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When was the last time you went to the funeral of one of your patients?

Whereas I have had patients with whom I developed strong relationships over the years, whose funerals I might have attended had I known them in any other capacity than as their doctor, I tend not to go. Like many doctors I tell myself I’m too busy.

Although the death of our patients is (in some ways) inevitable, its timing can be difficult to predict. Cancelling or rearranging our working days to attend funeral services is hard to do at short notice, and even though an out-of-hours appearance at a local early evening removal is logistically possible, it is always easier to head on home. It is better to use our time catering to the needs of those above ground, we convince ourselves, than to those below.

But apart from logistics, there may be other reasons why doctors don’t attend the funerals of patients who have died.

Dr Danielle Ofri, writing in The New York Times, suggests that funerals make doctors feel awkward: “Now that the medical care chapter has closed, we’re not quite sure how we fit into the patient’s life. We were so recently actively directing the medical care — doing something — and now we are the awkward bystanders.”

And also, being faced with the reality of the death of a patient hurts. “It hurts to keep seeing the bodies of your patients — bodies with whom you have been intimately familiar — laid out in stone-cold carriage. It hurts to see the face of someone with whom you’ve had deeply personal conversation, now rigid with that oddly blank expression. It just hurts.”

For some of us, turning up at a funeral may also feel like returning to the scene of a crime, with the attendant fear of ‘being lynched’ by angry, grieving relatives. Whereas it is possible that this feeling may occasionally be justified, most of us, on some level, will feel that we have failed our patients in some way when they die. Facing up to this perceived failure can be a difficult part of doctoring in general.

Most of us, on some level, will feel that we have failed our patients in some way when they die
It is not surprising therefore — given the practical and metaphysical realities of attending — that most doctors don’t.

And yet, attending funerals may have unexpected benefits for those who make the effort. Thomas Lynch, a Michigan-based undertaker, poet and essayist, gave some advice to doctors about the benefits of attending. Speaking at a dotMED conference, he told the audience: “As humans, being present at a funeral forces us to look into the abyss. It presses us against the ontological and the existential, and makes us ask the important human questions. Is that all there is? Can this happen to me? Am I all alone? What comes next?” He also suggests that for doctors in particular, facing the human realities of a death among our patients reminds us that not only are we fallible but also that death is an inevitable. “You spend your lives trying to stop the sky falling. But the sky is falling.” Most of those who end up on his embalming table, he points out, are also very likely to have recently attended a doctor.

“Lead with your humanity,” he says to those of us uncertain how to proceed when the time comes. “I encourage you to be among the people of the dead when the time comes — as it always does. You will be improved by it. You can do some really good medicine by just being part of that, when you can, to the extent that time allows — a phone call, a bereavement letter, five minutes at the wake, a cameo appearance at the funeral, a handful of dirt over the grave.”

Whereas our continued involvement and communication with a patient’s family and loved ones after death is not expected, sometimes the smallest sparks of kindness at the darkest times are the ones that illuminate the most. These kindnesses, Lynch says, “are the stuff of good medicine — these ordinary miracles we do for one another”.

Sometimes healing can come about in unexpected ways.

This article was originally published in The Medical Independent

 

“I learned that whatever we say means nothing, what anyone will remember is that we came” (Julia Kasdorf)

The “rituals and practices around death”, poet and Undertaker Thomas Lynch writes in his book ’The Good Funeral’, “are a window into the soul of a culture. A society that is unsure about how to care for the dead and is confused what to do with grief and loss is a society that is also uncertain about life”.

The Irish tend to acknowledge the importance of, and participate in these rituals ; the wake, the paying of respects to the deceased in the family home or funeral parlour, and the funeral itself. In a situation where words are inadequate, these rituals afford us an opportunity to bear witness to the grief of others and acknowledge our shared humanity. The “dead don’t care” Lynch says, – “but they do matter”.

However clear our roles and responsibilities surrounding the death of a friend or relative, things aren’t always so clear when it comes to the death of one of our patients.

Very few of my medical colleagues (rural GP’s excepted) regularly attend the funerals of their patients. Reasons often centre around the logistics of cancelling clinics and operating lists at short notice. Our primary responsibilities, we feel, are to those still above ground and that our care of our patients ends when they do. For some funerals may be too painful a reminder of our fallibility as doctors  – and we may even be concerned that we will be blamed for the death at the graveside by angry, grieving relatives.

Dr. Danielle Ofri, writing in the New York Times, suggests that there may be deeper, unacknowledged reasons for not attending; “Now that the medical care chapter has closed we’re not quite sure how we fit into the patient’s life. We were so recently actively directing the medical care — doing something — and now we are the awkward bystanders”.

It also hurts; “It hurts to keep seeing the bodies of your patients — bodies with whom you have been intimately familiar — laid out in stone-cold carriage. It hurts to see the face of someone with whom you’ve had deeply personal conversation, now rigid with that oddly blank expression. It just hurts.”

There are so many practical and psychological hurdles to attending, its not surprising we don’t usually turn up.

And yet medical relationships are not purely professional. Because of the intimate and deeply human nature of our interactions it is not unusual for us to build up strong relationships with our patients over time, to develop mutual affection and even friendship with them and their families. To deny this part of the relationship by not acknowledging its end, is a denial of an important part of ourselves and our patients.
So what should we do? How do we reconcile our human responsibilities and our need to grieve with those of being a doctor?

“Lead with your humanity” says Thomas Lynch (speaking at the recent dotMED conference). “I encourage you to be among the people of the dead when the time comes – as it always does. You will be improved by it.” He urges us to attend, or reach out in some way; “You can do some really good medicine by just being part of that – when you can – to the extent that time allows – a phone call, a bereavement letter, five minutes at the wake, a cameo appearance at the funeral, a handful of dirt over the grave”.

The funeral, he explains is a means of “getting the dead where they need to go and getting the living where they need to be”.  As humans, being present at a funeral forces us to look into the abyss it presses us against the ontological and the existential, and makes us ask the important human questions.  “Is that all there is? Can this happen to me? Am I all alone? What comes next?”.

He also suggests that for doctors, facing the human realities of a death in one our patients reminds us that not only are we fallible but also that death is an inevitable. “You spend your lives trying to stop the sky falling. But the sky is falling”.

Whereas the attendance of a doctor at a removal, funeral or at the home of one of their patients after they die is not usually expected, sometimes the smallest spark of kindness at the darkest time are the ones that illuminate the most. These kindnesses are the “stuff of good medicine – these ordinary miracles we do for one another”.

It’s comforting to know, that some of our best medicine can come about by just showing up.

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Thomas Lynch spoke at the dotMED Conference in December 2014. Next meeting will be in February 12th 2016.