Brittany Goetzel

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Ms. Brandi Bradley
ENC 2135
02/18/16

Matters of Life and Death with Oneself
There are many communities that makeup the medical field, but one of the
most heartbreaking communities, is the Pediatric Oncology community. This
community is very special, because it helps to cure babies, children, teens and
adolescents from serious diseases or illnesses. The primary focus in this medical
field, is on cancer and hematology, which is the study of the blood. No matter what,
communication is always a key requirement for any community to function well, but
of course issues can arise whether it’s from lack of communication, or various other
reasons. A commonly noted issue in this community, is whether or not the Pediatric
Oncologists’ (PO) medical practices are affected after the death of a patient that
they worked with.
In the pediatric community there are well over 1,000 doctors throughout the
world. Several of those doctors are in hospitals in the United States. The United
States of America contains 3 hospital programs that are in the top 10 throughout
the world for Pediatric Cancer. Those hospitals are St. Jude’s, Children’s and Aurora
(Ranking Web Hospitals). The reason these hospitals are ranked so high in the
world, is because they have low mortality rates, high cure rates, good patientphysician relationships, and a well working community as a whole (Ranking Web
Hospitals). In order for a community to work properly, it starts with its members.
This community can contain many members throughout its structure. Some of those
members are the physicians or doctors, nurses, radiologists and surgeons. All of
these members have to communicate effectively with one another, in order for

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everything to go smoothly throughout this field. If one part of the communication
goes wrong, then major consequences can happen, like performing wrong surgeries
or giving the wrong medications to the wrong patient. Although those are worst
case scenarios, they are very detrimental to a hospitals ranking system.
Since this community relies on communication greatly, which means the
communication has to be immaculate; whether it’s with the patients, families or
other colleagues. There are different ways to communicate within this community,
which is otherwise known as the genre. Some specific genres within this community
is consultations, end of life conferences and diagnosis. The first genre that occurs
once a patient is newly admitted to the hospital, is diagnosis. After, the patient
explains all of the symptoms that they have, then the Pediatric Oncologist will do
whatever tests that they think is necessary to figure out what kind of cancer the
patient has. Once the diagnosis is figured out, then the Pediatric oncologist has to
communicate to the patient what the actual results are. This type of communication
is strictly informative, since it is informing the patient about their situation. The
audience for this genre of communication, is the patient and the family because
both are qualified to know about the situation, unless the child is too young to
understand, then it is mostly directed to the parents or guardians. During this genre
of communication, the rhetorical appeals would strictly be pathos, because the
doctors have to emotionally appeal to the family since it is hard to explain to any
family that their child has cancer and could die, depending on how bad the cancer
is. The mode of this communication is auditory and visual. The reason that this
genre could be both, is because the doctor will mostly explain what is going on,
which is auditory, but some Pediatric doctors will also bring in scans, which then

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incorporates the visual aspect. A common type of media used for this genre, is faceto-face communication.
A second form of communication, is consultations. A consultation is a
discussion between two or more medical professionals about the diagnosis or
treatment in a particular case (“Consultation”). When this genre of communication
occurs, the rhetorical appeal is logos because each doctor is trying to make a case
on what the actual diagnosis is based off the facts or known items in the case. In a
consultation the mode of the communication is audio and visual, because the
doctors listen to each other on what their stance is. The mode is also visual,
because the doctors have to prove with visual statistics, charts, diagrams or scans
for why they came up with this specific diagnosis. The media of this communication,
is face-to-face, because the doctors are in a room together debating with each other
about the issue and who is right. This type of communication is very effective,
because it helps give different perspectives to certain cases to help consider all
possibilities that the cancer could be.
A third common communication, is end of life conferences. An end of life
conference is a very unbearable situation to be in. An end of life conference is the
verbal communication with the terminally ill patient and family about what is going
to happen now, since no medical practices or medicines are helping eliminate or
shrink the cancer. The audience, would be any family members that are present and
the patient. During this communication, a strong rhetorical appeal that needs to be
used, is pathos. Pathos is used, because in an end of life conference emotions will
be very high because death is the only answer now, which the doctor has to
emotionally care for both the family and patient to help show that the doctor truly

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cares and that they tried everything they could possibly do to try and heal the
patient. The mode of communication that is prevalent in this situation, is only
verbal. A media for this type of communication, is only face-to-face since the doctor
is in a private room with the family that is present and the patient.
With that being said, a common conception that all doctors or soon to be
doctors have to realize, is that Pediatric oncologists will not be able to save all of
their patients’ lives. Death for a Pediatric Oncologist can truly be heartbreaking and
arise problems for the doctor with their work ethic. With that said, the issue within
this community is whether or not a Pediatric Oncologists’ work ethic and medical
practices change after the death of a patient in general.
Dr. Ofri states in her Introduction of her book What Doctors Feel: How
Emotions Affect the Practice of Medicine, she states that emotions exert the
strongest influence on medical practices (Page 1). A common misconception that is
viewed throughout the world, is that doctors are emotionless (US News and World
Report Ratings). Dr. Ofri states in that same book about how doctors are not strictly
heartless human beings. The common emotions that are touched on throughout her
book, which can affect medical practices are: anger, nervousness, jealousy, fearful,
ashamed or burned out/tired (Page 1). Students in the medical field are told from
the get go that emotions will always cloud judgement. People can make irrational
decisions if they are in distressed emotional places, but doctors have to overcome
this problem in some way.
The most challenging aspect with empathy to a doctor, is when the sufferings
don’t make sense; for example, a tumor (Ofri, 15). This relates completely towards
the Pediatric Oncologist community, since this field deals with finding tumors all of

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the time. Finding a tumor can be distressful, if the tumor is incurable, which then
means the patient most definitely is going to die. When distress is settled in from a
death of a patient and there is no grieving time given, that’s when things can go
wrong. “When there is no time or space to give grief its due, burnout, callousness,
PTSD and skewed treatment decisions are at risk” (Ofri, Chap. 4). Doctors in the
Pediatric Oncology field never get the time to actually grieve, since they have so
many patients to deal with every day. That’s when medical practices can start to
diminish. One affect with death that can impact the Pediatric Oncologists medical
practices, is sense of belonging. One doctor stated in the Nature and Impact of Grief
Over Patient Loss on Oncologists’ Personal and Professional Lives, that “I come in
and I don’t really want to be here at all. It’s an effort to drag myself down to the
hospital.” From this study, it was found that 55% of doctors agreed to this
statement. That then shows, that at least half of the doctors say that the emotional
distress that their job puts on them, makes it hard for them to go to work. If they
lack the motivation that much, then they aren’t fully there during their jobs, which
ultimately concludes that their medical practices could be affected and worsen.
This study was simply asking Pediatric oncologist doctors about the death situation.
With this same study, it was found that a lot of emotions came out, that aren’t ideal
in a medical situation. An example of one of those hurtful emotions, was feeling like
a failure, which then could also make it hard to come to work.
Another study that was conducted, called ‘Memorable Patient Deaths’:
Reactions of Hospital Doctors and their Need for Support. In this study it was only
about patients that were memorable to them, and it talked about how the patients
affected more than one person in the hospital most of the time. If more than one
person was affected by the patient after the death, then a lot of horrible things

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could come with that. For example, the doctors answered highly on being overly
sensitive, an increase in dependence on others, and withdrawn or slowed thinking.
In this kind of environment, having those kind of characteristics could be a life or
death situation. This just shows that their practice has most likely changed from
being on top of their practices and being able to do anything by themselves, to now
being a weak link in the hospital setting. No family nor patient would want to see
their Pediatric Oncologist like this, because then it is hard to trust them to be able to
cure another patient.
Now Pediatric Oncologists don’t deal with death just when they become a
doctor, they also experience it during their fellowship or internships. This is the time
for when doctors can really figure out if this career pathway is for them. In the study
Challenges Faced by Pediatric Fellows When Patients Die during Their Training, it
talks about all of the challenges that these interns/fellows face. Some of those
challenges dealt with structure, themselves and their relationships. An example of
structural challenges, was with ward duty. A ward duty, is like being on call
throughout the whole training, which means that the intern has to come in no
matter what time in the day it is. During this training, the interns are surrounded by
death because they are the ones pronouncing time of death (TOD). Another
emotional challenge with ward duty, is that relationships could be strongly
developed because they would care for the patients that others didn’t really care
for. The second challenge, was with themselves. Some examples of these
challenges, were feeling vulnerable and inexperienced since at this point in their
career they really don’t know anything. Also, the interns felt alone, since they felt
like they needed to be strong and not talk about any patient losses. These feeling
can eat anyone alive and make them not want to come back anymore either. The

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last challenge that was touched in this study, was dealing with relationships. Some
examples of these challenges were with patients/families because during the
rotations they never knew how much time they would have with that patient
whether if it would be days, weeks, months or years. Another challenge in
relationships, was with their superiors, since the superiors never helped with ways
to have them cope with the deaths.
A very common theme that explains why medical practices would be affected
after a death is emotions. Although, there could be possibly some other reasons for
why medical practices could change after the death of a young patient, besides just
emotions. One of those other reasons, was stated in the research study called
Exploring Moral Distress in Pediatric Oncology; A Sample of Registered Practitioners.
In this study it mostly touches base on patients that share several doctors and
nurses. During this study, it was found that once the patient dies or is about to die,
then the communication lacks greatly, which then gets in the way with work.
Sometimes the doctors didn’t even want to work together anymore because of what
happened previously. Then after there was a lack of communication noticed within
the team, then the physicians or nurses in the pediatric oncology community would
withdraw themselves from difficult situations. All of these facts above greatly show
for why emotions can really affect the medical practices of pediatric oncologist
doctors after the death of a patient.
Although there is another side to this issue that was found. This
argumentative side stated that there is no difference in the medical practices of
pediatric oncologists after the death of the patient for several different reasons. For
this side of the argument it was also stated, that the amount of time knowing the

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patients didn’t matter at all, because a good pediatric oncologist should be able to
overcome any kind of death they face and not allow it to get in the way with their
career. The three main arguments for no medical practice change after death were:
the doctor thinking positively, noticing that they tried their hardest or having
previous experience.
The first argument that is brought up, is that the doctors will think positively.
This helps a doctor so much. One of the common positive thoughts that is stated in
the study Doctors’ Emotional Reactions to Recent Death of a Patient, is that the
patient is in a better place. Yes, this might sound horrible, but when dealing with
cancer patients there can be severe pain incorporated. Another reason that the
doctor’s think like this, is because for a kid to go through all of the chemotherapy
and radiation can really harm their little bodies. Doctors believe that putting the
young kids through these medical practices more, is just unethical if it isn’t working.
One doctor stated in this article, “If you saw some of the kids’ reactions after
treatments or from the pain you would then understand the reasoning behind this, it
was heartbreaking because you couldn’t do anything to get rid of it even if you tried
your hardest.” No one can understand this, unless it is experience first handedly.
A second argument that is brought up, is that the Pediatric Oncologists have
tried every single medical practice of cure, but sometimes it just isn’t enough. This
argument was stated in the study called General Practitioners’ Beliefs and Attitudes
about how to Respond to Death. What the anonymous pediatric oncologist doctor
meant, is that sometimes the physician will try every medically known way to try
and cure the patient, but some types of cancers just can’t be cured. It might be hard
on the doctor at the time, but the physician doesn’t want to put the young patient in

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any more harm than good. The last and final argument for noticing no change in
medical practices after the loss of a patient also came from this same research
study. The argument, was that experience helps to make the loss a little easier.
When a person first starts out in this specific community, everything will hurt so
much, because the future doctors aren’t used to this kind of grieving process.
Although as time goes on, the grieving process does become easier, because the
doctors are more experienced and understand what helps them to get through the
loss of a patient, so they don’t have their emotions get in the way with work. As
time goes on people gain more knowledge in this career field, and understand that
sometimes it just happens and it isn’t the pediatric oncologists’ fault. Overtime
people will notice this too, but it will hurt at the moment in time.
No matter what side of this issue a person is on, there will always be the need
to cope with the situation. Some of those coping strategies, are bereavement
debriefing sessions and examples of personal ways to help cope. If a person copes,
then the chances of the Pediatric Oncologists’ medical practices being affected after
the death are slim. Although if a doctor does not deal with each loss, then previous
losses can be intertwined with their recent loss and just make the doctor a complete
mess (Keene, 185). The first coping strategy, is bereavement debriefing sessions. A
bereavement debriefing session, is specifically aimed at providing emotional
support and increasing one’s ability to manage grief (Keene, 185). In order for a
bereavement session to work properly, the session has to occur within the week or
next couple weeks after the death of the patient. In the bereavement debriefing
session, the physician gets to answer questions related to that specific patient
death that is causing distress and is with a bereavement coordinator. Only some
hospitals have this as an offering to their staff; for example, John Hopkins is one of

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those hospitals. During this study the Pediatric Oncologists that took part in it
resulted with 98.4% found these sessions helpful, 97.8% thought they were
informative and 97.8% also found them meaningful (Keene, 187). Based off of these
results the bereavement sessions tend to have high turnover rates from emotional
distress of the patient deaths.
There are then several ways to cope for a pediatric oncologist, which is all
given in two different articles. One of the articles, Oncologists’ Protocol and Coping
Strategies in Dealing with Patient Loss, states that seeking out social support and
attending activity-oriented coping techniques were the top two ways the doctors got
better (Granek, 941). Some given examples for social support, were talking to
spouses or family members, friends or other health care professionals. Although,
the best social support, is one that can relate to what the doctor is going through at
the time (Granek, 944). Granek also states on page 944 to be careful for what
colleagues the doctor talks to, because not everyone will agree with certain medical
practices. The second main coping strategy, attending activity-oriented techniqes,
consists of the doctor going to their hobbies, research opportunities, taking time off
or exercising (Granek, 941). One doctor stated that engaging in activities that don’t
involve thinking about the patient or remembering anything about the patient, gives
an ease of mind (Granek, 946). The next article that give different coping strategies,
was Dealing with Stress, Burnout, and Grief in the Practice of Oncology. This article
states that some common coping strategies, are to sleep, laugh, and make a
change or sharing responsibility with other doctors (Lyckholm, 754). These are
pretty much self-explanatory for how they could help, besides for making a change
and sharing responsibility. What Lyckholm meant for making a change, is by joining
in groups that will help. For example, doing clinical research for maybe the specific

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cancer that killed the patient (Lyckholm, 754). Lyckholm meant for sharing
responsibility, by working with other doctors, so it is easier on the doctor (754).
*Ask how to end conclusion*

*Still Need to Add Interview*

Works Cited
"‘Memorable Patient Deaths’: Reactions of Hospital Doctors and their Need for Support." Medical
education 41.10 (10): 942; 942,946; 946. Print.
Granek, Leeat, et al. "Challenges Faced by Pediatric Oncology Fellows when Patients Die during their
Training." Journal of Oncology Practice 11.2 (2015): e182-9. Print.
Granek, Leeat, et al. "Oncologists’ Protocol and Coping Strategies in Dealing with Patient Loss." Death
studies 37.10 (2013): 937,952 16p. Print.
Granek L, Tozer R, Mazzotta P, Ramjaun A, Krzyzanowska M. Nature and Impact of Grief Over Patient
Loss on Oncologists' Personal and Professional Lives. Arch Intern Med.2012;172(12):964-966.
Keene, Elizabeth A., et al. "Bereavement Debriefing Sessions: An Intervention to Support Health Care
Professionals in Managing their Grief After the Death of a Patient." Pediatric nursing 36.4 (2010):
185,9; quiz 190. Print.
Lyckholm, Laurie. "Dealing with Stress, Burnout, and Grief in the Practice of Oncology." The Lancet
Oncology 2.12 (2001): 750-5. Print.

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Ofri, Danielle (MD). What Doctors Feel: How Emotions Affect the Practice of Medicine., 2014. Print.
Pye, Kate. "Exploring Moral Distress in Pediatric Oncology; a Sample of Registered
Practitioners." Issues in comprehensive pediatric nursing 36.4 (2013): 248-61. Print.
Redinbaugh, Ellen M., et al. "Doctors' Emotional Reactions to Recent Death of A Patient: Cross Sectional
Study of Hospital Doctors." BMJ: British Medical Journal 327.7408 (2003): 185-9. Print.
Saunderson, Eric M., and Leone Ridsdale. "General Practitioners' Beliefs and Attitudes about how to
Respond to Death and Bereavement: Qualitative Study." BMJ: British Medical Journal 319.7205
(1999): 293-6. Print.