Relationships between personal attitudes about death and communication with terminally ill patients: How oncology clinicians grapple with mortality

https://doi.org/10.1016/j.pec.2015.10.010Get rights and content

Highlights

  • Communication styles with dying patients include direct and indirect approaches.

  • Most clinicians express a conditional acceptance of their own mortality.

  • A reciprocal relationship exists between personal views about death and patient care.

  • Some clinicians’ attitudes facilitate open conversations with patients about death.

  • Self-awareness and communication training are key to improving end-of-life care.

Abstract

Objective

Clinician discomfort with death may affect care of patients but has not been well-studied. This study explores oncology clinicians’ attitudes surrounding their own death and how these attitudes both affect and are affected by their care of dying patients and their communication with them.

Methods

Qualitative interviews with physicians (n = 25), nurse practitioners (n = 7), and physician assistants (n = 1) in medical or hematologic oncology clinical practices about communication styles, care of terminally ill patients, and personal perspectives about mortality.

Results

Clinicians described three communication styles used with patients about death and dying: direct, indirect, or selectively direct. Most reported an acceptance of their mortality that was “conditional,” meaning that that they could not fully know how they would respond if actually terminally ill. For many clinicians, caring for dying patients affected their outlook on life and death, and their own perspectives on life and death affected their approach to caring for dying patients.

Conclusion

An awareness of personal mortality may help clinicians to discuss death more openly with patients and to provide better care.

Practice implications

Efforts to promote self-awareness and communication training are key to facilitating clear communication with and compassionate care of terminally ill patients.

Introduction

Most patients with advanced cancer want honest, sensitive communication about prognosis and end-of-life issues [1]. Having these conversations can help patients and their families prepare for death, make informed decisions, and avoid aggressive medical care near death [2], [3], [4]. However, open discussions about dying often do not occur [2]. Instead, these discussions are deliberately indirect or ambiguous [3], [5], [6], [7], or they take place late in the course of the disease [8].

It is clear that many barriers to the delivery of clear communication about death and dying exist [9], [10], [11], [12]. Oncologists struggle with finding a balance between providing realistic information and nurturing hope [13], [14]. Frequently they provide overoptimistic estimates of survival [15] while failing to recognize or correct their patients’ misconceptions about intent of treatment and prognosis [16], [17]. Patients, meanwhile, often overestimate their life expectancy [17], [18], misunderstand the goals of palliative chemotherapy even when told it is not curative [16], [19], and prefer less information as their illness progresses [20], [21]. Often there is a discrepancy between what physicians think patients want to hear and what patients actually want [3], [22], as well as what physicians believe they say and what patients understand [23].

Despite suggestions that clinician discomfort with death affects communication, care, and the physician–patient relationship, this phenomenon has not been well-studied [9], [11], [24], [25]. Over thirty-five years ago, Schulz and Aderman found that dying patients of physicians who personally fear death have longer terminal hospital stays [26], and it has been suggested that those physicians who have not accepted their own mortality are more likely to focus solely on biomedical issues rather than dying patients’ emotional concerns [24]. Frequent exposure to death and suffering can evoke intense emotions [27], [28], [29] and lead to death anxiety, disengagement from patients, burnout, and nihilism [30], [31]. However, such exposure also can yield several positive outcomes, such as greater personal fulfillment and enhanced meaning in life [31], [32].

These studies highlight a unidirectional impact of caring for dying patients on clinicians’ well-being, but to our knowledge little is known about the reciprocity of this relationship. One qualitative study has detailed how palliative care physicians’ own spirituality impacts their practice and how their practice impacts their spirituality [33]. While spirituality can be an important component of one’s attitude toward death, our goal was to explore more broadly how oncology clinicians’ perspectives about their own life and death affect and are affected by their care of and communication with dying patients.

Section snippets

Study design

We conducted and analyzed semi-structured interviews with oncologists, oncology nurse practitioners (NPs), and oncology physician assistants (PAs) to explore how their personal attitudes about death affect and are affected by their care of and communication with dying patients. Data analysis was based on grounded theory [34], [35] and followed an editing analytic approach [36].

Study participants

Oncologists, NPs, and PAs in clinical practices of medical or hematologic oncology were recruited from multiple private

Results

Characteristics of the 25 oncologists and 8 oncology NPs and PAs interviewed are presented in Table 1.

Below we present clinicians’ accounts of their communication styles when discussing death and dying with patients, then their attitudes about their own mortality, and finally ways in which their own perspectives about death affect and are affected by their communication with patients. Contextual factors that affect how this communication occurs are considered at the end.

Discussion

This study’s main findings are that most oncology clinicians express a conditional acceptance of their own death, and for many, there is a reciprocal relationship between their attitudes toward their own death and their care of dying patients. In particular, caring for dying patients affected clinicians’ outlook on life and death, and their own perspectives affected their approach to caring for dying patients.

In the 1970s anthropologist Ernest Becker argued that humans’ unique condition of

Acknowledgments

This study was funded by the University of Rochester Offices for Medical Education and a presidential research grant from the Arnold P. Gold Foundation (RS-15-001).

The authors thank Robert Gramling MD, DSc, Leeat Granek PhD, and Paul Whitehead PhD for their guidance in development of an interview guide, as well as Supriya Mohile MD, MS for feedback on the interview guide and help with clinician recruitment. We also express gratitude to the oncologists, nurse practitioners, and physician

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