The Untaught Lesson

Ruth Kannai

doi:10.1370/afm.1855

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How Do Doctors Die?
Sheri Kittelson, MD

Published on: 11 February 2016
On humility and on colleagues
Michael A Weingarten

Published on: 19 November 2015
A painful but remarkable reflection
John Launer

Published on: 13 November 2015

Published on: (11 February 2016)
Page navigation anchor for How Do Doctors Die?
How Do Doctors Die?
Sheri Kittelson, MD, Palliative Care
Other Contributors:
Commentary: The Untaught Lesson
How do doctors die? Alleviating suffering imposed by incurable disease is a complex knot we attempt to untangle each day with our palliative care patients. Grief in those left behind can be immense, as insightfully reflected upon by Dr. Kannai in The Untaught Lesson. As physicians, we hope to epitomize dying gracefully, role modeling "a good death."
Physicians are...
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Commentary: The Untaught Lesson
How do doctors die? Alleviating suffering imposed by incurable disease is a complex knot we attempt to untangle each day with our palliative care patients. Grief in those left behind can be immense, as insightfully reflected upon by Dr. Kannai in The Untaught Lesson. As physicians, we hope to epitomize dying gracefully, role modeling "a good death."
Physicians are thought to die differently than the general population, forgoing burdensome and non-beneficial treatments.(1, 2, 3) However, studies of end-of-life care have recently found conflicting results. One study demonstrates that physicians do receive aggressive care (hospital days, ICU use, death in hospital)(4); while two additional studies show physicians utilize less (ICU, surgical care, death in hospital) aggressive care than the general population.(5,6)
Kubler-Ross classically described the common phases of terminal illness: denial, anger, bargaining, depression and acceptance.(7) With acceptance, tasks of closure can heal deep and longstanding wounds.(8) Experience reveals that serious illness does not follow a script or roadmap when the death is staring us in the face. Would Doctor Irene's last days have been better been spent writing letters to her children for future unattended events such as graduation and weddings, saying goodbyes, and mentoring from insight of her unique perspective through the lens of both physician and patient? Rather, her goal of care focused intensely on life prolongation, pursuing treatment with little chance of success at the cost of not having closure with loved ones. Goals became conflicted- Dr Kannai's goal of closure was not shared by the patient.
When death calls in an untimely manner, it shakes the very foundation of our belief system, prompting us to question the meaning of our work as physicians and life itself. Methods to cope with reality are as unique as every human being. Patients may struggle to accept their anticipated death and physicians struggle when they don't. The line between physician and patient is artificial, as the common denominator is mortality. Dignity and grace blossom from respecting each person's unique journey. The lessons learned for the surviving may be not as expected, as Dr. Kannai had experienced. I too unexpectedly lost my best friend of 30 years a week after the delivery of her twins. Sometimes closure occurs after our loved ones die, sometimes by sharing our reflections of The Untaught Lesson, or by kissing the children of our dearly departed appreciating the reminder of how very precious and fragile life is for both patient and physician.
References:
1) Murray, Ken MD. How Doctors Die. Humanities Journalism affilliate Arizona State University, http://stallseniormedical.com/wp- content/uploads/How-Doctors-Die.pdf : Socalo Public Square, 2011.
2) Gramelspacher GP, Zhou XH, Hanna MP, Tierney WM. "Preferences of Physicians and Their Patients for End-of-Life Care." Journal of general internal medicine, 1997: 12(6):346-51.
3) Periyakoil VS, Neri E, Fong A, Kraemer H. "Do Unto Others: Doctors' Personal End-of-Life Resuscitation Preferences and Their Attitudes toward Advance Directives." PloS one, 2014: 9(5):e98246.
4) Matlock DD, Yamishita T, Min S, Smith AK, Kelley AS, Fischer SM. "How U.S. Doctors Die: A Cohort Study of Health Care Utilization at End of Life." Journal of American Geriatric Society., 2016: (in press).
5) Weissman, JS, Cooper, S, Hyder, JA, et al. End-of-Life Care Intensity for Physicians, Lawyers, and the General Population, Journal of the American Medical Association, 2016:315(3):303-05.
6) Blecker, S, Johnson, NJ, Altekruse, S et al. Association of Occupation as a Physician With Likelihood of Dying in a Hospital, Journal of the American Medical Association, 2016:315(3):301-02.
7) Kubler-Ross, Elisabeth, MD. On death and dying. New York: The Macmillian Company, 1969.
8) Byock, Ira MD. The Four Things That Matter Most. New York: Atria Books, 2014.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (19 November 2015)
Page navigation anchor for On humility and on colleagues
On humility and on colleagues
Michael A Weingarten, Visiting Scholar
Ruth Kannai's new essay adds to her remarkable publishing record, and she does not disappoint in her incisive yet sensitive perspectives on life as a clinician.
In this essay she highlights a little-discussed dimension of clinical ethics - humility. We can just never know our patients well enough to judge their decisions, even when they are our life-long friends and colleagues. With all the openness, insight and...
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Ruth Kannai's new essay adds to her remarkable publishing record, and she does not disappoint in her incisive yet sensitive perspectives on life as a clinician.
In this essay she highlights a little-discussed dimension of clinical ethics - humility. We can just never know our patients well enough to judge their decisions, even when they are our life-long friends and colleagues. With all the openness, insight and dedication we will never be that close to fully understanding the existential motivations and the external contexts that underlie the dynamics of our patients' responses to illness, and in this case, to dying. This does not however leave us off the hook and allow us to retreat into the technician's corner, just doling out the facts of the case and leaving the patient to keep afloat herself. Humility is not the same as nihilism.
Quite the contrary, a second ethical imperative kicks in here, compassion (aka beneficence, empathy). Staying the course together with the patient, fidelity, is central to our therapeutic duty, even when we feel inadequate and peripheral, indeed even when we are rejected in the throes of the patient's negotiation with her medical and human condition. Being, not doing, is often what is called for.
The third ethical imperative of the triad is justice, making sure that the rights and duties of everyone involved, including our own, are respected and realized. Colleagues do sometimes challenge us on this count, for queue jumping and special attention seem so obviously part of being a doctor-patient. It is in this that the doctor-doctor is called upon to maintain a professional distance and consider the harm done to those other non-doctor patients who are pushed back in the queue, or are treated with less than complete clinical consideration. The flip-side of this is that sometimes we need to protect our doctor-patients from over- diagnosis and over-treatment. Not an easy task when they are also personal colleagues, teachers and friends. We are challenged with Ruth Kannai's question - how would/will I behave when I am in the same situation myself?
Colleagues and teachers are at one and the same time the most challenging and the most satisfying of patients. Dr Kannai shows this so clearly in this essay, where the role of patient-as-teacher reaches exceptional levels of significance. It is precisely in the identification with the patient that we may plumb the depths of our own personal and professional selves. We do not need to do so much cognitive work in explaining the condition and the therapeutic options, for often the patient knows more than we do, and we are free to do the human work of healing.
The ethical triad of justice, compassion and humility (cf Micah 6,8) may be our best guide.
Competing interests: I have known Ruth Kannai for many years
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Competing Interests: None declared.
Published on: (13 November 2015)
Page navigation anchor for A painful but remarkable reflection
A painful but remarkable reflection
John Launer, Associate Dean
This is a painful reflection to read, as it clearly was to write. It is also a remarkable account of a close friend's death, because it shows how each level of learning always has another another level above it, and then yet another level beyond.
As a profession, we are so often possessed by the idea that there is a "right" way to do everything - even a right way to suffer, to die, or to grieve. But perhaps the...
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This is a painful reflection to read, as it clearly was to write. It is also a remarkable account of a close friend's death, because it shows how each level of learning always has another another level above it, and then yet another level beyond.
As a profession, we are so often possessed by the idea that there is a "right" way to do everything - even a right way to suffer, to die, or to grieve. But perhaps there is a right way, and perhaps there isn't. Ruth Kannai's story poses this question and, quite appropriately, leaves it unanswered.
Competing interests: I know Dr Kannai as a colleague from teaching in Israel
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Competing Interests: None declared.