In general, healthcare professionals caring for critically ill and terminal patients must contend with the inevitable death and loss that occurs in this setting. Oncologists, in particular, are often faced with patient loss, but a new study has found that they might not be dealing appropriately with their grief.
The study, published online May 21 in the Archives of Internal Medicine, notes that this failure to deal appropriately with grief after patient loss can not only affect oncologists personally, but can also affect patients and their families.
The researchers, led by Leeat Granek, PhD, a critical health psychologist and researcher at the Hospital for Sick Children in Toronto, Ontario, Canada, explain that the grief experienced by oncologists has unique elements related to their sense of responsibility for their patients' lives.
"These feelings could begin before the death of the patient, arising from holding hard medical knowledge such as awareness of poor test results or likely patient death before revealing this information to the patient himself or herself," they write.
Their grief also comes from feelings of powerlessness, self-doubt, guilt, and failure.
Oncology can be a stressful specialty. At its extreme, stress can lead to emotional exhaustion, depersonalization, and self-perception of incompetence, according to Michelle Shayne, MD, and Timothy E. Quill, MD, in an accompanying commentary.
These issues can lead to burnout, but stress and burnout should not be confused with grief, say Drs. Shayne and Quill, both from the University of Rochester Medical Center in New York. Rather, grief is deep mental anguish that arises from loss; if it remains unaddressed over time, it can clearly contribute to burnout. This is an "occupational hazard for physicians in general and oncologists in particular," they write.
Education and Strategies
Education on how to recognize and work through the grief process can help oncologists reduce the adverse effects of grief, they explain. This would be combined with other strategies that emphasize self-care; the process should begin during training and continue throughout an oncologist's career.
Drs. Shayne and Quill describe the program at their institution. It was started in response to reports of burnout rates in practicing oncologists that are about 56% and about 30% in young trainees. A staff support group meeting was established in 2008 at the Wilmot Cancer Center, Drs. Shayne and Quill explain; the group meeting is mandatory for hematology/oncology fellows and is strongly recommended for all other team members who regularly interact with cancer patients (such as hematology/oncology attending physicians, nurses, secretaries, and social workers). The support group is facilitated by a palliative care expert, a medical oncologist, and a member of the clergy.
The group meets 6 times a year. Participants share stories and experiences and routinely reflect on self-care strategies. They are encouraged to voice any work-related personal experiences on their minds, and "feelings of frustration, anger, loss, isolation, and insecurity often emerge in a setting that is nonjudgmental and supportive," Drs. Shayne and Quill write.
"Over the past few years, we have witnessed each others tears and laughter — all while confidentially discussing our day-to-day impressions about, and personal reactions to, patients, their families, treatments, and death," they add. "This approach allows oncology staff and trainees to systematically share their loss and grief with others who have common experiences and values."
A Smokelike Quality
In their study, Dr. Granek and colleagues point out that even though there is evidence that grief after patient loss is "an intrinsic part of clinical oncology," there are no qualitative studies that examine the nature and extent of oncologists' grief over patient loss, or the impact of this grief on the lives of these physicians.
From November 2010 to July 2011, the researchers recruited and interviewed 20 oncologists selected from 3 Canadian adult oncology centers. They conducted interviews with oncologists who were at different stages in their careers, and who varied in subspecialty, sex, and ethnicity.
When it came to burnout, the single most consistent and recurrent finding was the description of "compartmentalization" that emerged from the loss of a patient. This compartmentalization involved oncologists' abilities to separate their feelings of grief from other aspects of their lives and practices. It was usually described as a coping strategy and the impact of continual patient loss.
Oncologists also discussed how losing a patient affected their treatment decisions, their level of distraction with patients, and their motivation to improve care for subsequent patients. One strategy that oncologists use is to distance themselves from patients as they move closer to death and their families. This includes making fewer visits in the hospital, fewer bedside visits, and expending less overall energy on the dying patient.
We found that for oncologists, patient loss was a unique affective experience that had a smokelike quality," the researchers 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."Patient loss was found to have a personal impact on oncologists. Study participants spoke about "grief spillover" — difficulty separating the grief in their work life from their personal life. Many also discussed how they had a better perspective on life as a result of frequent exposure to patient loss.
"Of greatest significance to our healthcare system is that some of the oncologists' reactions to grief reported in our study 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," they add.
The study was funded by Juravinski Cancer Centre Foundation in Hamilton, Ontario, Canada. Dr. Granek, Dr. Shayne, and Dr. Quill have disclosed no relevant financial relationships.
