aggressive treatment for other terminal patients under their care, such as suggesting a risky surgery, a more aggressive form of chemotherapy for cancer patients when palliative care would have been a more effective means of “treatment” [iv]. In comparison, the equally unethical response of a physician to impending or actual patient death is the altering of communication at the end of life. For some physicians, this may present as withdrawal or avoidance from either the patient, themselves, or the families of the patients. To cope with the persistent exposure to death, physicians are under the belief that their “professional detachment” will more effectively diminish the feelings of grief they may be feeling, but in actuality, it establishes an impenetrable barrier between the physician and patient or family[v]. As experienced by a patient, this presents as fewer bedside visits and minimal discussion about treatment or the expected timeline of events surrounding death. Often times this form of social isolation constructs a stereotypical image of physicians being “cold” or “uncaring,” creating a general mistrust between the patient and physician potentially leading to improper treatment. Under the conditions of grief, stress, or burnout, physician’s judgement will be compromised in regards to making beneficial medical decisions for the patients, known as iatrogenic suffering[vi].

In order to understand how doctors respond to the death of their patient, it is important to examine different surveys and studies conducted around the world. Prior to investigating the different studies, it is essential to comprehend the concept of palliative care because it is a central point in many of the studies conducted surrounding the relationship between doctors and terminally ill patients. Palliative care is a type of specialized medical care that aids people living with a terminal illness and alleviates any distress or pain they feel in order to improve their quality of life. Palliative care differs from hospice care because it can begin directly following the diagnosis whereas hospice care begins after treatment has commenced[vii].

While doctors and caregivers, alike, face many challenges and difficulties, none are as tumultuous as the death of a patient. This obstacle can result in a large amount of stress, potentially causing psychological disorders such as PTSD, compassion fatigue, burnout, moral distress and diseases of the mind. For instance, “Such stress has been linked to professional burnout and may put doctors at risk of psychiatric disorders”[viii].This type of burden can be potentially career ruining for experienced doctors and novices alike. Not only can this stress cause a doctor to lose their job due to poor performance in response to emotional distress, but it can also result in serious disorders of the brain. For example, “stress plays an extremely important role in the onset, the maintenance, and the aggravation of psychopathological disorders”[ix]. Often talked about behind closed doors, psychopathological disorders can be detrimental to almost anybody, in particular doctors who are given the responsibility of their patients’ lives. An example of a dangerous condition is compassion fatigue which is “described as diminished emotional energy needed to care for patients and has symptoms similar to primary PTSD, i.e. hyperarousal, avoidance and re-experiencing”[x].The stress, sadness, and grief associated with the loss of a patient, or care of a terminal patient, makes it difficult for these people to perform their jobs to the best of their ability,which could possibly violate the doctor’s personal performance.

Depicted here is a doctor watching as their patient begins to pass. Patient death is a traumatic issue that results in many ethical and physical dilemmas for physicians and nurses alike[xi].

Some people may believe that traumatic death only affects a small amount of doctors, which may be true, but contradictory evidence exists as presented below. These emotions are commonly present in casesas many doctors find traumatic death to be hard to deal with. Statistics show that a large amount of physicians feel this way, “A total of 86.4% (95/110) of respondents reported feeling distressed as a result of a patient death, 51.8% (57/110) at least moderately and 4.5% (5/110) to an extreme level”[xii]. This isn’t simply a phenomena that some doctors deal with, but almost all doctors deal with the death of their patient as a stressor. Even more concerning is the presence of symptoms of stress, PTSD and other psychological disorders. For example, “ Of the total sample, 42.7% (47/110) had repeated disturbing memories, 19.1% (21/110) at least moderately and 2.7% (3/110) to an extreme extent…” and “when respondents were asked if they felt angry or described having angry outbursts, 18.2% (20/110) identified that they had… Some respondents (28.2%; 31/110) had experienced difficulty concentrating following a patient death”[xiii]. These are the very symptoms of stress and PTSD being displayed by our physicians after dealing with traumatic death. It is imperative that people begin to understand the struggles that our caregivers go through and find the resources to help them deal with these unspoken issues.

Regarding the ethical treatment of effectively implementing the timeline in which to inform a terminal patient of their critical condition can be subject to ability of a health professional to maintain their composure. In particular, a study conducted in Sweden suggests that when physician has to break bad news to a terminal patient, specifically one with cancer, they face the potentiality of losing control of their confidence, professionalism, or the trust of their patient[xiv]. It is important to distinguish that physicians tend to face more of a struggle with “losing control” when treatment options are not as viable as palliative care. It is understood that the fear of losing control when informing patients of a terminal diagnosis can impede the conversational component as it creates a misrepresentation of the patient’s current of state of health. In this way, the lack or misrepresentation of information by a physician ethically violates the rights of a patient for knowing all of their treatment options, but also prevents the ability of the patient to make arrangements preceding or surrounding their death. Referencing the withdrawal often experienced by doctors as a coping mechanism for grieving the loss of a patient, it is understood that many physicians adhere to a policy of not sharing the diagnosis of a patient with a patient. Not only this, but many physicians take on the approach of only discussing the diagnosis and predicted timeline before death if the patient or their family approaches the subject[xv].

Utilizing a cultural approach to understand the emotional complexity of doctors response to patient death, a primitive study describes the relationship between doctors in palliative care services and end-of-life outcomes in Taiwan. As defined within the study, hospice is a very taboo among many Taiwanese because of the association with death and therefore many physicians spend less time with the patients. This results in a lower doctor-patient interaction time and indicates that the doctors are less emotionally attached to the patient. The results of the study concluded that patients who used palliative care services improved the quality of their end-of-life and suggested that it be implemented more widespread throughout Taiwan. The doctors illustrated that they wanted to prevent any additional harm to the patients and since there was limited exposure to the patients, the doctors were not severely impacted by the death of a patient[xvi].

The second study explores how doctors perspective palliative care with patients with metastatic cancer, which is cancer that has spread to multiple locations. This study was conducted in Turkey and all the doctors that were surveyed were non-oncologist physicians, meaning that their specialty was not cancer. Traditional Turkish families support the use of palliative care with a family member in pain, however physicians only recommend palliative care for patients with cancer. Turkey has a pain management shortage, which means that drugs such as morphine and opioids are less available for widespread use. This impacts the doctors view on death in Turkey because many doctors have to see patients suffer with higher levels of pain relative to other patients with the same condition around the world. This results in more burnout for doctors working with terminally ill patients and higher rates of resistance to the use of palliative care services and hospice care[xvii].

The final study is a survey carried out in the UK about doctor support following the death of a patient and how the death impacted their memory of the patient. This study exemplifies a westernized vision of how physicians interact with patients and found that nine out of ten doctors handle death well and do not have a significant and emotional response to the death of the patient in a way that would disrupt their medical practice. The study also found that patients that died in a traumatic way were more memorable for doctors. The survey discussed that the best way to address the emotional distress that some doctors feel is to provide them with a supportive environment that includes counselling services specializes in patient death[xviii].

Each one of these three studies displayed how there are different cultures and environments for doctors around the world that impact their response to patient death. A common thread throughout the studies was that doctors need support in the instance that the death of a patient impacts them to the point where they are unable to practice good medicine. In countries such as Taiwan and the UK, the doctor has an easier time separating from the patient because resources are readily available in these places. Considering Turkey has less resources to medicine that makes the patient more comfortable, the doctor suffer as a result because they are not able to treat their patient to their best ability. This expresses a universal idea of “primum non nocere” or “first, do no harm” that doctors around the world prescribe to[xix]. When doctors are in a position to make their patient more comfortable if they are inevitably going to die, they will be less distressed with the outcome of death. Inversely, when patients die in a way that is traumatic and doctors are able to provide little to no relief, that causes more distress for the doctor as well. There is also work to destigmatize palliative care in the Eastern world because is it often compared to the negative aspects of death and if doctors can improve the the experience of death and ensure the comfort of the patient, they will feel as if they have done everything they could do as professionals and as doctors.

Not only is the need for support shared by doctors around the world, but stress is also a common emotion that many doctors and nurses experience. A common question posed by many anthropologists are whether certain experiences happen to be universal across all cultures. Stress and its related symptoms are the opitimty of a shared human experience. In a study done on female nurses in Hong Kong, the results were unanimous in pointing towards the prevalence of stress and other mental disorders in hospital settings. For example, “Our study revealed a prevalence of depression, anxiety and stress at 35.8%, 37.3% and 41.1% respectively among nurses in Hong Kong. The proportion of nurses suffering from depression, anxiety and symptoms of stress is alarming.”[xx]. These results corroborate with the idea that stress is a universal human experience shared by people of all occupations, particularly those with increased stressors like doctors and nurses.

Accounting for the discrepancies among patient care and medical performance by a physician during the grieving process or as a response to stress, the ethicality of interactions with patients and families can be compromised. Ethics of care would be one of the most violated principals considering the role of a physician is to accurately advise the patient and their family, however, with the emotional state of the doctor being compromised it may lead in inappropriate treatment plans. When physicians create a social barrier from the patients they treat and their families it continually disrupts the right to ethics of care because of a potential for not being informed of all choices as well as a creating a general mistrust of the relationship. Not only this, but nonmaleficence can be seriously questioned regarding the impulsivity of a physician in response to emotional distress exemplified by the choice of a physician to select a more aggressive form of treatment instead of palliative care would be more ideal for the situation of the patient. Considering the evasion of ethics for informing a patient of their terminal diagnosis, it greatly compromises the ethical principle of autonomy.

Taking into account the evasion of ethics for informing a patient of their terminal diagnosis, it greatly compromises the ethical principle of autonomy. Particularly, the lack of open communication between the patients and physicians presents an issue for the autonomy of a patient the patient lacks all of the information they would need to make an informed decision about medical care. Not only this, but the ethical principle of justice is violated by the physician when the communication between the physician, patient, and family is severed as the information that is owed to the patient is not truly given. While this may not be a conscious decision by the physician to create these ethical dilemmas, it isolates all parties involved and contributes to the negative effect patient death has on the performance of physicians.

While it is understandable that all humans experience emotions and grief in a variety of ways, as a society we hold doctors to the highest of standards. When a doctor is unable to perform their work in a way that is received well by patients and families, alike, not only does this affect the treatment and care of their patients, but also alters their mental state. As a potential solution to aid in the ability of doctors to cope with the death of their patients, it has been suggested to implement a course during their medical school training on how to cope with death during their careers[xxi]. Even though this will not completely resolve the issues that arise for physicians from patient death, it can minimize the initial sense of shock as well as providing effective coping mechanism for grief. With the understanding that stress and grief are universal and interrelated processes, the effects patient death has on physicians, both domestically and globally, demonstrates the complexity of human nature and how we must further strive to support the rights of patients as well as assisting doctors through the process of grief.

 

 

Lillian Geis

Wes Yanowitch

Alexis Roberts

 

Word Count: 2931

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