Bioethics Discussion Blog: The Dying Patient: Some Questions

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Wednesday, November 08, 2006

The Dying Patient: Some Questions

It would be unusual for the patient's personal physician to be attending and witnessing the imminent death of his or her patient. Usually, that physician is somewhere else at the time and it usually is the family, attending nurses, pastor, hospitalists or paramedics who actually are present and attending to the patient. However, often, it is in the day or days before death that the personal physician has the opportunity to be present and therefore be able to professionally interact with the dying patient. But what should be that interaction?

The issue of the dying patient is an important topic that is discussed with medical students as they begin their medical education and their careers. At the medical school in which I participate, we talk about the dying patient in the first semester of the first year. The students are given the opportunity to sit with and talk to an actor (standardized patient) playing the role of a dying patient and then later are given feedback regarding their behavior by both the “patient” and the physician facilitator. Further, I give my students a series of questions to answer and which becomes the basis for a small group discussion regarding the role and responsibilities of the physician dealing with the dying patient. The students may each have different answers to some of the questions, perhaps based on their own personal experiences and these differences are discussed.

The public’s view of the role of the physician attending the dying patient may be different than any consensus arrived at by a group of students learning to become doctors. I would like to present these questions to my blog visitors and then read and learn how they would answer them. As I have noted in previous posts, a physician's role in medicine is often set by society and my visitors represent that society. ..Maurice.

1. What do you think is the physician’s role in dealing with the dying patient?
2. Do you think there is a time when the physician should back away and let the nurses, family and pastor deal with the patient?
3. What do you think a physician feels when he/she stands at the bedside of his/her dying patient? Is there any “right: or appropriate feeling?
4. Should a physician tell his/her patient that he/she is dying? Why or why not?
5. What should the physician be talking about to his/her dying patient?
6. What is the role of a bedside physician when his/her patient has just died?

1 Comments:

At Friday, November 17, 2006 3:00:00 PM, Anonymous Moof said...

1. What do you think is the physician’s role in dealing with the dying patient?

Ensuring that the patient is as comfortable as possible physically, and that the patient's emotional/spiritual needs are being met, through making it possible for the patient to see a rabbi, minister, priest ... counselor ... whatever seems to be called for.

2. Do you think there is a time when the physician should back away and let the nurses, family and pastor deal with the patient?

I think that depends on the relationship the patient and the physician have. Under regular circumstances, once he's ensured that the patient is comfortable, has taken measures to ensure that he will be given whatever he needs to remain comfortable ... and that the patient has access to the emotional and spiritual support he desires, then I think it would usually be appropriate for the physician to "back away."

3. What do you think a physician feels when he/she stands at the bedside of his/her dying patient? Is there any “right: or appropriate feeling?

You ask some pretty tough questions. How can you tell someone what an "appropriate feeling" would be?

Relief would be appropriate, if the patient had been in a lot of pain, and the pain was soon to end; disappointment, if the physician felt that he should have been able to save the patient; sadness for the end to what may have been a mutually enjoyable and perhaps lengthy relationship ...

Physicians are human beings first, professionals second. I think we all experience the "human condition" ... and are apt to feel in whatever way our personal experiences and individual makeup have led us to feel. I don't believe it's usually a question of appropriate or inappropriate. The only response that I would find inappropriate - and not just from a medical person - would be apparent flippancy or indifference.

4. Should a physician tell his/her patient that he/she is dying? Why or why not?

Under most circumstances, I would say yes, however I believe that as often as possible, the physician should try to know his patient well enough to know if the patient wants to be told ... or how much the patient wants to be told, and should do his best to respect those preferences.

Personally ... I would want ever little detail, and be very upset if the details were hard to come by, although my physician would probably never know how upset I was.

5. What should the physician be talking about to his/her dying patient?

That depends on the condition of the patient, and what seems to be called for at the moment. Gentle questions about physical comfort, requests which can be passed on to the staff ... ensuring that spiritual/emotional needs are being provided for ...

... and perhaps asking if there's anything the patient wants to ask, say, request ... that the physician hasn't thought about.

6. What is the role of a bedside physician when his/her patient has just died?

If possible, to be there for the family/friends, if no other reason than to ensure that if there are questions, that they are answered, or that those who are severely emotionally distraught are tended to.

Also ... if the physician was aware that the patient had certain directives with regard to the handling of their remains, he should try to ensure that they are carried out by having the proper people notified and informed.

Dr. Bernstein, I wish I had more time to spend on this set of questions, because there's a lot that can be said. You can tell quite a bit about a physician by his reaction - not only to the patient's death - but also to patient's family. I don't believe those "responses" can be taught in medical school ... I think that only time, experience, and the sensitivity that comes with the experience, is the best "teacher," in these circumstances.

 

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