August 1, 2003
Physician's emotional response to patient's death increases with length of care
Educators must prepare students to face death-related emotions, researchers say
The longer a doctor spends caring for a patient, the more vulnerable that doctor is to feelings of loss when that patient dies — but doctors often suffer these emotions in silence. These findings from a study by researchers at the University of Pittsburgh, Dana-Farber Cancer Institute, and Brigham and Women's Hospital are published in the July 26 issue of The British Medical Journal, a theme issue titled "What is a Good Death?"
Previous studies have shown that physicians, particularly those who are younger and less experienced, often feel sadness and even guilt over the death of a patient. This study expanded on that information to look at training level as well as other variables related to physician response, and how these physicians deal with emotions that arise over the death of a patient.
"Physicians form bonds with their patients, and when a patient dies, the physician is going to have some emotions surface," said investigator and senior author Robert M. Arnold, MD, the Leo H. Criep Chair in Patient Care, professor of medicine and chief of the Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine. "Today's medical education system does not address this important issue. I worry that this may be partly responsible for the high rate of burnout among physicians."
Researchers surveyed 188 interns, residents and primary attending physicians who were caring for 68 patients at the time of death at two U.S. teaching hospitals. They measured how training level, sex, marital status and duration of care predicted outcomes such as doctors' experiences, emotional reactions and use of coping resources.
As is usually the case in a teaching hospital, most physicians (82 percent) had not known the patient before the final hospital admission. At the time of death, 36 percent knew the patient for three days or less, and 36 knew the patient for four to seven days. Only 28 percent of surveyed physicians cared for the patient longer than a week. As a result, 62 percent classified their relationship to the patient as "not close." Providing care for a longer period of time was associated with stronger doctor-patient ties, with 11 percent of physicians describing their relationship as "very close."
Thirty-one percent of doctors reported having a strong emotional reaction to a patient's death; 23 percent found the death "disturbing," and 6 percent reported feelings of grief.
"We had expected that younger and less experienced doctors would experience more distress when a patient died but this was not the case," explained Susan D. Block, MD, chief of the Division of Psychosocial Oncology and Palliative Care at Dana-Farber and one of the paper's authors. "Instead, we found that physicians who had known their patients longer had stronger emotional reactions."
The researchers were also intrigued to find that women generally experienced more intense reactions when their patients died. "This finding suggests that male and female physicians may form different types of emotional attachments with their patients," said Block.
While most doctors surveyed reported requiring little emotional support from their colleagues, interns and residents required the most support, and females reported needing more than males. However, most residents and interns found the support they needed from one another or their families instead of from attending physicians, and attending physicians in need of support reported finding no one to help them.
"This study points to a major gap in the clinical education of interns and residents, with a culture of silence about emotions that are bound to surface in physicians many times during their careers," said Arnold. "Educators must address this issue and know how to identify clinicians who may be at risk of higher levels of emotional distress, then provide guidance in dealing with these emotions."
The study was funded by the Nathan Cummings Foundation.
Dana-Farber Cancer Institute is a principal teaching affiliate of the Harvard Medical School and is among the leading cancer research and care centers in the United States. It is a founding member of the Dana-Farber/Harvard Cancer Center (DF/HCC), designated a comprehensive cancer center by the National Cancer Institute.
