Joshua Niforatos & Gregory Rutecki
Cleveland, Ohio, United States
ROSENCRANTZ: “Whatever became of the moment when one first knew about death? There must have been one, a moment, in childhood when it first occurred to you that you don’t go on forever. It must have been shattering – stamped into one’s memory. And yet, I can’t remember it. It never occurred to me at all. What does one make of that? We must be born with an intuition of mortality. Before we know the words for it, before we know that there are words, out we come, bloodied and squalling with the knowledge that for all the compasses in the world, there’s only one direction, and time is its only measure…”1
|Marie Francois Xavier Bichat (1771-1802) dying surrounded
by the doctors Esparon and Philibert Joseph Roux
(1780-1854) (oil on canvas), Hersent, Louis (1777-1860).
As early as Scene 1, Tom Stoppard’s play Rosencrantz and Guildenstern are Dead uncomfortably reminds audiences of their mortality.1 The eponymous protagonists whimsically toss coins to pass the time while travelling. The laws of probability predict the chances of “heads” versus “tails” approximates 50% for each. However, Stoppard’s character runs a consecutive streak of “heads” one hundred times! Although the streak is statistically absurd, in a symbolic way it is not only possible, but inevitable. Every person who has ever lived has died. That reality will not change. If death is humanity’s “heads,” every coin toss should accurately predict life’s finitude. There can be no “tails.” Life is evanescent. Death has been and will be difficult to rationalize. Stoppard, Rosencrantz, and Guildenstern as “everymen” probe the darkest recesses of death throughout this drama. They explore with a mindset reflecting Tennyson’s In Memoriam, “Thou madest man, he knows not why, he thinks he was not made to die.”2
Do physicians share a unique perspective on death? Doctors as early as training witness an average of twenty-eight deaths per year.3 They wage intense and at times uncomfortable battles to stave it off. Like every human, they are prone to death’s inevitable intrusion. If physicians joined Rosencrantz and Guildenstern on stage, would they muse differently about humanity’s mortal enemy? Since physicians have a redundant interface with death, and control the access to invasive, life-prolonging medical technologies, do their end-of-life goals contrast with the general public? Are their mortal exits scripted according to hospital rituals—with ventilators and ICUs? Or, is their end-of-life itinerary free of aggressive care and codified in Advance Directives (ADs)?
These questions engage human nature at its most fundamental level, probing deep fears and emotions. Could it be that physicians fear death more than their patients? Since physicians’ attitudes toward their own mortality may be subconscious, might these preferences inadvertently intrude upon their dying patients’ wishes?
A national survey of US patients, families, physicians, and other healthcare providers (nurses, social workers, chaplains, and hospital volunteers) revealed critical differences about end-of-life preferences.4 Although eight items were of strong importance to patients—including pain, symptom management, coming to peace with God, and being prepared for death—these items were scored lower by physicians. In another study, end-of-life care preferences were rated for six interventions comparing patients to physicians (Hospitalization, Intensive Care, Resuscitation, Surgery, Ventilation, and Nutrition/Hydration).5 The results all demonstrated statistically significant differences for physicians vis-à-vis patients, with doctors desiring nutrition/hydration more and everything else less.5
These data suggest that physician preferences regarding how they die are at variance with others. In another publication, 88% of physicians (n=1081) said they personally wished to forego high intensity treatments at the end-of-life, consistent with earlier research.6-7 The authors observed, “why (do) doctors choose to forego high-intensity treatments for themselves at the end-of-life, but continue to provide such care to their terminally ill patients?”6
While the studies demonstrate physicians prefer less aggressive care when surveyed, objective data suggests they choose otherwise when confronted with death. Results from the National Longitudinal Mortality Study demonstrated that physicians are only slightly less likely to die in a hospital compared to the general population.8
Serial follow up of physician preferences concerning ADs (1989-2013) also reveals negative perceptions in the medical community.6,9 About half of physicians in one survey said their own health care providers were not aware of their end-of-life preferences and nearly 60% said they had no intention of discussing them within the next year.10 In a cohort of geriatricians, only one-third had ADs and many did not inform their healthcare provider of their personal wishes for terminal care.11,12
What accounts for these differences between physicians and other people about end-of-life preferences and ADs? Could it be that physicians’ disparate attitudes toward terminal care and death are due to excessive anxiety about their own mortality?
The question whether physicians fear death more than others first surfaced in 1965.13 Answers to a survey designed to score fear of death were obtained from forty physicians and then compared to patients and other controls. Analysis of the responses led the author to say, “the reason certain physicians enter medicine is to govern their own above average fears concerning death.”13 Since 1965, however, subsequent research has failed to show that physicians fear death more and in some surveys many physicians feared death less.14,15,16
The proposition that doctors fear death more than their patients was recently suggested again by George Lundberg and Benjamin Corn.17,18 Lundberg, a forensic pathologist, and Corn, a radiation oncologist – claim that a personal fear of death is the reason why the only funeral physicians attend is their own.17,18 Corn surveyed 126 physicians and about two-thirds admitted that they do not attend patients’ funerals.19 Other surveys demonstrate that fewer than 10% of doctors send cards or flowers to the families of deceased patients.20 There are plausible reasons – other than a fear of death – justifying physician absence from patients’ funerals. Some have observed that funeral attendance intrudes on physicians’ family time.21,22 Others say that a funeral is not the right venue for talking to families.21,22 The paucity of physicians at the funerals of their patients does not appear to be a surrogate for a greater physician fear of death.
While the evidence sheds light on physicians’ personal end-of-life preferences, self-use of ADs, and fear of death, other attitudes require study. Perhaps a more critical question would be, do physicians’ personal end-of-life preferences affect their management of dying patients?
In the 1990s, a study demonstrated that physicians misinterpret patients’ end-of-life preferences and tend to replace them with their own.22,23 Four treatment scenarios were suggested for response: cardiopulmonary resuscitation, ventilator dependence, medical nutrition/hydration, and hospitalization for pneumonia. The outcomes led the authors to observe, “…physicians’ predictions of their patients’ end-of-life treatment choices are closer to the choices they would make for themselves than to the choices expressed by their patients. Since physicians ultimately exercise control over these important decisions, any unrecognized projection of personal preferences on to their patients would raise serious concerns.”23
In an anonymous survey of nephrologists (n=125) – a specialty that has a frequent interface with mortality – physicians who admitted a greater discomfort with dying patients reported they were more likely to initiate or continue life-prolonging treatment for patients despite wishes to the contrary.24,25 Twenty-five percent of the nephrologists in this survey admitted they had difficulty honoring Advance Directives if the directives contrasted with what they thought was best for their patients. Although not all physicians score highly on fear of death scales, those with higher scores more frequently exhibit negative attitudes toward dying patients.14
While physicians are aware of the inevitability of death, experiencing it frequently in others may cause them to forget that every death is a uniquely personal experience. Divergent perspectives on what constitute a good death are the rule and not the exception. The manner in which people prefer to die is inextricably linked to the individual, their family and friends, and existentially derived beliefs. Compassionate end-of-life care is compelled to acknowledge and respect patients’ cherished preferences. Empathy for the dying requires physician reflection and introspection – or else authentic compassion for the dying will be absent. Physicians are privileged to be present at birth and later to intersect with the lives of their patients during both good and vulnerable times. That unique privilege is magnified when they are not only present with dying patients, but supporting them as they walk through the valley of the shadow of death at their own pace and in their own way. True empathy in medicine must extend itself from the beginning to the end of days.
Bibliotheque de la Faculte de Medecine, Paris, France. Found at WikiCommons:http://www.wikigallery.org/wiki/painting_209628/Louis-Hersent/Marie-Francois-
- Stoppard T. Rosencrantz and Guildenstern Are Dead. New York: Samuel French, Inc., 1967. Available at: https://coldreads.files.wordpress.com/2016/08/rosencrantz-and-guildenstern-are-dead.pdf. Accessed September 1, 2017.
- Tennyson A. In Memoriam A.H.H. The Literature Network, online-literature.com; accessed January 21st, 2018.
- Chen PW. Final Exam: A Surgeon’s Reflections on Mortality. Alfred A. Knopf, New. York, 2007. P. 195.
- Steinhauser KE., Christakis NA., Clipp EC., et. al. Factors considered important at the End of Life by patients, family, physicians, and other care providers. JAMA 2000; 284:2476-2482.
- Gramelspacher GP., Zhou X-h, Hanna MP., Tierney WM. Preferences of physicians and their patients for end-of-life care. J Gen Intern Med. 1997; 12:346-351.
- Periyakoil VS., Neri E., Fong A. and Kraemer H. Do Unto Others: Doctors Personal. End-of-Life Resuscitation Preferences and Their Attitudes toward Advance Directives. PLOS one 2014; 9: e98246.
- Hiller TA., Patterson JR., Hodges MO., Rosenberg MR. Physicians as Patients: Choices regarding their own resuscitation. Arch. Intern. Med. 1995; 155:1289-1293.
- Blecker S., Johnson NJ., Altekruse S. and Horwitz LI. Association of Occupation as a Physician with Likelihood of Dying in a Hospital. JAMA 2016; 315:301-303.
- Vyjeyanthi S., Neri E., Fong A., and Kraemer H. Do Unto Others: Doctors’ Personal. End-of-Life Resuscitation Preferences and their Attitudes toward Advance Directives. PLOS ONE 2014; 9:e98246.
- Hughes DL., Singer PA. Family physicians’ attitudes toward advance directives. CMAJ. 1992; 146:1937-1944.
- Gallo JJ., Straton JB., Klag MJ. Et. al. Life-Sustaining Treatments: What Do Physicians. Want and Do They Express Their Wishes to Others? JAGS 2003; 51:961-969.
- Lester PE., Sykora A, Wolf-Klein GP., et. al. Do Geriatricians practice what they preach? Geriatricians personal establishment of Advance Directives. Gerontol. Geriatr. Educ. 2009; 30:61-74.
- Feifel H. The function of attitudes toward death. Death and Dying: Attitudes of patients and doctor (Ed.) International Group for the Advancement of Psychiatry, 1985; New York: Mental Health Materials center, pp.632-641.
- Neimeyer RA., Wittkowski J., Moser RP. Psychological Research on Death Attitudes: An Overview and Evaluation. Death Studies 2004; 28:309-340.
- Wood K. and Robinson PJ. Fear of Death in a Sample of Physicians. Can. Fam. Physician 1984; 30:416-420.
- Hamama-Raz Y., Solomon Z., Ohry A. Fear of Personal Death Among Physicians. Omega 2000; 41:139-149.
- Lundberg G. Why don’t doctors attend the funerals of their patients who die? MedGenMed. 2007; 9:54.
- Corn B. Are physicians more afraid of death than the general population? MedPage
- Corn, B. W., E. Shabtai, O. Merimsky, M. Inbar, E. Rosenbaum, A. Meerovitz, R. IsraeliSociety of Clinical Oncology and Radiation Therapy (ISCORT).” Journal of Clinical Oncology 27, no. 15_suppl (2009): e20588-e20588.
- Irvine P. The Attending at the Funeral. N. Engl. J. Med. 1985; 312:1704-5.
- Schneiderman LJ., Kaplan RM., Pearlman RA., and Teetzel H. Do physicians’ ow preferences for life-sustaining treatment influence their perceptions of patients preferences? J. of Clin. Ethics 1993; 4:28-33.
- Schneiderman LJ., Kaplan RM., Rosenberg E., Teetzel H. Do Physicans’ own preferences for life-sustaining treatment influence their perceptions of patients’ a second look. Cambridge Quarterly of Healthcare Ethics 1997; 6:131-137.
- Rutecki GW., Cugino A., Jarjoura D., et. al. Nephrologists’ subjective attitudes towards end-of-life issues and the conduct of terminal care. Clin. Nephrol. 1997; 48:173-180.
- Lim M. Influence of Physician Bias on End-of-Life Care. AMA Virtual Mentor 2003; 5:1-3.
JOSHUA D. NIFORATOS, MTS, is a medical student at Cleveland Clinic Lerner College of Medicine. Born and raised in the suburbs of Chicago, he earned bachelor degrees in both ethnology and biology at the University of New Mexico, then proceeded to earn a Master of Theological Studies at Boston University School of Theology, where he studied theology, anthropology, and ritual.
GREGORY W. RUTECKI, MD, received his medical degree from the University of Illinois, Chicago in 1974. He completed Internal Medicine training at the Ohio State University Medical Center (1978) and his fellowship in Nephrology at the University of Minnesota (1980). After twelve years of private practice in general nephrology, he entered a teaching career at the Northeastern Ohio Universities College of Medicine, the Feinberg School of Medicine, Northwestern University, and the University of South Alabama in Mobile, Alabama. While at Northwestern, he was the E. Stephen Kurtides Chair of Medical Education. He now practices general internal medicine at the Cleveland Clinic.