Learning to Cope: How Far Is Too Close?

Abstract

PRESENTATIONA 44-year-old woman with a 25 pack-year history of smoking presented to her primary care physician with rapidly progressive dyspnea and pleuritic chest discomfort. She had no medical problems and took no medications. At this urgent clinic visit, the patient's physician noted decreased breath The case is presented of a patient with a precipitous decline in health due to rapidly progressive, metastatic non-small cell lung cancer. The discussion at Schwartz Center Rounds centers on oncologists' feelings of failure and coping mechanisms when dealing with patients' deaths. This discussion is followed by a first-year oncology fellow's reaction to caring for this and other terminally ill patients. Then, to provide a broader framework in which to understand these issues, the emotional cost and measurable benefit of close relationships with patients is investigated. To conclude, further educational initiatives are advocated to assist both physiciansin-training and more senior clinicians in dealing with the difficult issues that arise when caring for very ill and dying patients. LEARNING OBJECTIVESAfter completing this course, the reader will be able to:1. Describe the human aspects of caring for dying patients and the frustrations of futile oncology treatment.2. Explain the importance of addressing how issues of life and death affect caregivers.3. Discuss the advantages and risks of close relationships with patients.

Difficult Patient Loss and Physician Culture for Oncologists Grieving Patient Loss

“…18,19 This is particularly true for physicians who deal with patients at the end of life and has been associated with burnout in some oncologists. 15,20 Some of these difficulties were caused by relational factors and had to do with identification with the patient, closeness with the families, and the nature of these long-term relationships. 3,9,[20][21][22] Others had to do with contextual reasons considered outside of the oncologists control such as unprepared families and patients, unrealistic expectations on the part of patients and families, physician blame, and high-needs families.…”

“…15,20 Some of these difficulties were caused by relational factors and had to do with identification with the patient, closeness with the families, and the nature of these long-term relationships. 3,9,[20][21][22] Others had to do with contextual reasons considered outside of the oncologists control such as unprepared families and patients, unrealistic expectations on the part of patients and families, physician blame, and high-needs families. 3,9 Wallace and Lemaire 4 found that in a sample of 182 physicians, the emotional demands of their work including coping with suffering and death were reported as more detrimental to physician well-being than any other challenge they faced, including working long hours and juggling worklife demands.…”

Experiences of Canadian Oncologists with Difficult Patient Deaths and Coping Strategies Used

“…In the cancer care context, this literature has additionally focused on how oncologists and other health care professionals cope with patient death [13][14][15][16][17][18][19][20] . Much of the literature to date has been anecdotal, with physicians writing personal essays about their own experiences with patient death and offering advice or lessons learned to other physicians about how to cope with deaths 2,12,[21][22][23] .…”

Residents' End-of-Life Training Experience: A Literature Review of Interventions

“…27,28 Various methodologies could be used, such as death debriefing, a forum, or focused curriculum, to give them time to reflect on their decisions and on the patient's death, and which could address their psychosocial, ethical, and sometimes even legal issues. [28][29][30] Scheduling such meetings on the right occasion, like immediately after the events, would be more beneficial. 5 An attending should take this opportunity to convene ''death'' meetings, provide emotional support, address concerns, and provide resources, if needed.…”