The Interface

the importance of doing so in an

effort to stave off burnout.

KEY WORDS
Death, dying, grief, patient death,
physician grief

INTRODUCTION
At some point in their careers of
medicine, most clinical physicians
face the specter of patient death.
However, despite this widespread
professional phenomenon, the
emotional experiences of physicians
with regard to patient death have
undergone limited investigation.
Why is physician grief relevant? In
addition to the foremost sense of
loss, according to Redinbaugh, grief-
related job stress may culminate in
job-related burnout—a deleterious
outcome that may affect up to 50
percent of physicians treating the
terminally ill.1 In this edition of The
Interface, we review the sparse
available research literature and
fertile commentary over the past 20
years in the area of physician grief in
Physician Grief relationship to patient death.

THE PREVALENCE OF GRIEF

with Patient Death RESPONSES IN PHYSICIANS
While the explicit prevalence rate
and symptom intensity of grief
by Randy A. Sansone, MD, and Lori A. Sansone, MD reactions in physicians due to patient
death has never been fully studied, a
Innov Clin Neurosci. 2012;9(4):22–16
number of investigators and authors
have touched on various parts of the
This ongoing column is dedicated to the challenging clinical interface between psychiatry and
proverbial “elephant standing in the
primary care—two fields that are inexorably linked.
middle of the room,” and provided
some piecemeal insights. For
example, from an impressionistic
ABSTRACT arena. In addition, it appears that perspective, Kasket stated that
The genuine prevalence and the grief response of physicians may physicians often experience grief
intensity of grief reactions among be tempered by a number of when faced with the death of a
physicians in response to patient personal and patient under their care.2 Given this
death is unknown. However, a environmental/contextual factors. A initial starting point, we will now
number of authorities and studies number of authors have proffered review the limited prevalence studies
indicate that such experiences are various approaches to resolving grief on the grief phenomenon associated
fairly commonplace among responses in these unique with patient death among trainees
physicians practicing in the clinical circumstances and many emphasize and physicians-in-practice.

22 Innovations in CLINICAL NEUROSCIENCE [VOLUME 9, NUMBER 4, APRIL 2012]

THE INTERFACE
Studies of primarily trainees.
In a qualitative study from the
United States, Rhodes-Kropf et al3
interviewed 65 third-year medical
students from two schools regarding
their emotional reactions to patient
deaths. In the final analysis, 32
interviews were examined. In this
sample, 57 percent of respondents
rated the effect of patient death as
highly and emotionally impactful. As
one might suspect, the finality of
death and sudden death were the
two items that evoked the strongest
emotions from trainees.
Interestingly, in those cases in which
the patient was cared for by the
student’s team, 63 percent indicated
that there was no discussion by
colleagues of the experience in the
aftermath of the patient’s death.
The next two studies include both
trainees and physicians-in-practice,
although trainees appear to
comprise the majority of
participants. In the first, a study
from the United States, Sullivan et
al4 explored the feelings and
attitudes about patient deaths
among medical students (n=1,455),
residents (n=296), and faculty
(n=287).4 While the explicit
frequency of bona fide grief
responses among participants was
not reported, nearly half felt
unprepared to manage their
emotions about patient deaths.
In a second study from the United
States of 188 medical personnel (i.e.,
medical students, residents, and
attending physicians) in two
academic teaching institutions,
Redinbaugh et al5 examined
participants’ reactions to the recent
death of an “average patient.” While
participants reported overall
satisfying experiences in caring for
dying patients, they also reported on
a Likert-style rating scale moderate
levels of emotional impact. Women
participants and those physicians
who had cared for the patient for a
longer period of time experienced
the strongest emotions. In the
aftermath of the patient’s death,
interns reported needing
significantly more emotional support
than attending physicians.
Interestingly, although residents
discussed the patient’s death with
their attending physicians, less than
a quarter found the experience to be
helpful in terms of support.
Studies of physicians-in-
practice. In a study from Scotland,
Linklater surveyed 79 physicians
about their experience with dying
patients.6 Respondents indicated
that they were frequently exposed to
patient deaths, but the authors again
reported no explicit frequencies. In
terms of their emotional
experiences, 61 percent of
respondents found their most
memorable patient death to be
emotionally distressing. Likewise,
26 percent reported recent personal
bereavement due to a patient death.
Studies of crying on the job.
While crying on the job may appear
to be an unusual venue for
exploration, there have been several
studies of this behavior in trainees
and physicians-in-practice, and
investigators have consistently
concluded that crying was most
frequently related to patient death.
For example, Angoff queried medical
students about whether they had
cried during a clinical rotation.7 Of
the 182 students, 73.1 percent
reported crying and 16.5 percent
reported near crying. When asked
what specific clinical event had
precipitated this emotional response,
the majority stated that it was in
response to the suffering and dying
of a patient and/or the family’s
associated distress.7
In an Australian study of medical
personnel, Wagner et al8 found that
crying in hospitals was reported by
[VOLUME 9, NUMBER 4, APRIL 2012]
76 percent of nurses (n=103), 57
percent of physicians (n=52), and 31
percent of medical students
(n=101).8 As previously indicated,
investigators found that the primary
reason for participants’ on-the-job
crying was identification and bonding
with the suffering of dying patients
and their families.
Finally, on-the-job crying was
examined in an Austrian study by
Barth and colleagues.9 These
investigators found that the
emotional response of crying was
fairly prevalent among the 275
medical personnel and medical
students studied, and again most
often occurred as an emotional
reaction to dealing with dying
patients.
Overall, findings indicate that a
significant proportion of medical
students and physicians-in-practice
have experienced crying in response
to patient dying or death. However,
whether or to what degree crying
behavior is predictive of an emerging
grief response remains unknown.
PSYCHOLOGICAL ISSUES
RELATED TO PHYSICIAN GRIEF
WITH DYING PATIENTS
Studies of trainees. Anderson
et al10 examined graduating medical
students with regard to their
personal experience with a patient
death. Among the 380 participants,
76 percent confirmed personal
experiences with patient death, and
participants generally reported a
negative emotional experience to
end-of-life care.10
In a Canadian study of medical
students’ first experience with
patient death, Kelly and Nisker11
examined 29 students with
interviews, focus groups, or e-mail
interview. One pervasive theme
among students was the tension
between emotional concern for the
patient and family and the intuited
Innovations in CLINICAL NEUROSCIENCE 23
THE INTERFACE
need for professional detachment.
How this tension was negotiated was
dependent upon the student’s clinical
situation (e.g., supervisors’ response,
support of supervisors and peers,
opportunities for debriefing).
Studies of physicians-in-
practice. One study has examined
the emotional context of physicians-
in-practice with regard to grief and
dying patients. In this endeavor,
McQuade12 interviewed 25 physicians
about their experiences with dying
patients. The key psychological
themes reported were grief and loss,
uncertainty and lack of control, care
versus cure, and issues of personal
growth.
Other observed psychological
themes. While not formal studies, a
number of investigators have offered
insights into physicians’ emotional
responses to patient death.
Rousseau13 described the historic
constraints of physicians in
expressing emotion with and about
patients for fear of allegedly
contaminating clinical objectivity.
Majhail and Warlick14 affirmed the
controversy around whether it is
appropriate for physicians to display
personal emotions in front of
patients. In contrast, Siegel
admonishes, “Please, fellow
physicians, don’t cry in empty rooms,
on stairwells, or in locker rooms—cry
in public and let the patients and
staff heal you and see you are
human.”15
In keeping with this theme of
suppressed emotion around patient
death, in a Danish study, Vejlgaard
and Addington-Hall16 compared
physicians and nurses who were
working in palliative care. In this
study of 347 participants,
researchers found that physicians
were more likely to leave the care of
dying patients to others
(avoidance?).
Finally, in a Hungarian study,
24 Innovations in CLINICAL NEUROSCIENCE
Hegedus et al17 examined 124 family
physicians regarding their attitudes
toward dying and death. In this
study, researchers found that
physician attitudes were generally
negative toward the process and that
participants tended to avoid
communication with others about
such matters.
Overall, the preceding material
suggests a number of psychological
themes around patient death, which
are common among medical
students, as well as physicians-in-
practice. These themes center on
uncomfortable feelings, grief,
threatened control, and generally
suppressed emotions. Why is it
important to expose these themes?
According to Pantilat and Isaac,18
physicians must attend to these
feelings to avoid burnout.
ENVIRONMENTAL/CONTEXTUAL
FACTORS RELATED TO PHYSICIAN
GRIEF WITH DYING PATIENTS
In additional to psychological
factors, there appear to be a number
of environmental or external
contextual factors that affect how
patient death is experienced by
physicians. For example, in a Greek
study of physicians and nurses
providing care to children dying of
cancer, Papadatou et al19 found that
the grieving process of these
participants was affected by how
they perceived their roles, the
interventions given to the child, and
the contribution of the participant to
the care of the child.
In a study of internal medicine
physicians, DelVecchio Good et al20
examined the contextual themes
associated with the recent death of a
patient. In this qualitative analysis of
75 physicians, researchers found
three major themes: 1) time and
process (i.e., was the death expected
or unexpected, peaceful or
chaotic/prolonged?); 2) medical care
[VOLUME 9, NUMBER 4, APRIL 2012]
and treatment decisions (i.e., was
treatment rational and appropriate or
futile and overly aggressive?); and 3)
negotiation (i.e., was communication
with the patient’s family effective or
conflictual?). Again, findings
indicate the importance of
contextual factors in the tempering
of emotional experiences of
physicians as they process a patient’s
death.
Finally, Jackson et al21 examined
the emotional experiences of
physicians at two Boston hospitals
regarding their most emotionally
powerful patient death. Using semi-
structured interviews, the
investigators found that physicians
reported “powerful deaths” at all
points in their careers. The “power”
in these deaths was usually
attributed to one of three general
themes: 1) a “good” death, 2) an
“over-treated” death, and 3) a
“shocking” or “unexpected” death.
MASTERING GRIEF
Understandably, each physician
has his or her own unique
psychological composition, pre-
existing existential belief structure,
and experiences with death,
suggesting that each will also have
his or her own unique way of
processing a patient-death
experience. However, while the
literature is sparse, several authors
have offered suggestions for dealing
with grief in this particular context.
Moon suggests that physicians
participate in death talks—social
engagements that examine the
complex dynamics of grief.22 Other
authors emphasize the importance of
adequate professional grief support,23
didactic preparation24 such as end-of-
life curricula in medical school
settings,25 death rounds (i.e., an end-
of-life educational tool to address the
emotional needs of trainees taking
care of dying patients),26 self-
THE INTERFACE
attunement or personal awareness
(i.e., being attentive to personal
needs, acknowledging feelings of
grief and loss, pursuing healthy
coping strategies),27,28 the writing of
clinical obituaries (i.e., drafting
informal summaries of the benefits
gained in the relationship with the
patient in an effort to celebrate his
or her life),29 and the incorporation of
humor.30 There are probably other
countless ways to address grief as
well, and each professional must
determine his or her most effective
personal style for resolving patient
loss.
CONCLUSION
At the present time, we do not
know the genuine prevalence rate of
physician grief reactions in response
to patient death. However, the
literature seems to affirm that this
experience is fairly ubiquitous among
clinicians. A number of
psychological and contextual factors
may temper the physician’s grief
response, but again, studies are
limited. While each physician likely
has his or her own unique style of
effectively dealing with grief, a
number of authors have proffered
suggestions for resolving grief
reactions. The experience of patient
death clearly affects a substantial
proportion of clinicians, both in
psychiatric and primary care
settings. Effectively dealing with and
resolving these painful losses will
hopefully ease some of the emotional
demands of clinical practice and
curtail the risk of professional
burnout.
REFERENCES
1. Redinbaugh EM, Schuerger JM,
Weiss LL, et al. Health care
professionals’ grief: a model based
on occupational style and coping.
Psychooncology. 2001;10:187–198.
2. Kasket E. Death and the doctor II:
a phenomenological investigation.
Existential Anals.
2006;17:385–396.
3. 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. 2005;80:634–640.
4. Sullivan AM, Lakoma MD, Block
SD. The status of medical
education in end-of-life care: a
national report. J Gen Intern
Med. 2003;18:685–695.
5. Redinbaugh EM, Sullivan AM,
Block SD, et al. Doctors’ emotional
reactions to recent death of a
patient: cross-sectional study of
hospital doctors. BMJ.
2003;327:185.
6. Linklater GT. Educational needs of
foundation doctors caring for dying
patients. J R Coll Physicians
Edinb. 2010;40:13–18.
7. Angoff NR. Crying in the
curriculum. JAMA.
2001;286:1017–1018.
8. Wagner RE, Hexel M, Bauer WW,
Kropiunigg U. Crying in hospitals:
a survey of doctors’, nurses’, and
medical students’ experience and
attitudes. Med J Aust.
1997;166:13–16.
9. Barth A, Egger A, Hladschik-
Kermer B, Kropiunigg U. Shedding
tears in hospitals—a survey of
medical staff and students.
Psychother Psychosom Med
Psychol. 2004;54:194–197.
10. Anderson WG, Williams JE, Bost
JE, Barnard D. Exposure to death
is associated with positive attitudes
and higher knowledge about end-
of-life care in graduating medical
students. J Palliat Med.
2008;11:1227–1233.
11. Kelly E, Nisker J. Medical
students’ first clinical experiences
of death. Med Educ.
2010;44:421–428.
[VOLUME 9, NUMBER 4, APRIL 2012]
12. McQuade J. Physicians and death.
Loss Grief Care. 1992;6:39–75.
13. Rousseau P. Physician crying. Am
J Hosp Palliat Care.
2003;20:251–252.
14. Majhail NS, Warlick ED. To cry or
not to cry: physicians and emotions
at the bedside. Minn Med.
2011;94:40–42.
15. Siegel B. Crying in stairwells: how
should we grieve for dying
patients? JAMA. 1994;272:659.
16. Vejlgaard T, Addington-Hall JM.
Attitudes of Danish doctors and
nurses to palliative and terminal
care. Palliat Med.
2005;19:119–127.
17. Hegedus K, Pilling J, Kolosai N,
Bognar T, Bekes V. Physicians’
attitudes toward death and dying.
Orv Hetil. 2002;143:2385–2391.
18. Pantilat SZ, Isaac M. End-of-life
care for the hospitalized patient.
Med Clin North Am.
2008;92:349–370.
19. Papadatou D, Bellali T, Papazoglou
I, Petraki D. Greek nurse and
physician grief as a result of caring
for children dying of cancer.
Pediatr Nurs. 2002;28:345–353.
20. DelVecchio Good MJ, Gadmer NM,
Ruopp P, et al. Narrative nuances
on good and bad deaths: internists’
tales from high-technology work
places. Soc Sci Med.
2004;58:939–953.
21. Jackson VA, Sullivan AM, Gadmer
NM, et al. “It was haunting…”:
physicians’ descriptions of
emotionally powerful patient
deaths. Acad Med.
2005;80:648–656.
22. Moon PJ. Death-talks:
transformative learning for
physicians. Am J Hosp Palliat
Care. 2008;25:271–277.
23. Lee KJ, Dupree CY. Staff
experiences with end-of-life care in
the pediatric intensive care unit. J
Palliat Med. 2008;11:986–990.
24. Bruce CA. Helping patients,
Innovations in CLINICAL NEUROSCIENCE 25
THE INTERFACE
families, caregivers, and physicians,
in the grieving process. J Am
Osteopath Assoc.
2007;107:ES33–ES40.
25. Ratanawongsa N, Teherani A,
Hauer KE. Third-year medical
students’ experiences with dying
patients during the internal
medicine clerkship: a qualitative
study of the informal curriculum.
Acad Med. 2005;80:641–647.
26. Smith L, Hough CL. Using death
rounds to improve end-of-life
education for internal medicine
residents. J Palliat Med.
2011;14:55–58.
27. Kutner JS, Kilbourn KM.
Bereavement: addressing
challenges faced by advanced
cancer patients, their caregivers,
and their physicians. Prim Care.
2009;36:825–844.
26 Innovations in CLINICAL NEUROSCIENCE
28. Meier DE, Back AL, Morrison RS.
The inner life of physicians and
care of the seriously ill. JAMA.
2001;286:3007–3014.
29. Goldstein A. Goodbyes. J Am
Board Fam Med.
2006;19:416–417.
30. Bruce CA. The grief process for
patient, family, and physician. J
Am Osteopath Assoc.
2002;102:S28–S32.
FUNDING: There was no funding for the
development and writing of this article.
FINANCIAL DISCLOSURES: The authors have
no conflicts of interest relevant to the content
of this article.
AUTHOR AFFILIATIONS: Dr. R. Sansone is a
professor in the Departments of Psychiatry
and Internal Medicine at Wright State
University School of Medicine in Dayton,
[VOLUME 9, NUMBER 4, APRIL 2012]
Ohio, and Director of Psychiatry Education at
Kettering Medical Center in Kettering, Ohio;
Dr. L. Sansone is a family medicine physician
(civilian) and Medical Director, Family Health
Clinic, Wright-Patterson Medical Center in
WPAFB, Ohio. The views and opinions
expressed in this column are those of the
authors and do not reflect the official policy
or position of the United States Air Force,
Department of Defense, or US government.
ADDRESS CORRESPONDENCE TO:
Randy A. Sansone, MD, Sycamore Primary
Care Center, 2115 Leiter Road, Miamisburg,
OH 45342; Phone: (937) 384-6850;
Fax: (937) 384-6938;
E-mail: randy.sansone@khnetwork.org.