The Physicians Attitude

Less than 10% of people die suddenly, whereas more than 90% experience a protracted life-threatening illness (Emanuel et al., 2003). Terminal illness is more taxing on the physician than sudden and unexpected death. Not surprisingly, an empathic family physician with a long patient relationship may be uncomfortable in dealing with the patient's impending death. Physicians are most uncomfortable when they feel helpless. Unfortunately, this leads to withdrawal from the patient who is terminally ill, because the physician inappropriately feels helpless and impotent, when in fact a great deal of comfort and help can be provided.

While expressing concern and compassion for a terminal patient, the family physician still must maintain composure and objectivity to remain effective. Osler (1904) referred to this as "calm equanimity" and added, "Our equanimity is chiefly exercised in enabling us to bear with composure the misfortunes of our neighbors" (p. 8). Medicine long has emphasized the need for physicians to remain objective and deal with problems factually; if a physician is unable to do so effectively, attempts to hide emotion may lead the physician to adopt a facade that appears unsympathetic and insensitive to the patient's needs. A son reported that "with the worsening of my father's condition, the physician stopped being friendly and warm; his visits became rare and brief; his manner became quite detached, almost angry" (Seravalli, 1988, p. 1729).

Physicians sometimes lose enthusiasm for care once an illness has been recognized as incurable. If this occurs, interaction with the patient diminishes at the very time emotional support is needed most. Time-motion studies indicate that nurses and other ward personnel also spend less time with the terminally ill patient when giving baths and providing routine care. Using videotape surveillance of terminally ill patients' rooms in a university hospital, Sulmasy and Rahn (2001) found that the average patient spent more than 10 hours alone while awake per day. Since abandonment is a major fear of terminally ill patients, we must remain aware of the need to reduce the time patients spend without human interaction by physicians, nurses, or family.

Compassion fatigue is a form of emotional exhaustion and diminished empathy more common in health professionals caring for dying patients. Symptoms parallel those of post-traumatic stress disorder (PTSD), that is, hyperarousal, in the form of disturbed sleep and irritability, avoidance of the patient, and intrusive thoughts or dreams relating to the provider's work with dying patients (Kearney et al., 2009).

During the terminal stages of a fatal illness, it is vital to the dying patient that the family physician maintain a warm and caring relationship and, through the strength of the doctor-patient bond, provide support for the patient.

The physician who is uncomfortable discussing impending death can discourage conversation in many subtle ways. Hospital rounds are made rapidly, perhaps in a superficial, lighthearted manner, never pausing long enough to give the patient an opportunity to express fears and concerns. Comments such as "everything will be all right" effectively close lines of communication with an intelligent patient who is fully aware of the seriousness of the situation. When the physician tells a patient, "Don't worry," the patient interprets this as, "Don't bother me." Patients are unlikely to initiate discussions regarding their fears of death or feelings of helplessness under such circumstances and will remain silent or will avoid these issues unless they think the physician is interested and will listen. The physician easily can squelch such conversation, but a slight indication of willingness to discuss the problems disturbing the patient often results in frank conversations, which relieve much of the patient's anxiety and reveal concerns that can be shared only with the physician.

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