American College of Physicians: Internal Medicine — Doctors for Adults ®

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Learning to say goodbye: healing physicians' grief

From the November ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By Mark Stafford, FACP

Recently, I was shocked and saddened to hear that a close friend had died unexpectedly after going to the hospital with seemingly minor complaints.

My initial response was one of numbness and disorientation. Time seemed to stop and then came disbelief. Surely it was a mistake. Had I not talked to her just days before and made plans to get together?

As I heard the sad news from different quarters, reality slowly seeped into my awareness and a deep, aching sadness descended on me. I felt anguish for her husband and children, who would be devastated by the sudden loss. As I recalled her laughter and enthusiasm at our last meeting, the emptiness returned, but it was mixed with bittersweet gratitude for having known such a fine person.

The inevitability of death

In medical school and residency, I was unable to hear a fundamental truth: Everyone eventually dies.

When I was a resident, we cared for patients for only one or two months before rotating to a new service, rarely forming deep connections. Residents today get a taste of long-term responsibility by providing primary care for a panel of patients during their entire training. But it is not until after residency that a doctor's commitment lasts until the patient moves, changes doctors or dies.

For the first 10 years after residency, I practiced general internal medicine in a small southern town. I cared for patients who prepared my taxes, fixed my car, sold me insurance, taught my children and dined with me and my wife. After living side by side with my patients, attending ball games, celebrating weddings, fishing, camping and sharing a dozen other activities over the years, they became my friends.

As my practice matured and my patients' health slowly but inexorably declined, a consistent number—10 to 20—died each year. No matter how hard I worked, studied and cared, I could not stop their cancer from growing, their arteries from clogging or their heart, lungs and kidneys from failing.

How empty I felt when called to the bedside only to see them slip away, then have to return to a crowded office of waiting patients. I tried to disguise my pain while showing concern for complaints that at times seemed trivial.

A private process

After years of losing friends, a light dawned. It led me from grief and despair to gratitude and hope, and helped me cope with losing my friends and patients to death. I finally learned to say goodbye.

I cannot recall the first time I said goodbye, but I remember the healing effect it had. Immediately after my patient died and I had talked to the family, I returned to the hospital room and asked the nurse or family to leave me alone.

I became aware that my patient's spirit lingered in the vicinity for a few moments following death. I reverently touched him and told him how much his life had meant to me, how knowing him had enriched my journey.

I apologized for any way I might have failed him. I celebrated his relief from the travails of illness. I smiled as I imagined him reunited with loved ones who had preceded him in death. I told him I would miss him.

This process almost always touches me deeply and helps me shed the tears that I need to release. In those tears, my soul empties the pain and rediscovers joy. In a matter of minutes, I am able to say goodbye and return to the land of the living, focused on my remaining work.

Losing patients to death remains a painful necessity of long-term relationships. Some say, "Pain is inevitable, suffering is optional." I am not sure I agree. When we care deeply for people and they die, suffering is inevitable as we grieve their loss.

The nature of our profession demands that we find ways to cope effectively with loss. In learning to say goodbye, physicians can minimize their pain and heal more quickly.

Dr. Stafford is a clinician-educator in the division of general medicine at the University of Alabama at Birmingham.

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