Surgery News - September 2007 - (Page 10) 10 PRACTICE TRENDS SURGERY NEWS • S E P T E M B E R 2 0 0 7 THE REST OF YOUR LIFE End-of-Life Care: Going Beyond the Disease eath is not often discussed among physicians, but after Dr. Pauline W. Chen’s critically acclaimed book “Final Exam: A Surgeon’s Reflections on Mortality” (New York: Knopf, 2007) hit bookstores, many physicians approached her, eager to share their own stories about caring for patients at the end of life. “I feel the same way,” they’d tell her, said Dr. Chen, an ACS Fellow and transplant surgeon who lives near Boston. “They don’t feel so alone in some of their emotions.” The book chronicles Dr. Chen’s transformation from a medical student taught to depersonalize death to a transplant surgeon who must be emotionally present for patients and their families during the end of life. “I don’t pretend to be an end-of-life care expert,” she said. “I’m certainly not perfect, and I continue to struggle to do the best for those I care for; but this is my experience. I hope that being open about my experience helps their efforts.” In one chapter she recalls the challenges of her Aunt Grace’s kidney failure. On the one hand, she knew what to expect and was a key person for relatives who wondered, “What happens next? What really happens when someone dies?” But Dr. Chen became preoccupied with her aunt’s physical status and transplant candidacy, and forgot about her as a whole person. Three weeks before her aunt died, Dr. Chen asked permission to include her aunt’s story in an article she was writing about organ donation. Aunt Grace granted permission but insisted the article mention the care and support provided by Dr. Chen’s uncle and cousin. “They have been here for me always; they have listened to me always,” Aunt Grace told her. “Your uncle has taken such good care of me, and your cousin has helped him. They have sacrificed so much. . . . I owe everything to them.” D That brief conversation reminded Dr. Chen of the importance of caring for the person beyond the symptoms and illness. Despite the growing popularity of palliative medicine and hospice care, Dr. Chen said that some physicians equate patients’ deaths with failure. “The metaphor for a surgeon is that you’ve actually got your hand in there affecting the cure, so you really feel tied in with them and personally responsible,” she said. “When those deaths occur, it can be devastating for doctors, not only on the relationship level—because you form relationships with your patients—but also, personally, you feel like you failed them and you failed your profession in a way.” That sense of responsibility “can hamper our future ability to care for people and to care for ourselves,” she said. “I think we only worsen the situation by not doing the small little bit that we can, which is discussing [end-of-life care] with our patients and among ourselves. By talking about it––by being present for our patients––we can fulfill those ideals that brought us to medicine in the first place.” No One Is Immune When two of his patients committed suicide during his psychiatry residency in the 1970s, Dr. Robert S. McKelvey was so devastated that he considered leaving the field. “I took it as an accusation against me that I wasn’t doing a good enough job or that I wasn’t cut out to be a psychiatrist,” recalled Dr. McKelvey, now director of the division of child and adolescent psychiatry at Oregon Health and Science University, Portland. “I’ve practiced for many years now, so I realize that’s part of the profession: you’re going to have people die from time to time if you work with severely disturbed patients. But then I was brand new.” Physicians’ reactions to death vary, said Dr. McKelvey, author of “When a Child Dies: How Pediatric Physicians and Nurses Cope” (Seattle: University of Washington Press, 2007). Patient deaths tend to affect residents and early-career physicians the most, but no physician is immune. He recommends sharing your feelings about death with someone you can confide in. “Physicians usually find either someone within their own field to talk to, or a professional listener like a psychiatrist or psychologist, or their spouse.” “A lot of physicians are afraid to go see a psychiatrist because they somehow feel that it’s going to appear on their record and the medical board will wonder about them,” Dr. McKelvey explained. “If you could have somebody who’s paid to be there and is available and can listen, I think that would be very helpful.” Overwhelmed by Gratitude When San Diego–area physicians feel isolated due to a patient’s death, many speak with Dr. Charles F. von Gunten, a consultant in hospice and palliative medicine. “For most doctors, caring for a dying patient feels very lonely, because all the other consultants go away,” said Dr. von Gunten, medical director of the Center for Palliative Studies at San Diego Hospice and Palliative Care. “If I have been involved in the case or am asked to consult and agree that they have done everything that can be done and that they are doing a good job, hearing that from me helps them cope.” Such support marks one benefit of expanding palliative care and hospice programs, but medicine has yet to devote adequate training to coping with death, said Dr. von Gunten, who also is editor in chief of the Journal of Palliative Medicine. “The loud message from the medical culture is, ‘You should have no feelings about death; you move on to the next case who needs your help,’ ” he said. “Your personal feelings are not germane. The culture of medical training teaches that doctors are not supposed to be upset by this.” As an oncology fellow, Dr. von Gunten was rattled when his first patient died. He remembered what he’d learned: send a sympathy note and attend the funeral of patients with whom you are close, “to help you grieve, move on, and be emotionally available to other patients.” When Dr. von Gunten arrived at the funeral, the man’s family expressed unexpected gratitude. “He’d had a difficult course with difficult symptoms that I hadn’t controlled very well, and I couldn’t make sense of how grateful the family was. It was only with more maturity that I realized that they were expressing gratitude for the sense that I had cared as a doctor; cared enough to look after him, even though the cancer didn’t get better; cared enough to stick with him, even though I didn’t get his symptoms under better control; and cared enough to go to the funeral.” ■ By Doug Brunk, Elsevier Global Medical News The death of Dr. Pauline W. Chen’s aunt spurred her to contemplate the role of the physician in end-of-life care. Dr. McKelvey met with a psychiatrist for more than a year to discuss his feelings about the suicides. “Another thing that’s helpful is to continue to do the job and get some more experience under your belt. Gradually, you realize that there is only a limited amount of control you have over what patients do and what happens to them.” JOANNE CHAN E - M A I L U S YO U R S TO R I E S When the demands of life sap your energy, how do you refill that inner reservoir? Rock climbing? A spa retreat? Volunteering? Please send an e-mail to column writer Doug Brunk at d.brunk@elsevier.com. http://www.acscodingtoday.com http://www.acscodingtoday.com http://www.acscodingtoday.com http://www.acscodingtoday.com
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