Friday Reflection 8: Physician Mourning

LD was a 66-year-old woman with a history of diabetes, hypertension, heart failure, coronary artery disease, breast cancer and pulmonary fibrosis. She died unexpectedly, found by her daughter when she did not come out of her room for breakfast.

On the day LD’s daughter called me to let me know that her mother had died, the news was expected and surprising. I had seen her only two weeks before and she was, as we say, “stable.” She had recovered from her most recent health crisis. Her breast cancer was long in the past and her heart failure was well controlled. There was nothing at her visit that had worried me. On the other hand, she had already exceeded all expectations of longevity. She had lived with severe heart failure, coronary artery disease and pulmonary fibrosis for years. She had diabetes, hypertension and a history of breast cancer. Her survival was a testament to the wonders of modern medicine (she was on eleven different prescription medications) and to her remarkably resilient and optimistic spirit. Over the course of the years, when I would see her name on my schedule, my mood would always brighten.

How a doctor reacts to a patient’s death (and thus, maybe this whole reflection) is pretty unimportant. A person’s passing is most consequential to their family and friends: the people who loved, appreciated and depended on them. The physician’s reaction should barely register with the patient's family. It is also a topic that we in medicine hardly ever discuss. Yet for those of us who care for older or critically ill patients, the death of a patient is not infrequent.

My reaction to LD’s death was predictable. Instead of the Kübler-Ross stages of grief (denial, anger, bargaining, depression and acceptance) unfolding over months, I reacted with sorrow, guilt, anxiety and relief. These are the emotions that I always experience after a patient’s death. Though their order and relative intensity varies, I can expect to experience all of them.

Anyone would find my sorrow predictable. As a patient approaches death, the doctor–patient relationship often intensifies. I will see the patient more frequently and her increasing reliance on me reflexively increases my attachment to her. The sorrow is often compounded if I have become close with the patient's family. Witnessing a family's grief magnifies my own and the death of a patient often means that I lose contact with the family.

I do frequently continue to care for the family of my deceased patient. These visits can be therapeutic, for both me and the family member. We discuss loss and the experience of illness. Some patients relish talking to someone who not only knew their spouse/partner/friend/relative but who was also involved in the intricacies of a life's end. We talk about emotions without having to tiptoe around details.

Some patients, however, find these visits, with the doctor who presided over the death of a loved one, intolerable. I have had patients tell me that they can no longer come to the office, the site of some of their most painful memories.

Guilt is an emotion that is stronger in some situations than others. I can almost always think of something that I could have done better. Was there a medication I should have prescribed? Should I have been more aggressive in an evaluation? Should I have called a consultation earlier? In cases that I cannot find something to criticize, I can always find fault in the way things ended. I should have advocated more forcefully for hospice. I should have seen her in the hospital one more time before she died.

Anxiety is usually my first emotion; the one that surprises me most. I have been in practice for more than 25 years and feel like I should have outgrown this. The anxiety is rooted in a feeling that I will be “found out” for having done something wrong or for not having done enough. Maybe it is part of the ever-lingering imposter syndrome. Maybe it originated in medical school when professors felt the need to use the threat of malpractice suits as a way of motivating students. “The internist who treats iron deficiency without pursuing a colonoscopy will be sued.”

Relief comes in two forms. One is professionally acceptable, the other less so. Despite our efforts to craft a “good death”, many patients suffer terribly in their final weeks. Whether it is pain, the horrors of the 21st century health care, or existential dread, the process of dying remains hard. I am often relieved to hear that the suffering, natural or iatrogenic, has ended.

The other type of relief? Caring for patients is hard work and caring for dying patients is the hardest. When a patient dies, this work ends. I am relieved to know that I will no longer have to cut short a breakfast with my family to see a dying patient in the hospital or be paged out of exam rooms to discuss pain management regimens with a hospice nurse.

When LD died, I felt great sorrow. I was very close with her and her daughter. There was a bit of relief, her last year had been a tough one for her, she had lost that fire that I loved. There was some guilt, I had seen her so recently that I wondered whether I had missed something. There was very little anxiety, I was close to her daughter who saw me as part of a small group of people committed to her mom.

I am sure that I am not alone in experiencing these emotions. I am also sure there are other emotions that other physicians expect with every death. Mindfulness regarding these reactions is beneficial for me in my practice. I have found myself preparing for the sorrow and guilt that I expect to feel, reassuring myself that my anxiety is normal but probably unnecessary and accepting that my relief at a patient's death does not mean that I did not care.

An Earlier version of this essay appeared here.