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It was a long time ago now. I had been a doctor but three days. Mrs Gilmore (not her real name) had been brought to the emergency department with chest pain. As I took her history, her voice was soft, but her eyes were frightened.

When I had finished, I clasped her aged hand comfortingly. "Don't worry", I said quietly, "It'll be alright".

At that moment the light left her eyes. The monitor called the arrest, and white coats descended upon her like carrion birds to beat upon her lifeless chest. When it was all over, when it was all written up, I needed a moment and ambled, dazed, to the tea-room to sit.

I am still upset when a patient dies. We all are. Doctors tend to see healing the sick as their raison d'être, and when a patient dies it is hard to escape the notion that we have somehow failed. Even those who claim they are comfortable with a patient's death often wear such proud comfort emblazoned on their sleeves that we are prone to doubt they truly know their minds. How much more upsetting is it when we feel we have played a part in the death? In this issue of the Journal, Haverkate and colleagues report on a survey that, among other things, addresses that question.¹

For the survey, Dutch doctors were questioned on their emotional reactions to their most recent cases of euthanasia, assisted suicide, ending a patient's life without explicit request or the use of medications in doses that the respondents believed were large enough to have hastened a patient's death. Physicians' responses were recorded as either "of comfort" (satisfied, relieved, etc) or "of discomfort" (upset, burdened, etc).

While 75% of doctors who reported on a euthanasia case felt emotional discomfort, this figure dropped to 58% for cases of assisted suicide. In cases where an end-of-life- hastening medication had been administered with the primary aim of symptom relief, a mere 18% reported discomfort.

What are we to make of these figures and what are their implications for Australian doctors? I would argue that, in general, the more a doctor perceives herself or himself as an active participant in a patient's death, the more upsetting she or he will find the death. While previous generations of physicians would only rarely have seen themselves as active agents in the dying process, this perception must now be increasingly common. Our increasing ability to send death away when it calls (or at least to detain it at the door) has also meant that we are, more than ever before, in a position to judge that further efforts are futile and that we should stand back and let death in. This feeling of being an active agent is only magnified when we take active steps in the process and help our patients to die with euthanasia or assisted suicide. In this context, the relatively low rate of negative emotional response when life was ended without explicit request (34%) is worthy of special consideration. Surely here the doctor is as active a participant as she or he is in euthanasia, but now without a specific request from the patient? Why is she or he then less often upset? The important factor in an emotional reaction is, however, not what happened but how it was perceived. I suspect that emotional discomfort is low in these cases because doctors generally believe that death is already upon the patient and that they are doing little more than to ease its way. Much as in the cases where medication is used primarily for pain relief, the physician does not feel a strong sense of agency in the patient's death. The finding by Haverkate et al that end-of-life decisions thought to shorten life by more than one month were much more troubling than those judged to shorten life by a lesser time seems also to support this the-more-agency-the-more-upsetting model.

Doctors must deal with their role in their patients' deaths in Australia as much as in the Netherlands.² While Dutch doctors can, and do, openly seek support for their emotional reactions to the death of patients, such support is likely much harder won in Australia. It is not only that the current legal situation means that Australian doctors who help their patients to die place themselves at risk of harsh penalty if discovered. It is also, and perhaps more importantly, that there is a culture within the Australian medical community that a good doctor simply copes and gets on with it. This culture deserves scrutiny and perhaps change. This issue of the Journal is a good place to start.

I did not actively contribute to Mrs Gilmore's death, but as I sat in the tea-room I must have wondered if I could have done more. After 20 minutes, I was back in the fray.

Christopher J Ryan
Consultation-Liaison Psychiatrist
Department of Psychiatry
Westmead Hospital, Westmead, NSW

1. Haverkate I, van der Heide A, Onwuteaka-Philipsen BD, et al. The emotional impact on physicians of hastening the death of a patient. Med J Aust 2001; 175: 519-522.
2. Kuhse H, Singer P, Baume P, et al. End of life decisions in Australian medical practice. Med J Aust 1997; 166: 191-196.

©MJA 2001
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