Everyone who enters the field of oncology knows that many of their patients will die, but foreknowledge is not protection against the cumulative effects of loss.

Oncologists and oncology nurses work closely with their patients, many times for months or years, get to know them and their families well, and are often personally affected when patients reach the end of life.

Leeat Granek, PhD, and colleagues conducted interviews with oncologists regarding their reactions to patient death. They found that certain factors make losing a patient particularly difficult for oncologists, but the health care environment offers little support when they grieve.1

Oncologists reported that they found a patient’s death especially troubling if they had a close relationship with the patient and family, if the patient was young, if there was a sense of identification with the patient, if the relationship had been extensive or lengthy, or if the death was unexpected.1


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There were especially strong reactions from oncologists to patient death when patients were unaware or in denial that they were terminal, had unrealistic expectations for cure, or had undergone excessive treatments that the oncologist had not recommended.1 Families who blamed the oncologist or another physician for the patient’s death or were emotionally unstable also complicated the sense of grief.1

Some oncologists said that losing a patient could affect their care of other patients, in either a positive or negative manner: a patient’s death might motivate them to improve care for other patients or might act as a distraction.2

Grieving and the Health Care Culture

The culture of health care may make it difficult for oncology professionals to work through their grief.1 With so much emphasis on curing disease, little attention is paid to dying and end-of-life care—as if death had no place in the oncologist’s world.

The pressure to function under stress leaves little tolerance for the expression of emotions. Some oncologists consider grieving for a patient unprofessional and expressing emotion a sign of weakness, yet they acknowledge that unexpressed feelings of loss may have significant negative effects on work, family, and personal life.1,3

How Do Oncology Professionals Cope?

One of the most common coping strategies that oncologists use to ameliorate the pain of losing a patient is compartmentalization, or separating feelings of grief from other aspects of life.2

Most oncologists find that they have a need to maintain emotional boundaries—becoming close enough to a patient to foster good communication, but maintaining sufficient distance to protect themselves from excessive grief.2 Some acknowledged distancing or withdrawing themselves from patients and their families as death approached, making fewer visits and spending less time, so as to reduce their own sense of loss.2

Oncology nurses report that reaching out to patients’ families after the patient dies by sending flowers, writing letters, or attending funerals helps the nurses themselves cope with the loss.4-6

Nevertheless, grief tends to spill over into the oncologists’ personal and family lives. Granek et al wrote that oncologists’ grief has a “smoke-like” quality: “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.”2

How Institutions Could Help

Both oncologists and oncology nurses speak of the need for greater institutional support to help them deal with their grief.3,7 Both groups expressed a need for more education on the subject, and many spoke of the need to normalize grief by establishing settings where experiences could be discussed.

Some physicians expressed a need for access to professional help, but their ambivalence about their feelings was clear: they wanted to visit a counselor outside the hospital so that their colleagues would remain unaware of their distress.3 Oncologists who worked in a primary nursing care model—where one oncologist and one nurse provided an individual patient’s care throughout the course of the illness—said that having access to professional help allowed them cope with grief over a patient’s death.3

Ultimately, oncology professionals may continue to have difficulty managing their responses to patient death unless grieving is accepted as a normal part of working in a health care environment, and support is provided to manage it.


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References

1. Granek L, Krzyzanowska MK, Tozer R, Mazzotta P. Difficult patient loss and physician culture for oncologists grieving patient loss. J Palliative Med. 2012;15:1254-60.

2. Granek L, Tozer R, Mazzotta P, et al. Nature and impact of grief over patient loss on oncologists’ personal and professional lives. Ann Intern Med. 2012;172:964-6.

3. Granek L, Mazzotta P, Tozer R, Krzyzanowska MK. What do oncologists want? Support Care Cancer. 2012;20:2627-32.

4. Clerici CA, Ferrari A, Veneroni L, et al. At least we can send some flowers… Tumori. 2012;98(5):e146-e148.

5. Wujcik DM. Supporting family and colleagues can help nurses manage their grief. http://connect.ons.org/issue/october-2012/editors-note/supporting-family-and-colleagues-can-help-nurses-manage-their-grief. Accessed 12 July 2013.

6. How do you cope with patients’ death? http://connect.ons.org/issue/october-2012/you-tell-us/how-do-you-cope-with-patients%E2%80%99-death. Accessed 12 July 2013.

7. Lindberg D. When your patients die. http://connect.ons.org/issue/october-2012/up-front/when-your-patients-die. Accessed 12 July 2013.