Personal views: Doctors fighting, fleeing, or facing up to death
Authors: Janet Goodall
Journal: BMJ (1998)

It can be disturbing to consider medical practice as portrayed by the media. On the one hand, we hear of living wills, intended to forestall artificial prolongation of dying. On the other hand, incurable patients—and parents of incurably ill babies—are sometimes finding doctors who will hasten death. If these extremes are there how do they arise? 

My reflections about this were fuelled when three of my good friends died within a two week period. In their dying, they showed some of the emotional reactions to loss which doctors can so readily identify in others while imagining themselves to be immune. 

The non-medical friend, dying several months after surgery for ovarian cancer, had never admitted to declining health but kept speaking hopefully of improvement ahead. One of the doctors, with inexorably worsening cerebellar ataxia, had rejected offers of palliative therapy, fearing stupefaction. Instead, too unsteady to act for herself, she repeatedly asked her general practitioner and her husband to give her a lethal injection. The second doctor, after years of battling with breast cancer, developed a hemiplegia and then severe depression before finally coming to terms with her terminal state. 

Denial is well recognised as an early reaction to grief, often being followed by a confusion of anxiety, anger, bargaining, or depression before peace can prevail. It seemed to me that the first friend was showing denial in the face of the evidence, probably as much to protect her husband as to shield herself. The second was afraid of losing even more control, being sent into hospital, tube fed, or worse. The third had the opposite reaction, becoming acutely anxious just before her death that someone might decide to speed up her departure. 

Research has shown that doctors as a group are more afraid of death than either dying patients or healthy individuals. Long ago, our physiology lecturers taught us that fear is commonly expressed in fight or flight reactions. 

The doctor prepared to fight to the end may deny the reality of approaching death, bargaining that there are still a few things left to try. This has been found to be particularly true when the patient is another doctor. Alternatively, the one prone to flight may too readily deny the appropriateness of anything other than a quick exit. Reinforced by pleas from either desperate relatives or depressed patients, both routes might be pursued in the name of care. 

Yet all three of my friends showed that feelings can change. The denial of the first yielded to acute restlessness a few days before her death, when she expressed sadness for her bereft partner. She was relieved by assurances that friends would stand by him and calmed by a little anxiolytic. The second underwent a complete volte face, admitting that her suicidal thoughts had been wrong and accepting (well tolerated) palliative medication. Depression lifted and, although too dysarthric to speak, she finally died a storybook death, blowing kisses to each family member gathered round her and then falling asleep. Although at one stage needing antidepressants, the third achieved a remarkable degree of serenity before she died. All three died at home. 


If patients can change their minds how many have asked for death and been granted that rather than the medication or counsel which would have given them time to reach calmer waters? Also, if doctors keep battling to save a life which is clearly ending does not that itself spell failure? 


“Insight must be preferable to hindsight”



We might reasonably suppose that doctors, too, could have a change of mood but for them, as for some patients, this could be too late to act on. Significantly, some doctors in the Netherlands, after practising euthanasia, are now requesting instruction in palliative medicine. 

As they died, all three of my friends were receiving palliative therapy and supported not only by good doctors but also by those alert to the possibility of mood swings, ready to listen and support to the end. Physical, emotional, social, and spiritual needs were recognised and, as far as possible, met. Many others still die without this kind of care. Could it be, by their fight or flight reactions, that even the most intensively caring of doctors deny themselves input from other experts, so depriving some of their patients of peace at the last? 

One final thought has emerged over the two years since my friends died. Medical journals in Britain, Australia, South Africa, and the Netherlands have all rejected my submissions on this theme. Fighting notions about editorial denial, I am not yet ready to give up. Together with their partners, I am anxious that others might benefit from the lessons taught by my friends as they died. Insight must be preferable to hindsight.