Eventually, all people will confront their own deaths.
Their family members must cope with that death, as well.
But so must the medical professionals who were treating the person who has died.
Dr. Il Jun Chon, vice president of medical affairs for WellSpan Ephrata Community Hospital, is no exception.
As a medical student and then as a longtime hospitalist — a doctor who cares for patients in a hospital setting — Chon has experienced the death of patients under his care and communicated with family members left behind.
We recently sat down with Chon to ask him how he and other doctors deal with the deaths of patients, and how they learn to work with family members.
This interview has been edited for length and clarity.
How do doctors learn to cope with their patients dying?
A lot of times it’s watching patients die and developing your own way of dealing with these patients, based on your life experience, philosophy, family upbringing.
I lost my father when I was 11. So I had firsthand experience with someone dying.
A lot of what I feel in my experience in death and dying, in dealing with my own patients, is the respect for life.
That’s what I remember most from my Korean culture. So, respect for life, meaning you don’t do things just so you could extend your living or just continue life if it’s not a respectable living. I think that formed my opinion on how to live and how to die
As we learn more about how to take care of our dying patients or patients with poor quality of life, I try to measure it against that respect for living versus continuity of further care at all cost. And it has been a pretty good measuring stick for me as to how to come to the middle.
There’s always more to do (medically). The question is how much do you gain as a quality of life and how do you quantify the quality of life? It’s a juxtaposition.
That’s where I think the difficulty comes. I think a lot of that is based on (patients’) individual wishes, individual needs and their background, as well. And the provider’s background, too. As much as we try to make it a personal decision for the patient, a lot of the influence comes from the physicians, as well.
What training did you have in medical school to prepare you to deal, personally, with losing a patient?
Not much. A lot of times your initial contact is when you actually do your third-year medical training where it’s clinical rotation. So, you are kind of thrown into this (situation) with patients who might be dying.
One of my first patients at Mercy Fitzgerald (in Darby), where I did a rotation, was a gentleman who actually needed kidney dialysis to continue living. And his wish was, “I’ll never go on dialysis.”
And even after I explained to him, “If you don’t do dialysis, you will die, sir,” he said, “I’m fine with that.” At the time, I had trouble understanding. “Boy, how is this possible, that someone is willing to die just because he doesn’t want to do dialysis?”
I remember having struggled with that particular decision of the patient. He ended up passing away. It was sad. Really sad.
As a new doctor, how did that affect you personally?
Despite the Hippocratic oath of doing no harm, our training is, “We can always help.” It’s an active verb. To help, you have to do something. And there is something to do to extend this person’s life.
It was really difficult, at least for me, to say, “Boy, he doesn’t want my help.” That was the first thing I had difficulty reconciling. The second thing was, “Have I failed in some way by not saving his life?”
As I’ve gotten older (I’ve realized) help doesn’t always have to be an active “I’ve got to do something for the patient.” Help actually can be helping them make decisions on their own. Sometimes, getting rid of the treatments that are not necessary, that may make their quality of life worse — sometimes that’s a better help than doing something.
How about your feeling of having failed the patient?
I thought, “Have I really failed him? Maybe he wasn’t given all the information. Maybe he didn’t realize how easy dialysis was.” Twenty years ago, dialysis had a lot of negative stigma with it.
That’s the part I always have to ask myself nowadays: If we are asking the patient to make that informed consent, is it really based on all the information, all the reasons and the expectation of the patient?
That’s still a work in progress for a lot of docs. Because, what we know, as a physician, can be done can’t always be translated to the patient and have their full understanding of what that means. I think that’s going to be a challenge for every doctor, everywhere, at every time.
If a young doctor would come to you for advice on how to treat and communicate with a patient nearing death, and that patient’s family, what would you say?
You need to have relationships. You need to have respect for all, including your patients.
Medical care is given. That’s what our profession is. So, for us to say I gave great medical care to that patient, that’s the bare minimum. If you have respect for the patient and the family, I think that will just obligate you internally, that “this is what I need to do, this is how I need to talk to them.” This has been my message to the young doctors.
Treat them as you want to be treated. How would you like to be communicated with? How would you want your doctor to come in to talk to about, possibly, your mother dying?
What advice would you give a doctor on how to tell a family their loved one has died unexpectedly?
Be vulnerable. Talk about how it makes you feel. Don’t be defensive. Don’t just state the (medical) facts. Don’t tell them what was done and (say), “I don’t understand why this happened.” That will eventually have to be done. Be vulnerable, and say, “This troubles me. As someone who had a relationship with the patient, this really hurts and this really makes me sad.”
As I tell all my patients and all my colleagues, when one of my patients dies, that person takes a little bit of me with them emotionally, spiritually. If it doesn’t affect you in that particular way, perhaps you’ve been in medicine a bit too long.
When you have lost a patient, what are the things you do to cope with that? Do you talk about it at home?
I never talk about patient care at home. On the days we have a challenge or a patient death, maybe it’s my and a lot of doctors’ defense mechanism: We just don’t talk a lot. We internalize a lot of it. That actually might be a problem.
Who do you talk to about these things? A couple of times, I’ve spoken to some of my colleagues and said, “I’m really troubled by this; help me think through this.” But most times it’s more of a “did I do everything right, medically?” Rarely do we talk about, “Oh, this makes me really sad. What can I do?”
How has the way doctors are advised to deal with death changed over the years?
There are employee assistance programs for a physician or providers, nurses or anybody who’s in that risk group of emotional stresses, emotional distress.
I think there is an avenue for us to seek that. I’m not quite sure how often we use that. I think a lot of times it is kind of a given that physicians should be able to deal with that because that’s what they do.
There isn’t any formal process to teach us how to deal with this. And I think that’s across the entire health industry, to be honest with you.
We deal with folks who pass away all the time. Do we adequately address how to deal with that process other than having those employee assistance programs, having a psychiatrist program?
There are some structures and programs that actually help us prepare for that, I think, (such as) having discussions with patients (about their failing health). It prepares the patients as well as the physicians.
If you have that discussion, and ask them, “Hey listen, what do you want to do when this happens,” when it actually happens, physicians and providers know that we’re following (the patient’s) direction, just as with my patient with dialysis. That’s what he wanted. And that’s what we follow.
Do you think doctors’ individual faith traditions affect how they deal with a patient’s passing and how they deal with a family?
I think it does.
I’m a Presbyterian. When I was growing up, it was about that Calvinism, in which everything is predetermined — that somehow, this was all meant to be.
No matter how unjust it seems to me or to the patients, somehow this is meant to be, because it happened.
Whether God knew it from the beginning to the end, I think a lot of folks argue about that. But in the end, that forms my philosophy that this was meant to be and there’s some purpose in this, no matter how tragic it seems. So, at least to me, it makes a big difference.
I think it does help (doctors) cope with their emotional stress, and finding meaning in their lives and their patients'. The biggest trauma encountering death or dealing with death is not knowing what happens next. Is this the end? Is this the finality? Religion closed that gap.
I think trying to find the human, rational reasoning for everything that happens in life or this world, it's not possible.
My dad was a chicken wholesaler back in Korea, and he bought chickens from farms and sold them at the wholesale market. He happened to have a sleep disorder, so we were always concerned he was going to have an accident while driving. But, when I was young, he was crossing the road and wound up getting hit by a drunk driver.
Perhaps in some way, somehow, this is part of the grand old plan. It's hard to understand. I think that really gave me a different perspective on death. Had he not died, I probably wouldn't have come (to the United States with my mother). I probably would never have met my wife. I probably would have never had this conversation.
You sing in church choir and at events such as weddings and funerals. How does singing at funerals inform your coping with death?
I’ve sung at least four or five of my patients’ own funerals. That was interesting. It is emotional. You learn something about a person’s life at funerals.
When you go to the funerals and they talk about (the who was) your patient, and you see the pictures of their life, and see the places they’ve been, I think you appreciate what he has done or what she has dperson one as a person, not as a patient. And it really helps you appreciate that person as a person, not as a patient.
I think that is something we’re missing as physicians. Do you really know your patients?