Cancer docs often deal with own grief, doubts when patients die

In a profession where death and dying "are part and parcel of the work," study author Leeat Granek said grieving is mixed with "feelings of self-doubt, failure and powerlessness that come from the idea that doctors are responsible for their patients' lives and for making their treatment decisions."

Twenty oncologists at three adult cancer centers in Ontario described how they dealt -- or didn't deal -- with grief, and its effect on their professional practice and personal lives. The report was published online May 21 in the Archives of Internal Medicine.

"The issue with doing oncology is that you walk a very fine line," one doctor said. "If you get too involved with your patients you can't function because it's too much emotional load to bear, and if you get too distant from your patients then I don't think you're being a very good physician, because people pick up on that."

"Sometimes the grief comes home with the oncologist," said Granek, a postdoctoral fellow at the Hospital for Sick Children in Toronto. Although some doctors "compartmentalized" in order to function, others had difficulty sleeping or enjoying time with their family.

But there were positive reactions, too. Some physicians found they had a better perspective on life from frequent exposure to patient loss. And some felt motivated to give better care.

The study referred to the physician's burden of "holding hard knowledge."

"Sometimes I'll take a chart and I'll look at the imaging, and everything's worse and the numbers are worse," a doctor said, "and I have to drag myself into the patient's room and figure out what can I offer them that's hopeful and positive. It's tough."

Several oncologists said they cried on the way home in their cars. But feelings were kept private or submerged.

"Losing any patient is difficult," said Dr. Len Lichtenfeld, deputy chief medical officer at the American Cancer Society. "But there is no time to grieve. You have a moment or two to reflect and then you're on to the next patient who needs your help."

Granek said that "even just acknowledging that grief over patient loss exists and that it's part of the profession would be healthier than what is happening now. There is no acknowledgement at all, and there's denial."

Other patients might be affected in the aftermath of a loss, some respondents suggested.

"Maybe I got that case after someone had just died and I was in a more aggressive mode," one physician said. "Or, maybe I undertreated someone because I just saw a patient with terrible toxicity."

Doctors talked about being distracted, less focused. When patients were dying, some physically distanced themselves, avoiding the hospital and bedside.

Patients and family members can sense this distance. Lichtenfeld told of a bereaved husband who confided in him after his wife had died of breast cancer.

Caring professionals "would spend time with him, talk to him, look at him, hold his hand, ask how he was feeling," Lichtenfeld said. But others "would not engage in those behaviors -- they would look the other way, they would not look him in the eye, they would rely on 'the data, the data, the data,'" in conversations.

"If you're troubled about the way the physician or members of that team are relating to you," Lichtenfeld recommended "bringing it up as part of the conversation."

An accompanying journal commentary described how one institution is dealing with the situation. Since 2008, the University of Rochester Medical Center in Rochester, N.Y. has held staff support meetings -- mandatory for oncology fellows -- where practitioners are encouraged to discuss their experiences with patient loss and grief.

"Feelings of frustration, anger, loss, isolation and insecurity often emerge in a setting that is nonjudgmental and supportive," wrote oncologists Dr. Michelle Shayne and Dr. Timothy Quill. "At the end of each one-hour session, a moment of silence is observed in remembrance of patients who have recently died, and the opportunity to remember and honor a patient who has died by saying his or her first name is offered."

Oncologists "are working very hard and doing this phenomenal job with very large numbers of patients," Granek said, "and they could use a little bit of support with this piece."

More information: Visit Healthguide.org to learn about anticipatory grieving.

Journal reference: JAMA Internal Medicine

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