On dealing with death and dying : a qualitative study of the experiences of surgeons, oncologists, intensive care, and palliative medicine specialists.

摘要

This thesis explores the experiences with death and dying of medical specialists who frequently deal with patients with life-threatening illnesses. Thirty-three participants from Surgery, Oncology, Intensive Care, and Palliative Medicine responded to interviews that lasted between 29 and 105 min, with an average length of 48 min. The interviews were analysed thematically. Measures to preserve qualitative rigour were employed from the initial stages of the process until the writing of the results.From the thematic analysis, four areas were chosen as a focus for the thesis, each was the subject of a separate paper: a) the experiences of surgeons, b) the experiences of palliative medicine specialists, c) the emotional connection as developed in the four specialties, and d) an analysis of commonalities and differences between specialties in how they experienced the death of their patients. Surgeons’ experiences and coping mechanisms, as described in Paper One, were influenced by personality traits favoured in surgical practice, such as distancing from patients. In contrast, participants from cancer surgery displayed a proclivity towards developing a closer relationship with their patients. Sources of support, particularly peer support, were not considered essential. Palliative medicine specialists were the focus of Paper Two. These participants highlighted the role of emotions, and emphasised their ability to derive positive meaning from their work. Religion was identified as a coping mechanism, and differences were identified in relation to those participants with no religious affiliation. The homogeneity of participants’ experiences was attributed to aspects that may refer to the philosophy of practice within palliative care. Paper Three drew on the emotional connection that developed between participants from all four specialties and their patients. Ambivalence about developing or refraining from establishing an emotional connection with their patients was the central theme. To reconcile the ambivalence, some participants resorted to finding a balance in their exchanges with patients, but tended to employ strategies that invalidated their emotional reactions. Other participants preferred an approach where they reaffirmed the emotional nature of working with dying patients. The common themes amongst the four specialties were the subject of the fourth paper. These themes were related to two overarching aspects: participants’ professional practice, and the impact of their professional role on their personal lives. Professional practice aspects were related to frequent exposure to death and dying, limited training opportunities, decision-making process, and the delivery of bad news. The impact of the professional roles on personal lives was related to these medical specialists’ experience of emotional uncertainty, individual differences (e.g. gender, years of medical practice), the impact of dealing with death and dying of their patients, and how they deal with death and dying without support. The findings presented in this thesis may be valuable in the development ofstrategies to support medical practitioners to deal with common aspects of medical practice, such as the recognition of one’s and others’ emotions, as well as to enhance learning opportunities through medical training. Furthermore, the results suggest that the focus of research should be widened from death itself, to experiences during practitioners’ entire contact with patients approaching death, particularly from when an impending death is acknowledged.