Readers Respond to "Why Don't the Doctors Attend the Funerals of Their Patients Who Die?"

To the Editor:

I have read your article with great interest and, living in England, remembered fondly the close associations and bedside manners of the English country doctor 45 years ago.^[1] I am also reminded of the target-driven accountability regimens that have since become commonplace in every aspect of working life in Great Britain.

Since trends in the United States are usually followed within a number of years by similar trends in the United Kingdom, it would be nice to return to humanitarian ways and not economic-driven decisions.

I have suffered slings and arrows like most people, but, to be honest, having my GP [general practitioner] there at funerals would not be beneficial for either them or me or the relatives, and could essentially be abused in an unrealistic moment adding to the stress a doctor does not need. A well-timed visit after a short time has elapsed and everyone else has got on with their own lives -- and you are struggling with the acceptance and moving-on stage -- would be more beneficial, which is my personal opinion.

What you referred to as the mentality of the future doctor as one who can cure, but finds it hard to deal with death, is true. However, someone needs to take up the staff of a medical career because so many choose not to (because of the gamble involved and the dedication it takes to get you there).

I think rather than encourage attendance at funerals as a means of accepting that all they did was not in vain as doctors or that death is inevitable, medical students should spend time working in hospices; this would have immense value to families and to people, and aid the understanding that doctors are a gift but not infallible. They can be there as you either enter or leave life, which, as you say, is inevitable for all of us.

Thank you for your article.

Diane Harris
The Lake District, Great Britain

Reference

1. Lundberg GD. Why don't the doctors attend the funerals of their patients who die? MedGenMed. 2007;9:54. Available at: https://www.medscape.com/viewarticle/557500 Accessed August 23, 2007.

Dear Dr. Lundberg,

In your editorial "Why Don't the Doctors Attend the Funerals of Their Patients Who Die?" you appeal to those who train medical students and residents to do something about their discomfort with death and dying.^[1] To this end, I would like to encourage you to see a short video entitled "Cameron's Arc," which is available through the American Academy of Pediatrics bookstore (https://www.aap.org/bst/showdetl.cfm?&DID=15&Product_ID=4340 ).

This lovingly shot, edited, and produced film is designed to help pediatric residents understand life-limiting illness in the context of family-centered care.

The film documents what happened -- both from the parents' perspective and the pediatrician's --when a child was discovered to have Tay-Sachs disease. There is a hugely affirmative message that runs right through the film. It's a wonderful distillation of how communication can work -- ought to work -- in primary care. It's a tincture of medical home.

Sincerely,

Whit Garberson, MSW
Newton, Massachusetts
wgarberson@gmail.com

Reference

1. Lundberg GD. Why don't the doctors attend the funerals of their patients who die? MedGenMed. 2007;9:54. Available at: https://www.medscape.com/viewarticle/557500 Accessed August 23, 2007.

To the Editor:

I've just listened to your comments on the subject.

The considerations you put forth had frankly not occurred to me.^[1] It's an issue I've thought of, but my conclusions as to why this is so are practical in nature. There are wide-ranging repercussions to funeral attendance, the loss of income by the physician springing to mind first.

As we know, physicians, especially here in Canada, are torn in many directions with an abundance of demands for their time. A dead patient is beyond further help, but waiting rooms are full of patients still in need of physician services. When you consider the duration of funeral services and the travel time back and forth, a significant amount of otherwise productive time is lost. Patients of the physician planning on attending are having their often long-awaited appointments canceled on short notice.

Here in Manitoba, family/general practice physicians generally book 6 to the hour, although a few plan to see only 4 or 5. In the first case, probably 9 or more patients will have to be rescheduled. This can be disruptive and annoying to patients, and in some cases, disruptive to treatment in cases in which issues of importance are being closely followed. Here, popular family physicians are booking 4 or 5 weeks in advance, and very few specialists see patients in less than 3 months from date of referral with 6 being the standard. In major population centers, it is common for rural residents to make the trek to "the city" for basic as well as specialist appointments. Spouses/parents book time off work to accompany the patient, and in some cases, arrange in advance for hotel accommodation, and on it goes.

Certainly in my experience, patients' families have no expectation whatsoever of physician attendance because practical considerations occur even to grieving families. It is also my experience that physicians rarely if ever send sympathy cards. In my opinion, most families would be tickled pink to receive a card, as there is no expectation of even this happening. However, whose valuable time is dissipated poring over the obituaries, either in print or online? What if one is missed and the deceased's family is aware that the practice of attending funerals exists due to other connections with the same physician? Noses are out of joint!

I certainly acknowledged and profusely thanked my late mother's (and also my) physician in my mother's obituary -- a common practice here; yet at an appointment of my own shortly afterward, he said nothing to me. I asked whether he was aware that she had died, as she was then seeing a geriatrician at her personal care home. His answer: "Yes I was, and it must be a loss for you." He instantly moved on. Perhaps a more reasonable goal might be to improve the sensitivity of physicians to grieving families in face-to-face encounters with the deceased's family. My physician is not averse to improving his interpersonal skills: After a recent study was published on greeting patients, he began extending his hand to patients upon entering the exam room. It may just take some "guidance" in the medical literature to institute improved relations with surviving family members.

Finally, some bereaved families may wonder whether treatment was aggressive enough and whether more intensive treatment might have prevented or at least delayed the fatal outcome. Others might even question the appropriateness of whatever treatment was applied. In the paranoid bereaved, might funeral attendance be misconstrued as something done out of "guilt" over whatever perceived or suspected malfeasance "caused" the loved one's death? Does prudence perhaps dictate that neither funeral attendance nor a card is worth the risk?

Perhaps simply improving physician sensitivity to the bereaved is all that's needed, and obviously, only required in which the physician also sees other family members. But aren't physicians' minds already crammed with more pressing considerations? I say let sleeping dogs lie.

Gord Richardson
Winnipeg, Manitoba, Canada
grichardson20@shaw.ca

Reference

To the Editor:

I appreciate Dr. George Lundberg asking the question: "Why Don't the Doctors Attend the Funerals of Their Patients Who Die?^[1]" I must start by saying it is somewhat odd for Dr. Lundberg, a pathologist who does not work in direct patient care, to be the one who asks this, but I am glad that someone did as I have never seen it discussed in any journal or lecture hall. As a medical oncologist in a busy community practice, it is a subject that comes up frequently and one that I have discussed with my partners several times.

The first time I was faced with this decision was during my oncology fellowship training. A patient with whom I had become close died of small-cell lung cancer after a rather protracted battle, and his wife invited me to his memorial service. He was a rather eccentric man, and before his death he gave me one of the first gifts a patient ever gave me -- a brand-new, plain white handkerchief. When he gave it to me, I asked whether there was any specific reason he gave me this or whether there was any symbolism I was missing. Was he surrendering? Did he think I didn't blow my nose enough? No to both. He just thought it was something that people needed.

After a lot of debating, I decided not to attend the service. At that point in my life, I had been so fortunate to have only attended 1 funeral -- that of my grandfather. I believed that attending my patient's funeral would in some way diminish the significance of my own grandfather's death.

Right then I adopted a practice that I still continue to this day, over 10 years later. When one of my patients dies, I handwrite a long and personal letter to the surviving spouse, partner, or closest relative or friend. This benefits both the family and me.

For me, it is my way to take a quiet moment to reflect on my care of the patient. What did I do right? What could've been done better? What will my staff and I miss about him/her the most? How admirable was the patient's fight against insurmountable odds? That is one of the things that drew me to oncology in the first place. Why not remind myself of that?

Regarding the patients' families, I can say that there is no act for which I have received greater appreciation. Many patients who I have cured have never written a letter of thanks, but uniformly my condolence letters are answered, generally with very touching verbiage.

Returning to Dr. Lundberg's original question, so why then do I not attend funerals knowing now how much families would certainly appreciate the gesture? The answer is 2 simple reasons. First, could I really "pick and choose" which funerals to attend? Truly, I cannot, and if not, attending every funeral would significantly cut in to my ability to see patients. Chemotherapy regimens are on fairly rigid schedules, and moving patients around on short notice is highly problematic. Second, beyond the time taken, attending frequent funerals would just be too much. Avoiding burnout is a necessity for those caring for the dying. For some physicians, attending funerals gives them a secondary gain, and they commonly do so for certain favorite patients. To each his own.

Just as each individual physician needs to develop his or her own style as to how to care for patients, physicians need to decide what method of offering condolences works best for him/her. I hope that Dr. Lundberg believes that choosing to not attend funerals is not a blow to a physician's professionalism.

Thank you,

Joel Grossman, MD
Naples, Florida
joelgrossman1@hotmail.com

Reference

To the Editor:

I don't accept the argument that doctors don't attend the funerals of their patients who die because they have higher "personal anxieties about dying" than other professions. Do we see lawyers, accountants, bank managers, nurses, or other healthcare professionals attending their clients' funerals? Not in my experience.

As a result of caring for patients, doctors certainly know death and dying more intimately than most other people in the community. However, in over 25 years of specialist practice, student teaching, resident training, and CME involvement with family physicians and other specialists, I have seen no evidence that doctors' attitudes to death are different in any other regard. If anything, fatalism and a morbid sense of humor would be more characteristic.

Offering condolences to a family when a patient dies in the hospital is normal practice. When a patient dies outside the hospital, sending a card or a note to the family is sometimes appropriate. But attending a funeral is something I only consider doing if I have had a close and long-standing relationship with a patient, and am invited by a partner or close family member. I can only remember this happening once in the past 10 years.

In my view, funerals are a family affair. The fact that doctors rarely attend funerals has more to do with respecting professional boundaries than anxieties about death, guilt, denial, or any deeper emotional response. For the same reasons, I am very selective about attending the weddings, birthday celebrations, or graduations of patients or their relatives, and I never accept invitations to dinner or recreational or other social functions.

I acknowledge that the situation is different for doctors practicing in small and isolated communities, where the boundaries between professional relationships, social relationships, and friendships may be more blurred, or even completely overlapping. It would be interesting to know how often those doctors attend their patients' funerals.

Robert H. Loblay, MBBS, PhD, FRACP
Department of Medicine
University of Sydney
Sydney, Australia
roblob@med.usyd.edu.au

Reference

To the Editor:

I am one of the doctors who does attend a lot of patients' funerals, especially those of my chronic cancer patients.

Without being a masochist, most of the time, I find myself obliged to follow a person who trusted me for a possible cure to his/her last journey. I am also obliged to the relatives, too, whose higher expectations and hopes proved untrue.

Feelings of the crucial moments? Grief, yes, but guilt, no (at least not anymore). The thought that another surgeon could prevent the event? Not anymore (although it took me some time to deal with it). The main feeling throughout the whole ceremony is that this should be the last patient whose funeral I am attending, despite the fact that a surgeon is shorter than surgery, surgery is shorter than medicine, and medicine is shorter than illness.

The result? Modesty and complete loss of the sense of immortality. On the other hand, these are some of the strongest motivations for becoming a better doctor.

In fact, maybe some of my patients are still alive (against all the odds), not only because of "state-of-the-art" therapeutic management but also because of these soul-stirring attendances.^[1]

Sincerely yours,

Argirios Birmpilis, MD
Director of A Surgical Department
Hellenic Airforce General Hospital
Athens, Greece
argbirb@hotmail.com

Reference

To the Editor:

Dr. Lundberg raises an interesting question and makes many good points from a psychosocial perspective; however, there is also a practical side.^[1]

Most funerals are scheduled with little advance notice, perhaps 2 or 3 days at best. Most practicing physicians have daily schedules filled with appointments that were either scheduled weeks ago or very recently in response to an acute problem. Canceling a morning full of appointments can potentially inconvenience many, many people whose health may be put at risk.

Although I agree that it is unusual for physicians to attend funerals for their patients, it is not as uncommon for them to attend evening calling hours or wakes. Our family may be fortunate to be in the care of some truly compassionate physicians. The doctors and nurses who cared for the last 5 people in my family who died did stop by to comfort our family during evening calling hours, expressing their regrets that their schedule did not permit them to attend the daytime funeral.

Diane L. Maxson
Medfield, Massachusetts
dimaxson@comcast.net

Reference

To the Editor:

In response to Dr. Lundberg's article on the likelihood of doctors not attending funerals, I have personal experience with this subject and the related subjects of house calls and home care (now called hospice care for the dying).^[1] My father was a family physician and surgeon for nearly 50 years. As a child, I regularly accompanied him to the office, hospital, homes, and funerals. He treated not only the whole patient, but included the family home and dynamic in his diagnosis and treatment. He said you could learn a lot by visiting a patient at home, and in the early days there were still quarantines.

House calls and home visits were made at the end of each day. When I was with dad in the office, I'd carry the black bag to the car with its special license plate for physicians. He'd pull down his visor when we parked. It said "physician on call," and provided free and special parking privileges. He was greeted and treated like family, and so was I, as his daughter. "Dr. Jim" would be there as long as it took for care, and then maybe a cup of coffee and a sweet, and a little conversation.

Dad's method was good for him and for his patients, but there was a price -- less family time with his own family. But, dad was in practice with his brother, who was more comfortable in the office and hospital setting. My uncle's method worked for him.

Dad was most comfortable in any setting where he could benefit his patient. As a general practitioner, he treated the whole patient and often the whole family. As long as he was not out of town, he visited funeral homes, attended funerals, and was the one consulted by the grieving family should they experience symptoms. He saw to it that family members knew they could depend on him in this time of awful distress. If dad was out of town, he sent his condolences by phone or mail. He was personally moved by the loss of a patient. Some became close friends.

I remember sitting in the car as he composed himself before one funeral home visit. He asked me to wait in the car. When he came back, and I could see how he'd been crying, he told me how hard it is to see your patient lying in a tiny little coffin with brothers and sisters crying. It's hard to know there was nothing you could do to save her and how much she will be missed.

My dad was still practicing medicine when he died in a plane crash at age 78, 3 years ago. He still loved his job and was involved in a research study for NIH [National Institutes of Health] at the time. He hoped to practice into his 90s. His office staff and our family were active in finding his patients new doctors for their special needs. His calling hours and funeral were overflowing, because his patients thought "Doc" was family. We were comforted by dad's patients.

Sincerely,

Kathy D. Chuparkoff
In loving memory of Dr. James Ventresco, Jr., DO
Cleveland, Ohio
kdchuparkoff@earthlink.net

Reference

Dear Dr. Lundberg,

I, too, wonder why more of my colleagues do not attend funerals.^[1] Not only do I try to attend every one that I can, sometimes I send flowers if I have known the patient or the family for a long time. Perhaps it is my Southern, small-town, Christian background, but even here in my small town, most doctors do not do what I do. I think a lot of it is because of "lack of time," or at least that is the excuse most of them give, when in reality we all have 24 hours in a day. A more proper assessment would be that this activity doesn't have a high enough priority in their lives.

When Dr. Wall asked me 32 years ago during my medical school interview why I wanted to be a doctor, I said, "I am good in math and science and I like people." I think we need more physicians who genuinely "like people": more physicians with an attitude of humility rather than an air of superiority, more physicians who take time to sit down in the exam room and really listen to what the patients have to say instead of talking to them like they are inferior beings, more physicians who smile at their patients instead of greet them with an expression of impatience, and more physicians who abandon greed as their top priority (as opposed to seeing patients only as a source of income and by only thinking of how many tests or procedures they can order on them). Jesus said to treat everyone else the way they, themselves, would want to be treated. Because I do this, I think there will be a lot of patients at my funeral.

Charles E. Leonard, MD
Talbott, Tennessee

Reference

To the Editor:

It is not common for me to have patients die. It is common, however, to have me attend their funeral services. This is considered a great boon by their family members, and they are always proud to introduce me to other family members, hug me, shake my hand, and express their gratitude for the care I've rendered to the deceased.

Usually I attend the wake, which typically occurs during evening hours. This allows me to finish my office practice, and visit informally with family members. I answer questions, but mostly I just be there with them, hug them, hold their hands, kneel before them if they're sitting, visit with the deceased briefly if the coffin is open, and express love and support both verbally and nonverbally. Often the mood is jocular, as we remember with gentle good humor the quirks, foibles, and strengths of the deceased.

The most important and valuable thing is to just be there, to let everyone express themselves as much as they wish, and to listen attentively, while maintaining eye contact and, if appropriate, physical contact. Compassion is the key.

It helps to have done all I could during the patient's life. That way, I get the precious message from their relatives: "I appreciate all you've done, Doc!" Sometimes I'll briefly go through the chart before the service, to make sure that I have a handle on all that happened.

Occasionally I will attend a funeral service itself. This is usually when I'm specifically invited to do so as a speaker. On these occasions, I usually will chant something in Hebrew or Aramaic (the Kaddish blessing), along with a very few spoken words and translation. This is enormously appreciated by the family and friends, even though (or because) they're all of Christian faith and tradition. It turns me into a rock star, and the attending relatives feel much uplifted.

When a patient dies, I almost always contact the family either by phone, or by handwritten letter. If by phone, I ask about the circumstances of death, so that my death certificate is accurate. If by letter, then I'm pretty familiar with what happened, and I limit myself to expressions of gratitude and blessings.

In general, I find that these events are an excellent way of creating and maintaining good relations with the patient's family members and friends, and handling any questions that may linger in their minds.

Steven E. Landau, MD, FAAFP, ABHM
Raleigh, North Carolina
pashupati@bellsouth.net

Editor's Note:
The author was shown these letters and chose not to reply, except to say that he and the journal received a total of over 120 letters from many states and countries in response to this WVE [Webcast Video Editorial]. Experiences shared and opinions held were strong and highly variable, and much of this variety is reflected in these published letters.

This is a topic that merits further discussion, and perhaps study.

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Readers are encouraged to respond to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication as an actual Letter in MedGenMed via email: pblumen@stanford.edu

© 2007  Medscape

Cite this: Readers Respond to "Why Don't the Doctors Attend the Funerals of Their Patients Who Die?" - Medscape - Sep 05, 2007.