Early in 2000, a BMJ article started with: ‘Are you ready to die? If not then you might begin some preparation. Every BMJ reader will die this century, and death is constantly beside us.’
There are many taboos and fears about death and the subject is avoided and skated round by both patients and doctors. When patients die, particularly if they are young, it reminds us of our own mortality, and so we often ease our anxiety by ignoring or steering clear of the subject. But, as the quote above illustrated, life is a terminal condition and death is inevitable to us all.
The key is taking the discussion at the patient’s pace while listening and being honest. The honesty in discussing death and dying should be clear and empathetic.
The discussion about dying comes at different times to different people with different conditions. At some stage in a disease it will become obvious to the doctor that curative treatment has nothing more to offer and that caring changes from cure to palliation of symptoms. Death in the near future is then inevitable.
We tend to think of this happening with cancer, but we arrive at this situation with patients with heart failure, COPD and some neurological conditions.
To make sure that your patient gets the very best death possible you will need to discuss this with them and their relatives.
Almost certainly the patient and the family will have arrived at the same conclusion, so the starting place is to find out what they are thinking and feeling and to listen very carefully to the replies.
This is the basis of planning a ‘good death’ for that patient. It takes unhurried time and a receptive mind. You can make suggestions and check them out with the patient; you can offer care, the palliative care team and your expertise to alleviate symptoms.
Just because you might well be seeing these patients because of their symptoms or to monitor their disease, discussion about death and dying is not always necessary or even beneficial.
It is important to have your ‘active listening’ antennae tuned into the cues of concern or need for information. Open questions such as ‘how are things?’ or ‘how are you doing?’ can be very helpful.
At life’s end
As life’s end approaches, patients have many and individual concerns. It is essential to discover the ideas, concerns and expectations of the patient and their family with sensitivity and skill.
Listen carefully and allow the patient space to come to terms with their predicament.
Relatives looking after patients at home are often concerned about the moment of death, and so discussion about the reality and the peace of death is often very reassuring to them.
Those who are left
The work of the GP is often involved with bereavement and we can make a great deal of difference to a situation by handling it with sensitivity.
It is important to realise that bereaved people go through several stages of grief.
If the bereaved person is having trouble moving on through these stages and has issues about adjusting, further help is sometimes needed and the Cruse Bereavement Care organisation (www.crusebereavementcare.org.uk) can be very helpful.
Looking after a dying patient and their relatives can be the most fulfilling part of being a GP, but it can also be emotionally draining.
Remember that it is all right for the doctor to have feelings too: we also sometimes need to grieve.
Dr Havelock is a GP trainer in Wooburn, Buckinghamshire
Stages of grief
- Initial shock With numbness, disbelief, heart and head in conflict, the doctor can help the person accept the reality of the loss.
- Pangs of grief Here the person has sadness, guilt, regret, anger, social withdrawal, inertia, hallucinations and nightmares. The doctor’s role is to help them experience the pain and support them through it.
- Despair This comes with a loss of meaning and lack of a will to live. This can be worrying to a doctor but is a normal part of bereavement and does not need treatment unless it becomes abnormally long. The doctor can help the person to adjust to the new environment in which the deceased is missing.
- Adjustment Here the person is moving on and we can help them emotionally to relocate the deceased to an important, but not central position.
How to deal with death and bereavement
- Death is inevitable to us all and talking about it should not be avoided.
- Doctors have their own fears about death and dying that they need to understand.
- In the ‘end of life’ time a patient and the family need help in expressing their ideas, concerns and expectations.
- Talk carefully and empathetically to patients about death and dying.
- Patients close to death will have specific communication needs.
- The strong emotions of bereavement are normal and people will need guidance.