Mairéad Geraldine McNamara, MB, PhD
When I interviewed for my current post as a first-time consultant in medical oncology in the United Kingdom, I was asked about my 5-year career plan. I remember some detail of my reply, but I don’t think it even remotely encompassed the depth of insight I would gain from the patients I’ve treated since.
Since medical school, I have entered, unbidden, into the lives of many people and patients; their stoicism and wisdom have shaped my daily life.
I am aware of the stereotypical images of physicians being “cold” or “uncaring,” which may arise as a result of our persistent exposure to death, as the coping mechanisms of physicians can vary and may include professional detachment.1 However, I must add that the grief experienced as a result of the loss of a patient is no less for the treating physician. All physicians will have their own unique psychological composition, preexisting belief structure, and experiences with life and death and so will process the patient death experience in varying ways.2
‘Emotionally Powerful’ Patient Deaths
Jackson et al assessed the experiences of physicians at two medical centers in Boston and Pennsylvania in relation to their most emotionally powerful patient deaths.3 They reported that the “power” of these deaths was usually attributable to one of three general themes: a “good” death, an “overtreated” death, and a “shocking” or “unexpected” death.
In my early medical career, the exposure to shocking or unexpected deaths was most often in the emergency department following an acute event, be it traumatic or otherwise. In these circumstances, one was surrounded by noise as everyone worked in advanced cardiac life support mode. It was often the smell of iron from the lost blood that stayed with you on walking away—and then someone speaks, and you revert to professional modus operandi.
A ‘Good’ Death
So then, what is a “good” death? From a patient and family perspective, death is far from “good,” whatever the age or occasion. A national representative sample of adults aged ≥ 55 years in Switzerland reported that views on a “good” death differ across sociodemographic groups, with age influencing the importance that is attached to avoiding being a burden on society and education levels influencing preferences in relation to overtreatment and advance care planning.4 From my point of view, I would characterize a “good death” as the passing from this life, comfortably, in an unobtrusive environment with loved ones by your side.
I have sat in these rooms, both as a treating professional and in a personal capacity. You have a heightened sense of hearing as you listen to the person’s breathing, the muffled coughs of others in the room, and, as you look back over your shoulder, the whispers of those leaning against the walls in the corridors echo in your subconscious. As day becomes night, you put your hand on the bed covers and you feel the warmth beneath, while in your mind acknowledging that cold will soon ensue. You wait until the end and then you escape, descending the stairs, and leave the smothering confines of mortar to feel the cooler air outside envelop you.
Although it may be expected, it is not always an easy passage for some. They cannot come to terms with leaving life and their family, friends, or loved ones. Sometimes, their symptoms cannot be optimally controlled. I recall attending a young person in the middle of the night who was nearing the end. The person suddenly started to empty retch. The person’s partner became distressed and left the room to go to the nurses’ station. Knowing that death is imminent, the only thing you can do is place your hand on their back so they know they are not alone as they slip away.
There are others, often young, who demonstrate wisdom beyond their years and who, in the face of adversity and on being presented with their own mortality, display a poise that is humbling. When they thank you for all that you have done, it takes you by surprise. As you leave the room, you look back at the yellow replacing the white in their eyes, but you move on as the next patient waits.
So, do health-care professionals cry on the job? An Australian study suggested that the primary reason for health-care personnel’s on-the-job crying was identification and bonding with the suffering of patients who are dying and their families.5 You hide this demonstration of emotion, though. Additionally, a study examining the emotional reactions of medical students to their “most memorable” patient death and the support they received highlighted that, predominantly, there was no discussion by colleagues of the experience in the aftermath of the patient’s death.6 Thus, many health-care practitioners cope in isolation.
Lessons Learned at the End of Life
So, as a medical oncologist, what are the stand-out lessons I have learned?
Your well-being and health cannot be taken for granted, as exemplified by the saying from Imam Shafi’ee: “Health is a crown that the healthy wear, but only the sick can see it.” Many of you will have walked slowly with friends or significant others who have a diagnosis of cancer, and they do not have the energy or breath to go faster. You fear that others will knock against them; they may be over 6 feet tall, but in your eyes, they are made of glass.
“Since medical school, I have entered, unbidden, into the lives of many people and patients; their stoicism and wisdom have shaped my daily life.”— Mairéad Geraldine McNamara, MB, PhD
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Cancer does not differentiate. A general practitioner whom I treated looked at me one day in the consultation room and asked: “Why not me?” when discussing his diagnosis. You wonder if you would have that same resolve in a similar situation.
There is no point extending life if you don’t live it. I said this to a patient one day in the clinic, and the patient quoted this back to me, in a positive light, for the 4 years the patient survived with an incurable cancer (projected median prognosis was less than 1 year).
“At the end of the day, people won’t remember what you said or did; they will remember how you made them feel.” I was attending a virtual meeting recently and one of the health-care professionals on the call proffered this quote (adapted from Maya -Angelou, American author and poet). As medical oncologists, although we treat patients with the intent to potentially cure, more often than not, the goal of treatment is to control disease while providing quality and quantity of life. Thus, the news we often have to deliver will be devastating for patients and their family. You know that you are going to be the person who will upturn their lives irreversibly as you share this information, yet you enter the room in trepidation and relive the experience repeatedly as part of your normal daily practice.
Have no regrets. A middle-aged patient said this to me in my early medical oncology career. On the way out of this world, people do not regret the work they didn’t do, but rather the less-than-harmonious personal interactions they had with family, friends, loved ones, and colleagues. Don’t leave things unsaid.
Express gratitude. I was once standing at a poster display at a conference in conversation with others. One person suddenly realized that the man she was talking to worked for a pharmaceutical company. The company manufactured the investigational drug she was taking as part of a clinical trial. She had a good quality of life, and her survival had been extended significantly as a result of this medication. She spontaneously hugged that man.
Love is what makes our lives better. As I walk behind couples in the hospital corridor, hand in hand; as they make their way to their clinic appointments or to the chemotherapy day ward; or as I pass a crying bride in the hospital reception area and see the bridesmaids and then the groom on a hospital bed waiting in a communal area with the church minister—the strength of their bonds emanates from them, and I know they worry about the unknown.
Every day can be a special occasion. A friend of mine with advanced cancer said to me that he had been granted three Christmases as a result of treatment, which he didn’t think he would see. Indeed, holidays have added meaning and are often milestones for so many patients. I remember one young person in her early 20s who knew she would not make the next Christmas. She proceeded to organize and celebrate it with her family in early autumn, together with fake snow and Father Christmas.
To echo the words of former Prime Minister (Taoiseach) of Ireland, Leo Varadkar, lest we forget: “Never forget what we’ve lost, what we’ve learned, and what we’ve gained.”
Unlike the slogan from a well-known sports brand, there is a finish line, and everyone’s time will come. So be kind and respectful, talk often, and live (which has become so much more relevant in the uncertain times we all now inhabit).
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
DISCLOSURE: Dr. McNamara has received honoraria from Novartis; has served as a consultant or advisor to Ipsen, Shire, and Sirtex Medical; has participated in a speakers bureau for NuCana BioMed; has received research funding from Ipsen, NuCana Biomed, and Servier; and has been reimbursed for travel, accommodations, or other expenses by Bayer and Novartis.
Acknowledgment: This work was presented in part at the 2020 Cholangiocarcinoma Foundation Annual Conference. The author would like to thank her sister, Denice McNamara, for her very helpful critique and all the patients and families she has been privileged to treat, as well as her family, friends, and mentors for everything else.
REFERENCES
1. Neimeyer GJ, Behnke M, Reiss J: Constructs and coping: Physicians’ responses to patient death. Death Education 7:245-264, 1983.
2. Sansone RA, Sansone LA: Physician grief with patient death. Innov Clin Neurosci 9:22-26, 2012.
3. Jackson VA, Sullivan AM, Gadmer NM, et al: ‘It was haunting...’: Physicians’ descriptions of emotionally powerful patient deaths. Acad Med 80:648-656, 2005.
4. Borrat-Besson C, Vilpert S, Borasio GD, et al: Views on a ‘good death’: End-of-life preferences and their association with socio-demographic characteristics in a representative sample of older adults in Switzerland. Omega (Westport). July 29, 2020 (early release online).
5. Wagner RE, Hexel M, Bauer WW, et al: Crying in hospitals: A survey of doctors’, nurses’ and medical students’ experience and attitudes. Med J Aust 166:13-16, 1997.
6. Rhodes-Kropf J, Carmody SS, Seltzer D, et al: ‘This is just too awful; I just can’t believe I experienced that...’: Medical students’ reactions to their ‘most memorable’ patient death. Acad Med 80:634-640, 2005.
Dr. McNamara is employed in the Division of Cancer Sciences, University of Manchester & Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom.
