Healthcare professionals' fear of death and dying: implications for palliative care.

Sir,

I wish to congratulate the editor for the editorial published in Indian Journal of Palliative Care (May-August issue) on “who is really afraid of death?” by Bhatnagar.[1] This letter was aimed to throw light on the fear of death among healthcare professionals, with implications for palliative care assessment and intervention in the developing countries.

According to Penson et al.,[2]“For many, cancer is synonymous with death and fearing death is a rational response. For too long, medicine has ignored this primeval fear.” Lowry[3] quoted the thoughts of Dr. Balfour Mount, a palliative care specialist who said that one of the factors preventing the healthcare professionals from providing good and compassionate care for the dying was a deep-rooted existential fear of death that lurks suppressed in their unconscious most of the time.

Medical trainees associated their highest fear of death with avoidance, dismissal, and seeking advice and their lowest fear of death with rationalization of the event. Individual differences such as gender, empathy, parental death, parental anxiety, and stress influenced their own fear of death.[4] The first experience of clinical death creates a tension between emotional concern and professional detachment among medical students, which could be negotiated by patient's clinical circumstances, supervisor role-modeling, and most importantly, the support of supervisors and peers, including debriefing opportunities.[5]

Howells et al.[6] reported that medical students’ intensity of fear of death did not depend upon previous clinical experience, but those with previous experience tend to think more frequently about their own dying process. Personal fear of own death and low level of determination of philosophy of life may restrain medical professionals from breaking bad news to patients.[7] Misperceptions such as death and emotion are negative aspects of medicine existing amongst medical students, and hence, supervising physicians need to ensure adequate debriefing sessions to support students in order to teach about death, emotions, and coping with stress.[8]

Del Vecchio Good et al.[9] found three major factors influencing internists’ perceptions of emotionally powerful death – Time and process: Whether death was expected or unexpected, peaceful, chaotic, or prolonged; medical care and treatment decisions: whether end-of-life care was rational and appropriate, facilitating a “peaceful” or “gentle” death, or futile and overly aggressive, fraught with irrational decisions or adverse events; and communication and negotiation: whether communication with patients, family, and medical teams was effective, leading to satisfying management of end-of-life care, or characterized by misunderstandings and conflict.

Bruce,[10] a hospice bereavement coordinator and counselor, opined that medical professionals need both didactic and personal preparation to assist in the often intense experience and intimate passage of life into death and later. Baider and Wein[11] reported physicians’ experiences, perceptions, behavior, and vulnerability, especially when confronted with death and dying, and the authors recommended that the success of a physician can be measured by the empathic, yet objective relationship he/she establishes with the patient, while simultaneously building clear emotional and professional boundaries.

Physicians’ emotional reactions to patient death affect not only patient care but also the personal lives of physicians. Emotionally powerful deaths were capable of teaching physicians on caring for dying, coping strategies leading to changes in clinical behaviors and career paths.[12] Hare and Pratt[13] found among nurses that the level of perceived comfort and fear of death while working with dying patients differed significantly by exposure to such patients and by the occupational role.

Assessment of fear of death and death-related competency[14] could be performed quantitatively using measurement tools such as Lester Attitude Toward Death Scale[15] and Collett-Lester Fear of Death Scale.[16] The interventions aimed at reducing the fear of death in healthcare professionals may include a contemplative care approach (training program on yoga) for hospice care volunteers, which fosters better emotional well-being and spiritual growth,[17] with training emphasis on philosophy and goals of palliative care, spiritual issues from a multi-cultural and multi-faith perspective, communication, the dying process, grief, and bereavement, and the role of the healthcare worker.[18]

With under-reporting of death and bereavement care among palliative care journals,[19] can Indian Journal of Palliative Care take another leading role in publishing evidence on fear of death among professionals and students, so that appropriate educational programs be implemented along an evidence-based palliative care model?