Being a doctor is far from being all fun. There’s the constant demand for keeping up with all that’s new in medicine by reading journals and keeping up with CME activities. If you’re in the first few years of your career then you probably have lots of debt that needs to be repaid. Then there are the long and demanding hours of work. None of that, however, compared to having to say goodbye to a patient. Of course if this was the “you don’t need me anymore, you’re better than ever” kind of goodbye there wouldn’t be any problems. Sadly you will have patients who you can’t help anymore. Some of your patients will be terminally ill and will need to be admitted to a hospice to be taken care of.
A hospice is where terminally ill patients go to be taken care of before they, usually, pass away. For instance patients who have terminal cancer where there’s nothing else a doctor can do in order to cure them. A patient with terminal esophageal cancer for example would need constant care and methods of feeding and pain control. It’s a terrible thing to experience as a person having to wait out your final days. As a doctor though it’s a different experience because you feel responsible and you’ll probably go through this more than once. What should you do and how do you say goodbye? How do you not let it affect your practice?
As a doctor there are several aspects to situations like these. First of all, you’re probably going to be the one to break the news to your patients that there’s nothing more you can do and that they need to be admitted to a hospice. You really need to work on delivering that kind of news because it can make a huge difference to a patient. Being told in a cold and nonchalant way can be devastating to the patient. You might give the impression that you’re being cold unconsciously because you’re trying to protect yourself emotionally. If you’re cold and nonchalant then you try to convince yourself you care less which will lead to less hurt. So be careful to not sound like that for your patient’s sake. You shouldn’t sound shaky and on the verge of crying either. Patients look up to their doctors and trust them. Naturally their friends and family won’t be able to keep it together, so who can? That leaves you. You need to show a little bit of strength that your patient can emulate. If everyone in a patient’s life is devastated including their doctor then what choice do they have but to be devastated? It’s important to find the balance. Be someone who cares and is affected by this, but at the same time someone who can keep it together and shows strength.
If you have a great relationship with your patient then delivering this kind of news will be a little easier because the two of you sort of know each other and there’s trust between you. The patient will know that you did everything possible in order to help them so they won’t blame you at all. Knowing this, you won’t feel too guilty either because it’s always a relief when someone you care about trusts you and doesn’t blame you. From the start of your relationship with any patient let them know through words and actions that you will spare no effort in order to make them better. Earn their trust and work for it and in return they will trust you too. This is essential with all patients not just ones who present to you with a terminal status.
The important thing for you is to not get too affected by patients being admitted to a hospice or passing away. Some doctors have a hard time doing that and spiral into depression every time they lose a patient. Learn to assess yourself adequately to see if there’s anything you could have done that would have resulted in a different outcome. Go through the patient’s records including symptoms, investigations, and the management plan to see if anything could have been changed. If you did everything right and there was no way things could have turned out differently then don’t be too hard on yourself. Of course you’ll be upset because you became a doctor to make people better and you’ll feel like you let them down, but there was nothing else you could do. It’s okay to be sad, but it’s not okay to feel guilty or suffer from depression. You might end up having to say goodbye to patients a couple of times per year and if you let each experience affect you deeply without limits then you’re going to end up down a very dark path. If something went wrong and the patient may have gotten better if things went differently then rest assured that a panel will be made to investigate the situation. So you’re not getting away with anything hence there’s no reason to beat yourself up and feel guilty.
Your practice may end up suffering due to your state of mind. If you let a patient being admitted to a hospice get to you so much then you’re going to lose focus and not be able to do your job as well as you normally can. If you’re grieving then your performance as a doctor won’t be optimal which will result in mistakes. Mistakes will lead to patients leaving you and potentially being harmed which will lead to more grief and you enter a vicious cycle that’s difficult to get out of. So don’t let grieving over terminal patients affect your duty towards the rest of your patients. You may have lost one or two, but there are dozens that still need your help that you can save.
Staying in touch with patients in a hospice is a great idea. At the end of the day you’re someone they really trust and probably adore, especially if you have a great relationship with them. Call them once a week for instance in order to check up on them and see if they’re okay. Perhaps you can ask if they need anything. Maybe you could visit once in a while see how they’re doing and take a look at their health status. It’ll also be important to follow up with the hospice and give them all the medical information you have on the patient in order to assist them with their care. Being admitted to a hospice is the end of your care for the patient, but it doesn’t mean you can’t contact them again.
It’s not easy being a doctor. The worst and most difficult part of it is being helpless. We stay up late studying and work for hours on end to be the best we can so that we never have to feel helpless, but we can’t play God. There will always be patients we can’t help and they’ll probably stick with us for the rest of our lives. The important thing is to not lose hope. You did everything you can and a patient becoming terminal is out of your hands. Don’t let that distract you from the fact that you still have tens and possible hundreds who need you and expect from you to give them the best version of you in order to make their lives better.