Salil Patel: The paradox of doctors dealing with death

The public need to be better informed about death, but doctors need to be prepared too, says Salil Patel

Contrary to popular belief, medicine is not a profession struggling against the finitude of death. Richard Smith recently wrote eloquently about why we need public health education and interventions for patients who are dying and their loved ones. This is an important step. However, as a medical community we often preach without practising. The public need to be better informed about death, but so do doctors.

We learn to break bad news, the prognosis of terminal conditions, and the importance of palliative care. However, we do not learn about how to react in the face of patients who are dying or in the immediate aftermath of death itself. And when offered the chance to learn, too often our profession shies away. We brush aside tips from weathered doctors on what they regret doing (or not doing) when patients were drifting away; palliative care nurses’ advice on when they should be consulted (and why); and the nuances in cultural differences around end of life care.

Books such as Atul Gawande’s Being Mortal have tapped into our collective anxiety about confronting death, and helped introduce the question of what makes a good life and a good death into the public consciousness. But as physicians, we have to be acutely aware of the part we play in this narrative on a daily basis—even when it’s a passive one.

A paper that looked at how physicians act with patients who are dying and after their death used a clever dichotomy to explain the differences in how doctors approach patients on the brink of death. The author explained how doctors use either an “action mode,” a mechanical rat a tat tat of actions (As, Bs, Cs, Ds) that will be familiar to all doctors and which help us cope with most clinical scenarios. This could take the literal form of ABCDE-ing an acutely unwell patient. But when comforting patients who are dying, it can mean a doctor shifting to an impersonal conversation focused on procedures or actions. “Presence mode” on the other hand was described as “simply being present” when nothing was left to be done. This more organic approach recognises when focusing on a functional checklist of actions will be redundant.

Sometimes this mechanical “action mode” may be necessary and perhaps easier in the absence of being taught otherwise, but if that’s all a doctor can offer a patient, they will likely feel unsupported. However, if we start to regard a patient’s comfort as the outcome we’re aiming for—even if this involves no active treatment—patients may well be more at ease near the time of death. This is a state that we should strive for.

We also can’t forget that the grieving process in the wake of a patient’s death can be similarly unfamiliar territory for doctors. A paper from Sansone and Sansone looked at the literature on grief among medics and found that doctors struggled with the lack of clinical control they’d felt over a patient’s death. The grapple between doctors’ sense that they had to maintain objectivity and professionalism, while experiencing natural grief and worry for patients, was of particular issue. Often it was easier to remain detached, under the pretext of professionalism, than attempting to weave clinical expertise with sympathy and guidance.

The ability to harbour a multitude of complex feelings is a virtue of being human. Yet when the situation is itself complexas the death of a patient usually iswe shy away from allowing ourselves to experience and move between these differing states of emotion.

So what can be done? Two studies from the University of San Francisco School of Medicine, which looked at the impact of incorporating formal teaching on caring for dying patients, might offer some ideas. The first focused on third year students during their internal medical (UK readers: acute medicine) rotation. The rota was designed so that all students encountered patients who were dying and most helped to care for such patients. The study found that this experience equipped students with a better understanding of patients’ values, the capabilities doctors needed to best comfort them, and the challenges they would face once qualified in treating these patients.

The second study focused on “death rounds” for internal medicine residents. Death rounds differ from the now ubiquitous morbidity and mortality meetings. These hour long sessions centre around doctors’ emotional reactions to deathnot the underlying pathogenesis and clinical mistakes. This had an overwhelming positive impact, with 97% of residents agreeing that regular death rounds would be beneficial to their training—and their grieving process.  

These ideas seem like they could easily be implemented into medical school and foundation year teaching curricula. Roundtable discussions and death rounds could be slotted into teaching time already carved out of busy junior doctor rotas. After all, we relearn to prescribe fluids; are reminded of major haemorrhage protocols; and rejig our memories as to the meanings of seemingly cryptic slants, inclines, and dips on ECGs. So why not set aside time for an initiative that could improve patient care at the end of life in addition to doctors’ wellbeing?

The wealth of knowledge that contributes to our arsenal of modern medicine is ever increasing. Yet our attitude towards death and dying has remained unchanged. Ensuring that we can make a person’s death as free of pain and full of support as possible is as important as healing, and doctors can be a steady presence at this critical time.

For most people, they might walk alongside someone who is dying a handful of times during their lifetime. But for medics, it is far more common. Is it not time we start to prepare ourselves to handle these experiences?

Salil Patel is an academic foundation doctor in London and research fellow at the Nuffield Department of Clinical Neurosciences, University of Oxford. Twitter @SalilPatel 

Competing interests: None declared.