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It may not make you a better GP, but experiencing grief is part and parcel of long-term care, writes Dr Bastian Seidel
I first met Patrick seven years ago. He was 81 years old then and a new patient to the practice. He made an appointment for an introductory visit and basically spent the first five minutes of the consultation weighing up the advantages of the new Apple iMac over the older model his octogenarian wife Donna was still using. Needless to say, over the years we talked about various iterations of new Apple products, but most of the time we talked about his medical conditions – after all I was his GP, and that’s what GPs focus on.
So, he had hypertension, and gastro-oesophageal reflux (made worse after drinking a cup of coffee or a glass of red wine). ACE inhibitors took care of the less than ideal blood pressure and a small dose of a PPI allowed him to enjoy a cup of Lavazza in the morning and a glass of Tasmanian Pinot Noir in the evening. He had the occasional SVT, which concerned him a lot – so we decided to use an anti-arrhythmic. That was it. I saw him every three
months “just for a check up”, but we basically talked about computers.
A year ago when he turned 87, he decided to become a bit fitter. Patrick was also determined to lose some weight. He changed his diet, stopped the alcohol (and subsequently the PPI) and we really were hoping that we could stop the ACE inhibitor as well. The diet worked well, and he lost weight. Fast. A bit too fast. When he became breathless, I decided to throw the medical textbook at him. He deserved all the medical investigations I had to offer, but I barely made it past page one – the 5cm tumour in the right upper lobe was obvious on the chest X-ray. So was the large pleural metastasis. So were the two spinal metastases. “But, I never smoked!” he protested. I knew that. I had taken a thorough medical history when we first met seven years ago.
I started grieving for my patient Patrick then. He died six weeks later.
What happens when GPs grieve over their patients? Nobody really knows. A study published in JAMA Internal Medicine studied oncologists and whether caring for critically ill and terminal patients can generate grief reactions. Of course it can. And it showed: oncologists felt sad and reported loss of sleep. Some were tearful. There were feelings of powerlessness, self-doubt guilt and failure. Some doctors were in complete denial.
So, how do we balance emotional boundaries? How do doctors address the tension between growing close enough to care about our patients, but remaining distant and professional enough to avoid the pain of the loss when the patient dies? If that’s difficult for oncologists, how do GPs cope?
GPs don’t just take over care after a terminal diagnosis. When we talk about “cradle to grave” care we take it very much literally. It’s our defining, professional aspiration.
We cope by going the extra mile. Quite literally for me that meant home visits to see Patrick, pretty much every day, including weekends – a 150km return journey. I understood that this was neither a “client” nor a “consumer” relationship. I knew it would not be sustainable in the long term. Often I cancelled patients in the practice on short notice when Patrick deteriorated and when medication had to be adjusted without delay. Those visits were longer than clinically or medically necessary, often including a cup of coffee or a glass of wine. The other patients who had to be rebooked understood. That’s the beauty of rural communities. People mind their own business, but are close nevertheless.
So how do we GPs grieve? I’m not sure. I know I did. I know I did with the help of my community: my patients, my practice colleagues, my young family. And there’s nothing wrong with grieving over patients. Does it make me a better GP? I don’t think so. Does it win me any acknowledgement for being a dedicated, caring clinician? No. That’s certainly not the case either. Grieving makes us, as professionals, human. Personally, it helps me to reflect. It’s a fermata in the busy professional life I choose to have.
So, tomorrow, I’ll do a home visit again, this time to see Patrick’s wife, Donna. No doubt we’ll have another cup of coffee or a glass of red wine, talk about the next computer she might buy, and we may even talk about some medical issues.
After all, I’m a professional.
- Granek L et al: Nature and Impact of Grief Over Patient Loss on Oncologists’ Personal and Professional Lives. Arch Intern Med. 2012;172(12): 964-966.
Dr Bastian Seidel is the RACGP president-elect and a GP in Tasmania