Letter to the Editor: Death Anxiety of the Physician

Dear Editor:

We read with interest Zarrabi and Kavalieratos's insightful editorial on the importance of understanding the forms and nuances of death anxiety faced by patients in palliative care. ¹ As such, the authors emphasized that palliative care is not limited to addressing physical pain/suffering in the terminally ill, but should also evaluate and manage psychological and even metaphysical sources of distress which may be hidden beneath the veil of generic psychiatric manifestations such as depression and anxiety. ¹ We suggest that beyond attempting to manage death anxiety of dying patients, physicians should also first seek to develop a personal insight into death by reflecting on their inner thoughts, attitudes, and emotions about death, so as to avoid the unfortunate implications of death denial and maladaptive behaviors in patient care.

First, the fear of death is universal, affecting both patients and physicians alike—because death is irreversible, a lonely and isolating experience and signifies a loss of personhood. Moreover, death is fraught with uncertainty, as there is no way for the experience of death to be conveyed to another. For physicians taking care of dying patients, beyond a personal identification with the universal fear of death, they may also feel a sense of defeat if they perceive that they have “failed” to carry out their professional duty to treat/cure the patient. As such, death becomes a topic that is often uncomfortable for the physician, which may even lead to denial of its inevitability.

Death denial is actually an innate human defense mechanism to cope with the negative emotions associated with mortality, ² and in the context of medical professionals, further reinforced by the sacrosanct duty of medicine to save and preserve lives. ³ However, physician denial of death is problematic as it can lead to patient suffering by pursuing medically futile treatments/interventions and even threaten patient autonomy. ³

In addition, many emotions can naturally arise in physicians caring for dying patients, such as fear, grief, sadness, anger, guilt, sense of helplessness, and frustration, all of which if ignored or left unchecked, can spiral into maladaptive coping mechanisms that have negative implications in patient care, for instance, avoidance/distancing from the patient/family, missing out details in patient care, constructing incoherent care goals, and persistence with futile therapies. ⁴ Over time, physicians may burnout, become depressed, and lose their professional sense of purpose. ⁵

Therefore, we opine that besides addressing death anxiety faced by terminally ill patients, it is perhaps also prudent for physicians to first reflect on their own thoughts and emotions about death. To this end, Meier et al. described five components of self-regulatory behavior that physicians should adopt when caring for terminally ill patients: recognizing risk factors for maladaptive emotions, watching for warning symptoms (feelings) and signs (behaviors) suggestive of such emotions, naming and validating these emotions when they occur, identifying underlying triggers, and finally, developing/restructuring a constructive response. ⁵