1. Harpham, Wendy S. MD

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Your patient died. I am so sorry for your loss.


I realize that in oncology death comes with the territory. And that such deaths are different than losing friends or family. But a pang accompanies any loss that changes your world.

WENDY S. HARPHAM, MD... - Click to enlarge in new windowWENDY S. HARPHAM, MD. WENDY S. HARPHAM, MD, is an internist, cancer survivor, and author. Her books include

Your patient's death may have silenced an inside joke or a distinctive greeting that always perked up your day. For sure, your patient's death retired a role you played. From now on, you were-past tense-your patient's doctor or nurse.


Death snapped the clinician-patient connection. That bond may have been rich, developed over years. Or it may have been brief and all-business. Either way, the snap stings because of routine medical tasks that are never rote. To ask patients about goals of care or to introduce the "H" word is to reach across the divide with humanity. So, too, is tenderly patting your patient's hand or admiring your patient's family photo.


You'd explored personal spaces, plumbing your patient's symptoms and desires and foibles and strengths and beliefs. Knowledge of those intimate details empowered you to guide your patient's journey with personalized treatments and meaningful words of comfort. Now your fund of knowledge about that patient is like a limp string falling to earth after its kite breaks free.


Death marks the loss of possibility. There's no more hope of recovery, comfort, or even just a bit more time. Where once you felt hope because there was hope, now you feel none.


Put another way, death signifies your lost opportunities to qualify a comment or try a new treatment. Not that you think you should have handled anything differently. Not that anything would have changed your patient's illness experience or outcome. You'll just never know.


What you do know is the wake of loss now rolling through. Maybe you noticed a staff member using the back of his wrist to keep tears from spilling, knowing he'd spent extra time with your patient whose phone never rang and side chair was always empty. Maybe you glimpsed a bedside tableau of bereft family members that stirred sympathetic sorrow, their tears as contagious as a lengthy, wide-open yawn.


There's a difference in the source of sadness, of course. Yours may be the inability to prevent a family's grief or the progress in medicine that feels painfully slow.


Or maybe the reason behind the water pooling inside your lower eyelids is that the death hits too close to home after a personal loss. You've been dutifully keeping your own pain hidden. Now a surge of grief splashes over the wall that usually separates professional and personal.


Indeed, compartmentalizing emotions is a fundamental job skill in oncology, where death occurs regularly. You cannot allow anything-including sorrow-to hamper the objectivity needed to provide expert and compassionate care. You simply cannot walk into an exam room with tear-streaked cheeks.


So what emotional analogue to physical hand washing might protect clinicians and their subsequent patients from unwitting harm? A phrase comes to mind, the one my call partner, Scott, used whenever anyone (patient, family, or colleague) praised his work: "It's an honor and a privilege."


That got me thinking about the uplifting moments in clinical medicine. I started imagining spaces and rituals for clinicians that highlight those moments.


My first idea may sound like pure fantasy. Imagine a room near the nursing station, where privacy is guaranteed if a cryptic sign-"M.R."-hangs on the door. That room would serve as a refuge for a physician and a nurse (or social worker or other team member) to share the gifts their patient left behind: their amazement at a patient's talent for whistling bird songs; the inspiration of a patient's volunteer efforts at a Food Bank until the end; their gratitude for the "Thank you" after every single solitary visit. In a space dedicated for Mourning Report, a patient's death could remind them why clinical medicine is an honor and a privilege.


Enough fantasy. Thinking more practically, you could keep a gratitude journal. In it, you'd jot down a touching vignette or some new medical fact or insight that added to your understanding of cancer, patient care, or life.


If writing is not your thing or a journal strikes you as morbid, what about making a donation to a favorite charity of yours-or the patient's? Most organizations notify the family, which brings them the comfort of knowing their loved one mattered to you. Donating anonymously is an equally powerful way to honor your patient.


For me, I'd probably invent a ceremony involving silk flowers, a love of mine. Alone in my office with the plastic stem of a tulip between my fingers I'd say "Thank you for...." as I returned it to its vase. In the days or weeks that followed, the colorful petals could remind me of the ongoing gifts of past patients. As for where I'd set that vase, I'd have to see if it helped me more in a highly visible spot or hidden away in a corner.


Ordinary routines in the course of your day can be transformed into healing rituals, too. Imagine you arrive home, turn off the ignition, and press the garage remote. Now, before you make a move, in the cocoon of your car and drowned out by the rumble of the door as it closes, say something: Express whatever you're feeling because you cared.


Underneath white coats and colored scrubs, health care professionals are people. Rituals for clinicians provide a compact way to deal with human emotions and move on. Routine exercises of the heart may energize your life-affirming passion to improve oncology care.


After the death of a patient, may you find comfort and inspiration in this twist on Tennyson's ode: 'Tis better to have cared and lost than never to have cared at all.