BMJ  2007;335:1296-1297 (22 December), doi:10.1136/bmj.39409.501435.AE

Mixed messages

Death messengers

¹ Department of Medicine, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA, ² The Ochsner Clinic Foundation, New Orleans, LA 70121, USA

Mandeep R Mehra and colleagues dissect doctors’ attitudes to dying

Among the most dreaded aspects of the practice of medicine is the need for direct communication with a patient or his or her family about "death and dying."¹²³ The mental suffering experienced by patients and their care providers is paralleled by the emotional angst evoked in the communicating clinician. For some specialists who focus on chronic illness, these talks can be a routine, even daily, task. Systematic studies of physicians’ attitudes in such scenarios show that most of them tend to avoid answering specifically poignant questions posed by patients and their families, and they often give overestimates of predicted survival.^{4 5} In the absence of a well defined training template, knowledge and recommendations about how to conduct such conversations reflect evolutionary behaviour gleaned from practical advice. Our primary objective was to ascertain physicians’ approaches to the "death and dying" talk and to correlate them with such vital characteristics as type of practice (general or specialty based), years of experience, and environment of practice (academic or private).

Distinct profiles

After years spent in critical observation of our colleagues, we developed a keen awareness of the distinctly segregated and tangential ways in which physicians deal with the "death and dying" talk. We were able to discriminate the following distinct clinical profiles.

The evangelist (fig 1)—These people are usually very reflective and readily invoke references to a "higher power" and "destiny." They are effusively empathic, seem genuine and caring, and are never hampered by time constraints. They are usually adept at the immediate expression of sadness or, when it is called for, can produce tears in concert with patients and family members. As the conversation proceeds, they express intense knowledge about the "after life." When asked if they have ever directly experienced the "after life," they usually become "deflectors."

View larger version (108K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 1 The evangelist

 
The deflector (fig 2)—People with this profile usually take on the semblance of a "lay person" and divest themselves of the garb of being a healthcare provider. They often shun the white coat or a stethoscope in an effort to "blend in." They are very aware of their environment and can immediately suggest and solicit the expertise of any person available in the near vicinity to proclaim them as an "expert" in the field. They are enthusiastically supportive of the "don’t ask, don’t tell" policy.

View larger version (86K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 2 The deflector

 
The amateur (fig 3)—These are often a well intentioned people, thrust into a critical conversation by the deflector or through aimless wanderings. They are usually typified by anxiety and the easy manifestation of forehead sweat. Once they realise the precarious nature of their situation, they often hope and wish for an immediate rescue by another person, irrespective of that person’s category. Unfortunately, help is usually unavailable and unwilling.

View larger version (97K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 3 The amateur

 
The precisionist (fig 4)—This profile is exemplified by a "numbers" person, who seeks to provide probabilistic certainty of future events. Such people tend to create the aura of certainty by often using a calculator as they seem to be deep in thought, calculating the odds of survival. People fortunate enough to interact with the precisionist are often left marvelling at his or her knowledge, but they later develop grave confusion. Interestingly, contrary to their own personal beliefs, precisionists exhibit great disappointment in their ability to predict the stock market, as well as the eventual outcome of the patient.

View larger version (98K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 4 The precisionist

 
The grim reaper (fig 5)—This is a special category of usually personally disgruntled healthcare providers who often initiate a dialogue with "Well, this won’t take long." They are often perceived as "cut and dried," "matter of fact," and insensitive and are usually dreaded and avoided by colleagues from other categories.

View larger version (38K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 5 The grim reaper

 
The knight (fig 6)—Polar opposites of the grim reaper, people in this category are usually charming to a fault and can always determine at least one more possible treatment approach, irrespective of the miraculous nature of their suggestion. They often create the perception of "leaving no stone unturned" in the patient’s medical defence, despite fruitless use of resources. Such people quickly create gnawing sensations in insurers and hospital administrators.

View larger version (110K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 6 The knight

 
The chameleon (fig 7)—This rare entity describes a person who is capable of matching the situation to the approach by transforming into the evangelist, precisionist, knight, grim reaper, or deflector but never the amateur.

View larger version (60K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 7 The chameleon

 

Further analysis of clinical profiles

Surgeons usually present themselves as knights, despite an obviously optionless situation, but quickly transform into deflectors when their intervention results in a clearly worse clinical scenario. Among physicians, those who specialise in cancer are only rarely identified as grim reapers or precisionists, and they often avoid fraternising with members of those classes. Cardiovascular specialists segregate most often as precisionists and are seen touting statistics gleaned from clinical trials that bear fortuitous acronyms such as HOPE,⁶ CARE,⁷ CURE,⁸ VALIANT,⁹ COURAGE,¹⁰ and MIRACLE.¹¹ Recently graduated physicians are, with only rare exceptions, identified with the amateur clinical profile. This class is also commonly encountered among people in their early years of practice or in specialties with limited contact with patients (pathology and radiology).

Compared with other profiles that remain stagnant, the amateur category is usually transient and quickly transforms to a more vivid category and follows a common pattern. The amateur becomes, for a brief period, a deflector and then develops into one of the other groups. A select minority (5%) of amateurs remain in that category for many years until the heavy emotional toll transforms them into grim reapers. Academic university practices enable and foster the persistence of the deflector profile, which thrives in the environment of being able to quickly identify an "expert" or unsuspecting "on-call" amateur from among circulating colleagues. Experienced private practitioners are most often identified as evangelists and cannot afford to be knights. In the rare situation in which a private practitioner falls into the grim reaper category, the practice is often faced with oppressive financial ruin.

The most coveted profile, the chameleon, can be seen in both academic and private practices. This clinical profile is the category most often imitated but is difficult to duplicate; all other categories except the grim reaper aspire to it. All chameleons should be tagged to teach and train others in this vanishing art.

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We thank Caroline Devereaux for her creative illustrations that capture the essence of the profiles.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

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