By Chris Haring

Several oncologists discuss how maintaining professional boundaries and regular self-reflection are crucial when treating patients with terminal illnesses.

When we talk about death and its effects on those left behind, we often think of loved ones of the deceased, such as family and friends. However, as Donavyn Coffey explains in a recent piece for Medscape, an oft-overlooked “survivor” is the healthcare provider who treated them during their illness.

While these providers are usually assumed to have some degree of “thick skin,” they certainly aren’t immune to grief. Although most successful doctors seem to possess an inherent ability to compartmentalize professional experiences from personal feelings, the emotional burden of trying to extend and improve lives can have significant consequences. 

When treating those facing limited end-of-life options, tragic outcomes are unavoidable

For oncologist Dr. Mark Lewis, an ongoing struggle with sharing the worst prognoses with patients led to a tipping point in early 2023, he said, when his partner in practice bluntly accused him of “sugar-coating” the truth.

Lewis said that when his father died young of a rare, hereditary cancer, the then-14-year-old was inspired to make a career out of helping patients who were diagnosed with advanced-stage diseases. However, with that vocational choice comes a heavy price: over half of his patients have died within two years, he reports.

Doctors must absolve themselves of guilt and learn how – and how not – to mourn

At first, Lewis said, he would attend the funerals of his patients when they died, driven by a sense of guilt and obligation, “[I]f I had done my job better, none of us would be here,” he often thought, blaming himself despite his best efforts and overwhelming odds.

Meanwhile, cancer specialist Don Dizon, MD says he learned his lesson about going to funerals two decades ago. It didn’t take him long to realize how unsustainable it was “when you have to do this multiple times a year,” he said.

Pediatric oncologist Molly Taylor, MD, MS, has experienced her share of particularly tragic patient deaths. She reminds us that grief can affect everybody working in healthcare settings – “the nurses, the translators, the cleaning staff” – and that it’s crucial to hold space for their struggles, too.

For end-of-life care providers, boundaries are the key to a lengthy, sustainable career

If a doctor who specializes in terminal illnesses wants to have a long, successful career helping as many folks as possible, they need to prioritize their own mental health. Establishing clear boundaries between their work and personal lives is paramount, says Tina Rizack, MD. “It’s hard sometimes,” she said, but “I really do need [them],” or else risk professional burnout.

Ultimately, although there is an inherent degree of overlap for many working people between those two worlds, doctors who become emotionally invested in their patients’ journeys must prioritize balance and learn to identify their own feelings before they become overwhelming. In the long run, that is often the best thing a conscientious provider can do for their patients – and themselves.

For more information about managing grief, check out the piece we wrote for National Grief Awareness Day in 2023.

Read the full article below:

‘There’s Nothing Left to Try’: Oncologists on Managing Grief

By: Donavyn Coffey
Published: February 29, 2024

In January 2023, Mark Lewis, MD, stood with the door slammed in his face. His partner in the practice had had enough. She accused him of sugar-coating prognoses and leaving her to tell patients the whole truth.

The reality was he just didn’t know how to grieve.

Lewis was well acquainted with cancer grief long before he became an oncologist. Lewis’ father died of a rare, hereditary cancer syndrome when he was only 14. The condition, which causes tumors to grow in the endocrine glands, can be hard to identify and, if found late, deadly.

In some ways, Lewis’ career caring for patients with advanced cancers was born out of that first loss. He centered his practice around helping patients diagnosed at late stages, like his father.

But that comes at a cost. Many patients will die.

Lewis’ encounter with his colleague led him to inventory his practice. He found that well over half of his patients died within 2 years following their advanced cancer diagnosis.

To stave off the grief of so many losses, Lewis became an eternal optimist in the clinic, in search of the Hail Mary chemotherapy, any way to eke out a few more months only to be ambushed by grief when a patient did finally pass.

At funerals — which he made every effort to attend — Lewis couldn’t help but think, “if I had done my job better, none of us would be here.” His grief started to mingle with this sense of guilt.

It became a cycle: Denial shrouded in optimism, grief, then a toxic guilt. The pattern became untenable for his colleagues. And his partner finally called him out.

Few medical specialties draw physicians as close to their patients as oncology. The long courses of treatment-spanning years can foster an intimacy that is comforting for patients and fulfilling for physicians. But that closeness can also set doctors up for an acute grief when the end of life comes.

Experts agree that no amount of training in medical school prepares an oncologist to navigate the grief that comes with losing patients. Medscape Medical News spoke with five oncologists about the boundaries they rely on to sustain their careers.

Don’t Go to Funerals

Don Dizon, MD, who specializes in women’s cancers, established an essential boundary 20 years ago: Never go to funerals. In his early days at Memorial Sloan Kettering Cancer Center, the death of each patient dealt him a crushing blow. He’d go to the funerals in search of closure, but that only added to the weight of his grief.

“When I started in oncology, I just remember the most tragic cases were the ones I was taking care of,” recalled Dizon, now director of the Pelvic Malignancies Program at Lifespan Cancer Institute in Lincoln, Rhode Island.

Dizon recalled one young mother who was diagnosed with ovarian cancer. She responded to treatment, but it was short-lived, and her cancer progressed, Dizon said. Multiple treatments followed, but none were effective. Eventually, Dizon had to tell her that “there’s nothing left to try.”

At her funeral, watching her grieving husband with their daughter who had just started to walk, Dizon was overwhelmed with despair.

“When you have to do this multiple times a year,” the grief becomes untenable, Dizon said. Sensing the difficulty I was having as a new attending, “my boss stopped sending me patients because he knew I was in trouble emotionally.”

That’s when Dizon started looking for other ways to get closure.

Today, Dizon tries to say his goodbyes before a patient dies. After the final treatment or before hospice, Dizon has a parting conversation with his patients to express the privilege of caring for them and all he learned from them. These talks help him and his patient connect in their last moments together.

The Price of Wildly Happy Days

Molly Taylor, MD, MS, pediatric oncologist in Seattle, sees the deeply sad days as the price an oncologist pays to be witness to the “wildly happy ones.”

Taylor has gone to patient funerals, has even been asked to speak at them, but she has also attended patients’ weddings.

To some degree, doctors get good at compartmentalizing, they become accustomed to tragedy, she said. But there are some patients that stick with you, “and that is a whole other level of grief,” Taylor said.

Several years into her practice, one of Taylor’s patients, someone who reminded Taylor of her own child, died. The death came as a surprise, and the finality of it took her breath away, she said. The sadness only deepened as days went by. “I felt that mother’s grief and still do,” she said.

The patient’s funeral was one of the most difficult moments in her career as an oncologist. Even weeks later, she caught herself picturing the family huddled together that day.

Taking long walks, commiserating with colleagues who get it, and watching the occasional cat video can help take the immediate sting away. But the pain of losing a patient can be long lasting and processing that grief can be a lonely endeavor.

“We need space to recognize grief for all providers, all the people that touch these patients’ lives — the nurses, the translators, the cleaning staff,” Taylor said. Otherwise, you start to believe you’re the only one feeling the weight of the loss.

While it doesn’t make the losses any less poignant, Taylor finds solace in the good moments: Patient graduations and weddings, survivors who now volunteer at the hospital, and a patient who had a baby of her own this past year. If facing grief daily has taught Taylor anything, it is to not let the good moments pass unnoticed.

Towing the Line

Ten years ago, Tina Rizack, MD, walked into the ICU to see a young mother holding her 6-year-old daughter. The mother had necrotizing fasciitis that had gone undiagnosed.

As Rizack stood in the doorway watching the embrace, she saw a grim future: A child without her mother. This realization hit too close to home, she said. “I still think about that case.”

In her training, Rizack, now medical director of hematology/oncology at St. Anne’s in Fall River, Massachusetts, worked with a social worker who taught her how to deal with these tough cases — most importantly, how to not take them home with her.

Over the years, Rizack learned how to build and sustain a firm barrier between work and outside work.

She doesn’t go to funerals or give out her cell phone. If charts need to be done, she prefers to stay late at the clinic instead of bringing them home.

And she invests in the simple moments that help her detach from the day-to-day in the clinic — rooting on her kids at their games, carving out time for family meals most days, and having relaxed movie nights on the couch.

“It’s hard sometimes,” she said. But “I really do need the line.” Because without it, she can’t show up for her patients the way she wants and needs to.

Establishing the work-life boundary means that when at work, Rizack can be all in for her patients. Even after her patients’ treatment ends, she makes sure to check on them at home or in hospice. For her, sticking with patients over the long-term offers some closure.

“I want to love work, and if I’m there all the time, I’m not going to love it,” she said.

Trading Funerals for the Bedside

Like many other oncologists, Charles Blanke, MD, finds that going to patient funerals makes the loss seem more profound. He doesn’t find being at the bedside when they pass as painful. In fact, being there when his patients die offers him some comfort. He rarely misses a patient’s death because now Blanke’s patients can schedule their departure.

Blanke, an oncologist at the Knight Cancer Institute in Portland, Oregon, specializes in end-of-life care with an emphasis on death with dignity, also known as medical aid in dying. He admits it’s not a role every physician is comfortable with.

“If you’re paralyzed by grief, you can’t do this for a living,” he said. But he’s able to do the work because he genuinely feels he’s helping patients get “the relief they so strongly desire” in their last moments.

When cancer care can’t give them the life they wanted, he can give them control over when and how they die. And the ability to honor their last wishes offers him some closure as well.

“You know what kind of end they have. You know it was peaceful. You see them achieve the thing that was the most important to them,” he said.

Despite this process, he still encounters some circumstances utterly heart-wrenching — the very young patients who have advanced disease. Some of these patients choose to die because they can’t afford to continue treatment. Others don’t have a support system. In these instances, Blanke is often the only one in the room.

Believe it or not, he said, the paperwork — and there’s a lot of it in his line of work — helps remind Blanke that patients’ last wishes are being honored.

Making Changes

After Lewis was confronted by his partner, he began to face the shortcomings of his own coping strategies. His practice hired a social worker to help staff process difficult experiences. After the loss of every patient, the practice comes together to share and process the loss.

For him, funerals remain helpful, providing a sort of solace, so he continues to go when he can. But how to grieve is something every doctor has to figure out on their own, he said.

Deaths still hit hard, especially the ones he doesn’t see coming. The patients who remind him of his dad can also be hard. They restart a cycle of grief from his teenage years.

The difference now is he has space to voice those concerns and someone objective to help his process.

“It’s a privilege to prepare [patients for death] and help them build their legacy,” he said. But it’s also an unrelenting challenge to navigate that grief, he said.

Still, the grief lets Lewis know he’s still engaged.

“The day I don’t feel something is probably the day I need to take a break or walk away.”