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03/11/2013

Is Death a Medical Failure?

At our medical school, second year students have an opportunity, if they wish, to visit our local Coroner’s office to learn about the duties of the coroner but also watch autopsies in progress. I have been given the opportunity of taking groups of student there. Each group is usually taught by their physician-instructor but in the case of the coroner’s office experience, those groups which I take over, have instructors who have indicated that they didn’t want to participate in the experience. I have not talked in detail with these physicians regarding their rejection to participate but I suspect a reason. It is most likely too emotionally  traumatic to be present and to stand and watch the autopsies. But why? I think I know the answer. For many physicians, perhaps most, death represents a failure. If the particular death was not the result of the failure of that specific physician, it could represent the failure of another physician.

The idea that the death of a patient could represent a failure on the part not only of a physician but even the medical system might be suggested by the facts. Supporting this idea is that it seems it is the goal of the medical system to provide and perform everything and almost anything to keep a sick patient alive. This intense direction to maintaining life at literally “all costs” and not to “give up” was always an old goal but has become more common in recent decades when the knowledge and technology has developed so that attempts at maintaining life of the terminally ill has become more realistic and, indeed, possible.

The goal and detailing the techniques of preserving life usually starts in medical school and progresses as the student goes on to internship and residency when the individual’s responsibility for direct patient care is now present. Yes, teaching sessions about “telling the patient bad news” is part of the early medical student education but what I think is missing is the emphasis to the students about the need at some time and some point in the clinical course of the patient “to give up” both on the part of the physician but also the patient and family and then how to relate this “giving up” to the patient and family. Also, missing may be how to deal with the patient or family who refuses to “give up”.

That this teaching to students and young doctors appears to be inadequate is shown by the facts regarding the high medical expenditure for  tests and treatments in the last months of the patient’s life, the lack of time doctors spend with patients teaching and encouraging the creation of Advance Directives to set the limits of the patient’s desired life supporting treatment. Further, is the observation of seemingly prognostic inconsistency by consultants who provide “mixed messages” to the sick patient and family with some encouraging procedures and life-support despite rejection of this advice by other physicians.  Finally, is the fact that often futile cardio-pulmonary resuscitation  is always performed by default unless a “do not resuscitate” order had been written. All these facts support a conclusion that physicians and the
medical system find that death of a patient represents a professional failure. But is death by definition a medical failure or is it really part of but the ending of what is called life something that all who are alive must accept. It usually is the latter and this concept should also be emphasized in the teachings of the medical students, the doctors, patients and families.

It is encouraging that in recent years, in addition to medical technical advancements, the concept of palliative care and hospice management has develop emphasizing that attention and care for the patient can continue despite progression of the illness and actually not fail up to the end of the patient’s life.

So for those doctors who feel that the death of a patient is a failure on their part, it seems to be that it is only life itself that has failed to continue.  What is your opinion? ..Maurice.

ADDENDUM:  You may be interested to read more on this subject.  The following is an abstract and here is the link to a PhD Dissertation written by Deborah Jo Corker and titled “PHYSICIAN‟S EXPERIENCES WITH DEATH AND DYING: A PHENOMENOLOGICAL STUDY”

End-of-Life, the topic of the decade of 1990-2000, brought the focus on how we
die in America. Death encompasses cultural, ethnic, spiritual, social and physical
elements, which are often played out under the guidance of a medical provider or in
medical setting. As society redefines how we wish to handle our dying process and endof-
life care, medical society must also redefine how it trains its physicians and prepares
them to handle our death and dying. Medical school curriculum has added some end-of life
training, but there are limitations in time and scope of training available.
This qualitative phenomenological study attempts to gain the physician‟s
essences, meanings and understanding surrounding death and dying. Starting with
themes revealed in literature, in-depth interviews were used to ask selected physicians
providing care: How does death affect them? Are physicians receiving adequate training
in end-of-life care? Does the medical culture still see death as failure? How do they find
meaning in end-of-life care? Using three different groups of physicians: early in career,
mid-career, and retired, this research attempted to examine the phenomena of death
and dying over apparent time and developmental experiences of physicians.
Results: Physicians have not been adequately trained to handle end-of-life care.
Communications skills, specific end-of-life care training and support for physicians
dealing with death and dying are needed.

Graphic: From Google  Image

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