DOI: 10.1200/JCO.2013.51.4299 Noa was 42 years old when diagnosed with a 5-cm triple-negative breast cancer that had spread to two lymph nodes. She underwent mastectomy followed by adjuvant chemotherapy and radiotherapy. At the time of her diagnosis, Noa was married and had two daughters. She worked as an English teacher in one of the toughest high schools in town. I was inspired by her energy and passion for life and work, and this made me like her from the first time we met. The course of her adjuvant therapy was characterized by unexpected complications and adverse effects, and the way she handled these obstacles made me like her even more. Three months after she completed adjuvant radiotherapy, she walked in with right upper quadrant pain and a palpable, firm liver. Computed tomography (CT) scan and tumor markers confirmed the diagnosis of metastatic disease. Noa faced her terminal illness with stoic courage and a clear mind, acknowledging the unfortunate facts of her illness. Her spirit was unfaltering, and she remained the same smart, sensitive, and resilient person she had been before. I treated Noa until she died as a result of hepatic failure, 10 months later. As time passed, I became aware of a new and unpleasant feeling of discomfort during our meetings. It was not obvious at the start when her disease responded dramatically to chemotherapy. But as the disease progressed and her condition deteriorated I realized that I was not as happy to see her name on my list of patients, and that during our meetings there was something in me that wished that the meeting would already end. I still cared a great deal about her. I continued to treat her to the best of my professional ability, wishing her treatment to be as successful as possible, but something inside me had changed. I found it relatively easy to speak to her about medications and blood tests, but found it more and more difficult to establish a personal connection. As treatment failed, I felt I had little to offer her. Treating her became more demanding and psychologically exhausting for me. At the time I was near the end of my fellowship in oncology. I was valued as an empathic, caring physician and derived a deep satisfaction from creating empathic and meaningful relationships with my patients. That said, my reaction to Noa was not unique. I had noticed that when a patient’s disease became incurable I felt the deepest sorrow and sympathy for him or her, but in fact, it was also the last time I felt genuinely close to such a patient. It was as if an invisible wall started to build up inside me, creating a buffer between the patient and myself. This wall was small and easy to ignore at first, but it slowly grew taller as the patients became sicker. I attempted to resist the wall, trying to break through it at times, and avoiding it at other times by keeping myself and the patient busy with test results and treatment options. I made every effort to conceal the wall from my patients, not to hurt them during such vulnerable times. However, I had to pay my dues for this self-imposed detachment. Work became less satisfying and more exhausting, and subtle feelings of guilt further increased my exhaustion. I was starting to burn out, and I knew my patients would notice it sooner or later. I was deeply troubled by my increasing tendency to withdraw from terminally ill patients. I could sense that other physicians tend to act similarly, but nobody spoke about it. I tried to find an explanation and a way forward. It was then that I happened to hear a talk delivered by Professor Gilad Hirschberger, a social psychologist with an interest in understanding how the fear of death influences helping behavior. Hirschberger’s experiments showed that when awareness of death is aroused, people exhibit negative attitudes towards sick and disabled people, attribute blame to severely injured innocent victims, and even feel implicit aggression when they must help a physically disabled person. He concluded that such fear leads people to distance themselves from additional reminders of their mortality, even at the cost of neglecting their moral values and commitments. Hearing him speak, I felt his conclusions resonated directly with my own experience. I was trying to remain altruistic while dealing with negative feelings toward dying patients, perhaps aroused in me by my own fear of dying. To better understand my emotions, I first needed to understand why I was afraid of death. JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 31 NUMBER 28 OCTOBER 1 2013
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