Wednesday, May 23, 2012

Grief & the Oncologist

In recent books, studies and simply among chat groups on Twitter, better, earlier and ongoing dialogue concerning end-of-life issues is seen as pivotal to improved medical decision-making serving the patient’s best interests.
Often the patient is the focus of much of this perceived need for dialogue, with the implication that it’s primarily the patient or surrogate decision-makers who need educating -- which is what makes a scheduled article in Archives of Internal Medicine so intriguing. The subject is grief, sometimes a grief born of carrying burdensome news before death has even taken place. And yet this  grief is experienced not by patient or family, but by oncologists.
"Nature and Impact of Grief Over Patient Loss on Oncologists' Personal and Professional Lives" is the product of collaboration by an interdisciplinary team of authors from Toronto and Montreal -- notably including psychologist, palliative specialist and oncologist.
The authors find that oncologists experience grief in ways both common and unique, and suffer when they compartmentalize their feelings.
"The theme of balancing emotional boundaries captured the tension between growing close enough to care about the patients but remaining distant enough to avoid the pain of the loss when the patient died," the authors write.
Easier said than done? You bet.
"Few oncologists felt they had been able to do this entirely effectively, although they recognized that the inability to balance these boundaries might be problematic for them."
Oncologists experience expected aspects of grief, the authors say, but also emotions related their sense of responsibility and holding bad news that can arise even prior to the patient's death.
This grief can’t help but impact the care of other patients.
“Of greatest significance to our health care system is that some of the oncologists' reactions to grief reported in our study (eg, altered treatment decisions, mental distraction, emotional and physical withdrawal from patients) suggest that the failure of oncologists to deal appropriately with grief from patient loss may negatively affect not only oncologists personally but also patients and their families.” 
The authors eloquently connect oncologist grief with a darkly apt metaphor: cigarette smoke.
"We found that for oncologists, patient loss was a unique affective experience that had a smokelike quality,” they write. “Like smoke, this grief was intangible and invisible. Nonetheless, it was pervasive, sticking to the physicians' clothes when they went home after work and slipping under the doors between patient rooms.”
It’s a hopeful sign to to see a pallative specialist, psychologist and oncologist working together -- because a recurring scenario has the oncologist working heroically on a cure until all hope is lost, at which point the patient falls off an emotional cliff, palliative care is called in to mop up, and the compartmentalizing oncologist returns to another case that isn’t hopeless yet.
What worked well in producing this article -- the collaborative, interdisciplinary approach -- can be just as effective in provision of medical care. And in supporting the needed dialogue.
And, the authors conclude: “One way to begin to ameliorate these negative effects would be to provide education to oncologists on how to manage difficult emotions such as grief starting at the residency stage and as continuing education throughout their careers, with the recognition that grief is a sensitive topic that can produce shame and embarrassment for the mourner.”

(NOTE: Thanks to Carol Pollard at Yale for the tip to this article)

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