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. doi:10.1001/archinternmed.2012.1426
Author Affiliations: Department of Psychology, Hospital for Sick Children, Toronto, Ontario, Canada (Dr Granek); Department of Medical Oncology, Juravinski Cancer Centre, Hamilton, Ontario, Canada (Dr Tozer); Palliative Care Consult Team, Sunnybrook Health Sciences Centre, Toronto (Dr Mazzotta); Department of Family and Community Medicine, University of Toronto, Toronto (Dr Mazzotta); McGill Clinical and Health Informatics, Montreal, Quebec, Canada (Ms Ramjaun); and Department of Medical Oncology & Hematology, Princess Margaret Hospital, Toronto (Dr Krzyzanowska).
Caring for critically ill and terminal patients can generate grief reactions in health care professionals (HCPs).1- 4 While all HCPs can potentially experience grief over patient loss, oncologists face unique pressures because they are legally responsible for the patients' care and may be blamed when patients die.5 Despite the evidence that grief over patient loss is an intrinsic part of clinical oncology, there are no qualitative studies examining the nature and extent of oncologists' grief over patient loss nor the impact of this grief on oncologists' lives. The objectives of our study were to explore and identify oncologists' grief over patient loss and the ways in which this grief may affect their personal and professional lives.
A grounded theory approach was used.6 We recruited and interviewed 20 oncologists between November 2010 and July 2011 from 3 adult oncology centers in Ontario, Canada. We interviewed 3 groups of oncologists who were at different stages in their careers (ie, trainees and junior and senior oncologists) and varied in subspecialty, sex, and ethnicity. Exclusion criteria were the inability to speak English and never having had a patient die in their care. Approvals were obtained from the research ethics board at each participating center. Participants signed a consent form and agreed to the interview being audio-recorded. A semistructured interview guide was used, and interviews were recorded and transcribed; all identifying information was removed from the transcripts. Data collection and analysis took place concurrently. Analysis involved line-by-line coding and was inductive, with codes and categories emerging from participants' narratives.6
In the Table, we provide an overview of our findings, including overarching categories, themes and subthemes, number of oncologists who endorsed each theme, and supporting quotations illustrating each theme.
In addition to sadness, crying, and loss of sleep, oncologists' grief had unique elements related to their sense of responsibility for their patients' lives. These feelings could begin before the death of the patient, arising from holding hard medical knowledge such as awareness of poor test results or likely patient death before revealing this information to the patient himself or herself. Oncologists' grief also included feelings of powerlessness, self-doubt, guilt, and failure.
While oncologists spoke about burnout, the single most consistent and recurrent finding in the interviews was the description of compartmentalization resulting from patient loss. Oncologists' compartmentalization involved their ability to separate feelings of grief about patient loss from other aspects of their lives and practices and was described as both a coping strategy and an impact of continual patient loss. Physicians used phrases such as “denial” and “dissociation” in describing this process as patients died.
The theme of balancing emotional boundaries captured the tension between growing close enough to care about the patients but remaining distant enough to avoid the pain of the loss when the patient died. Few oncologists felt they had been able to do this entirely effectively, although they recognized that the inability to balance these boundaries might be problematic for them.
Oncologists talked about the impact of patient loss on their treatment decisions, on their level of distraction with patients, and on their motivation to improve care for subsequent patients. Another impact was the strategy oncologists used to distance or withdraw themselves from patients and their families as the patients got closer to dying, including fewer visits in the hospital, fewer bedside visits, and less overall energy expended toward the dying patient.
Oncologists spoke about grief spillover as having difficulty separating their work life from their personal lives when the grieving came home with them. Many also talked about having a better perspective on life as a result of frequent exposure to patient loss.
To our knowledge, this study is the first qualitative exploration of the nature and impact of grief in oncologists. We found that for oncologists, patient loss was a unique affective experience that had a smokelike 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. Of greatest significance to our health care system is that some of the oncologists' reactions to grief reported in our study (eg, altered treatment decisions, mental distraction, emotional and physical withdrawal from patients) suggest that the failure of oncologists to deal appropriately with grief from patient loss may negatively affect not only oncologists personally but also patients and their families. One way to begin to ameliorate these negative effects would be to provide education to oncologists on how to manage difficult emotions such as grief starting at the residency stage and as continuing education throughout their careers, with the recognition that grief is a sensitive topic that can produce shame and embarrassment for the mourner.7
Correspondence: Dr Granek, Department of Psychology, Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8, Canada (Leeatg@gmail.com).
Published Online: May 21, 2012. doi:10.1001/archinternmed.2012.1426
Author Contributions:Study concept and design: Granek and Krzyzanowska. Acquisition of data: Granek, Tozer, Mazzotta, and Krzyzanowska. Analysis and interpretation of data: Granek, Mazzotta, Ramjaun, and Krzyzanowska. Drafting of the manuscript: Granek. Critical revision of the manuscript for important intellectual content: Granek, Tozer, Mazzotta, Ramjaun, and Krzyzanowska. Obtained funding: Granek. Administrative, technical, and material support: Granek, Mazzotta, Ramjaun, and Krzyzanowska. Study supervision: Granek.
Financial Disclosure: None reported.
Funding/Support: Funding of this research was made possible by the Juravinski Cancer Centre Foundation, Hamilton, Ontario, Canada.
Previous Presentations: Selected findings were presented at the Association for Death Education Counseling Conference; June 24, 2011; Miami, Florida; a poster with selected findings was presented at the European Health Psychology Conference; September 20-24, 2011; Crete, Greece.
Additional Contributions: We wish to thank Ellen Warner, MD, for her insightful comments on earlier drafts of this article.
Online-Only Material: The Author interview is available here