2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

ENCOUNTERING GRIEF IN PATIENT CARE
Focus on Burnout
Grief and continuous exposure to death may contribute to
burnout. The key features of burnout identified by Maslach
et al include exhaustion, depersonalization (cynicism), and
ineffectiveness, and these symptoms are primarily job related.
16 Factors that may increase the risk of burnout
include younger age, single marital status, low self-esteem,
less hardy character trait, avoidant coping approach, belief
that others or chance are in control, and possibly job attitude.
Burnout affects patient care as well as the individual
physician.
Whippen and Canellos surveyed 1,000 oncologists regarding
burnout, 60% of whom were medical oncologists. 17 In the
598 completed responses, overall 56% of oncologists endorsed
burnout. The presence of burnout was similar across
the subspecialties with 58% for medical oncologists, 48% for
surgical oncologists, 44% for pediatric oncologists, and 52%
for radiation oncologists. The most common potential causes
of burnout were insufficient personal/vacation time (57%),
continuous exposure to fatal diseases (53%), and frustration
of ineffective therapies (45%). Interestingly, approximately
80% felt that their career fulfilled the expectations they had
in training.
A high level of burnout was observed in another study of
261 house staff, nurses, and oncologists. 18 The most common
stressor for burnout was unfavorable work events, such as
frequent exposure to death and controversies over do not
resuscitate status. Therefore, health care workers may be
predisposed to stress and burnout from a variety of factors,
including grief and exposure to patient suffering. 19-21
Possible Benefits
Health care professionals can learn much from the patients
who face death and their loved ones, if they are open
to listening. Despite the personal toll that results from
encountering grief on a regular basis, physicians and other
health care workers may achieve a profound fulfillment in
the knowledge that their contribution helped ease suffering.
This may favorably affect job satisfaction. 22,23 From a sociologic
perspective, there is evidence to suggest that giving
support may be more favorable to one’s health and wellbeing
than receiving support. 24
The bereaved may also benefit from engagement of the
physician. In a study of patients with terminal illness and
considerable care needs, their caregivers conveyed the importance
of the interaction with the physician. 4 If the physician
listened to them about the patient’s illness, they were
less likely to feel depressed. Bereavement outcomes may
also be affected by physician communication. 25
Facing Grief: What to Do
The Perspective of the Oncologist and Medical Team
As Mount succinctly noted, “To practice oncology . . . is to
augment our losses many-fold, for they are an integral part
of our professional existence.” 19 Grief, therefore, is a normal
part of an oncologist’s life. The overall perspective of the
oncologist toward these losses may be a crucial component of
the ability to cope with grief. If the oncologist views a cure or
prolongation of life as the only significant goals of patient
care, then he or she may miss a myriad of opportunities to
alleviate suffering from loss and to achieve greater insight
into the meaning of life. With this viewpoint, the physician
may particularly struggle when dealing with grief.
It is not easy to be reminded of one’s mortality on a
frequent basis. It is not easy to grieve or to watch another
grieve. Yet these experiences have the potential to ultimately
inspire and lead to a broader understanding of the
consequences of illness. A major challenge is to apply a
realistic approach to attain this idealistic ambition.
Realistic Suggestions to Cope with Grief
Grief is a normal and universal reaction to loss; engaging
one’s grief may be far more beneficial than avoiding it.
There are numerous strategies that can be used to work
through stress and grief. Several authors suggest that it
is crucial for the physician to be aware of his or her
emotions. 13,19 In addition, it is important to set reasonable
work goals, enhance time management skills, and limit
personal involvement with patients. 19,20 Integration of other
medical team members (i.e., nurses, chaplains, social workers)
may help to optimize care of the whole patient and
alleviate some of the emotional burden for the individual
physician and other medical caregivers. It may be beneficial
to foster a supportive work environment that encourages
discussion of these issues in a group or individual setting,
such as “Death Rounds”. 26
On a more personal level, a variety of suggestions for
coping include habitual exercise, optimal rest, interests
outside of work, writing one’s thoughts, reading other’s ideas
about these issues, laughter, and a focus on inner growth,
such as mindful meditation and expansion of one’s view of
life to reflect a more global/philosophic perspective. 20,23 In
particular, the field of narrative medicine employs reflective
writing to explore the physician’s relationship with self,
patients, colleagues, and society. 27 Physicians may also turn
to their own spiritual beliefs for support.
A classic symbol of grief is tears. In response to sadness,
does a physician crying indicate weakness? There may be
various responses to this question. 28 However, it may be
completely appropriate to cry for a patient or the loss of a
patient. In fact, it may be viewed by the patient or family as
a sign of compassion. 29
Bereavement Care by the Physicians
Bereavement care initiated by the physician may be very
meaningful to patient’s families. 30 In addition, it may improve
physician well-being and job satisfaction, although
further research is necessary to definitively confirm an
association. 22
Bedell et al noted that in the 1800s, it was common for
physicians to send a letter of condolence to a patient’s
family. 31 However, with the changing times, this practice
has diminished. Yet, for the bereaved, the words of the
physician may provide comfort and exemplify a more humanistic
approach to patient care. The authors suggest that
the letter include an articulation of the physician’s sympathy,
a personal reference to the patient, and an acknowledgment
of the family’s devotion to the patient. Obviously, only
sincere thoughts and emotions should be included.
A recent Canadian survey of medical oncologists, radiation
oncologists, and palliative care physicians focused on
bereavement practices. 32 The authors evaluated how often
the 535 physicians practiced one of the following: making a
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