1. No category

Archives of Medical Research 44 (2013) 394e400
PRELIMINARY REPORT
Facing Death in Clinical Practice: A View from Physicians in Mexico
Asuncion Alvarez-del-R
ıo,a Ma. Luisa Marvan,b Patricio Santillan-Doherty,c Silvia Delgadillo,a and
Luis F. O~
nate-Oca~
nad
a
Departamento de Psiquiatrıa y Salud Mental, Facultad de Medicina, Universidad Nacional Autonoma de Mexico (UNAM), Mexico D.F., Mexico
b
Instituto de Investigaciones Psicologicas, Universidad Veracruzana (UV), Veracruz, Mexico
c
Departamento de Cirugıa, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran (INCMNSZ), Mexico D.F., Mexico
d
Subdireccion de Investigacion Clınica, Instituto Nacional de Cancerologıa (INCan), Mexico D.F., Mexico
Received for publication February 11, 2013; accepted May 17, 2013 (ARCMED-D-13-00093).
Objective. Physicians’ decisions and actions, once they know that their patients’ death is
inevitable, will influence how patients are going to live their last moments. The purpose
of the present study was to explore the views of physicians about death in their clinical
practices.
Methods. Physicians who work at four high-specialty public hospitals and two private
hospitals in Mexico City provided responses to the Physicians’ Views about Death Questionnaire, which was developed for this study.
Results. Four hundred thirteen physicians were surveyed. The majority treat terminally
ill patients (73.3%), but only 28% received training regarding death. Nearly half of the
physicians reported a personal formative experience related to death which, together with
the experience of being exposed to terminally ill patients, appear to be the manner in
which the majority of physicians learn to deal with death. The great majority of participants (90.6%) would personally like to know the truth if they were going to die. Younger
physicians, those with !6 years of medical practice, those with no death-related personal
formative experience, no death-related academic training, and no experience treating
terminally ill patients were most likely to avoid telling patients about their imminent
death.
Conclusions. Death is an important topic for physicians in Mexico. There is a relation
between lack of information, experience, and formal training, and the withholding of information from dying patients. This suggests a possible value for interventions to enhance
and develop coping skills for professionals who deal with end-of-life situations. Ó 2013
IMSS. Published by Elsevier Inc.
Key Words: Facing death, Physicians, Terminal care, Truth disclosure, End of life.
Introduction
Death is a part of life and being alive implies not only that
sooner or later people will die, but also that we will suffer
through the death of important ‘others.’ However, people
try hard not to think about these facts. This has been
referred to as death denial, a strategy to elude uneasiness
Address reprint requests to: Asuncion Alvarez-del-R
ıo, R.P., Ph.D.,
Departamento de Psiquiatrıa y Salud Mental, Facultad de Medicina, Universidad Nacional Aut
onoma de Mexico, Circuito Exterior, Ciudad Universitaria, 04510 Mexico, D.F., Mexico; Phone: (þ52) (55) 5623-2300,
ext. 43133; E-mail: [email protected]
about mortality (1). Nevertheless, it also impairs people
from developing personal and social resources, which aid
in dealing with death when it presents itself (2).
Although anyone can die suddenly and unexpectedly, the
majority of persons die as a result of a prolonged illness or
a medical condition (3). Even for very old persons, it is said
that they die of a disease (4). Physicians are those who
know when their patients’ death appears inevitable and,
from that moment on, their decisions influence how patients
live out their last months, weeks, or days (5).
There is a point at which the use of curative treatments
ceases to be beneficial but they continue to maintain their
capacity to induce harmful side effects. This is especially
0188-4409/$ - see front matter. Copyright Ó 2013 IMSS. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.arcmed.2013.05.005
Physicians Facing Death
true for life-support therapies, and their use should be determined based on their expected benefits compared with the
burden that they impose (6). Unfortunately, many physicians frequently fail to engage in the conversations that
would enable patients and their families to understand
and discuss the patients’ wishes and their real options. Physicians are also part of this denial society and the majority
would not have received specific training to handle these
situations (7,8). Contrariwise, they probably learned to
avoid talking about death and feel guilty when they are
not able to ‘defeat’ it (9).
Fortunately, people are beginning to realize that worse
even than death is spending their finals days in pain and
isolation (10). Palliative medicine has been offering quality
end-of-life care to patients and their families (11), and general and specialty physicians are more aware of the importance of improving their communication with seriously ill
patients and their relatives (12e15).
Information on physicians’ attitudes towards death
in Mexico is mainly anecdotal and suggests that physicians
either avoid communicating ‘‘bad news’’ to their terminally
ill patients or offer the news without compassion (‘‘terminally ill patient’’ in this article refers to a patient who
cannot be cured and who has a reasonable expectation
to die within a short period of time). One of the scarce
studies on the subject found that communication between
physicians and very ill patients is incomplete and vague
(16). Therefore, it is important to improve on the knowledge of this problem with objective data; thus, strategies
during medical training could be designed to enhance
the physicians’ confidence to handle these situations (17).
With this in mind, the present study explored the
views of Mexican physicians about death in their clinical
practice.
Materials and Methods
Sample
This study included a non-probabilistic sample composed
of Mexican physicians who lived in Mexico City. They
were required to have had at least 1 year of clinical practice. They worked at four high-level specialty public hospitals and at two private institutions, which were selected
because physicians at those institutions care for patients
with highly complex medical situations including cancer
and other terminal conditions.
The study was approved by the Research Board of the
Faculty of Medicine (UNAM) and by the Ethics Committee
of the three National Institutes of Health that participated in
the study (Table 1).
Once physicians gave their consent and the inclusion criterion was fulfilled, they were surveyed. Of 417 physicians
who were invited to participate, 413 agreed. All physicians
were informed that the study was anonymous.
395
Table 1. Sociodemographic characteristics of the sample and clinical
experience
Gender
Masculine
Feminine
Age (years)
20e29
30e39
40 or more
Religion
None
Catholic
Christian
Evangelist
Jewish
Other
Years of medical practice
1e5
6 or more
Type of medical specialty
Do not treat patients directly
Do not usually treat terminally ill patients
Usually treat both terminally ill and nonterminally
ill patients
Usually treat terminally ill patients
Experience treating terminally ill patients
Never
Seldom
Frequently
Hospital
Instituto Nacional de Cancerologıa (INCan)
Instituto Nacional de Ciencias Medicas y Nutricion
SZ (INCMNSZ)
Instituto Nacional de Cardiologıa Ignacio Chavez
Instituto de Seguridad y Servicios Sociales de los
Trabajadores del Estado (ISSSTE)
Private hospitals
n
%
269
144
65.1
34.9
138
206
67
33.9
49.9
16.2
74
310
14
3
3
5
18.1
75.8
3.4
0.7
0.7
1.2
204
197
51.0
49.0
19
36
255
4.6
8.7
61.7
103
24.9
21
88
299
5.1
21.6
73.3
164
125
39.7
29.3
108
8
26.2
1.9
12
2.9
Procedure and Measurement
Surveys were completed from September 2011e
March 2012, and each took between 10 and 15 min for
completion.
Data were collected using the following two questionnaires developed for this study: general data questionnaire—participants were asked their gender, age, religious
affiliation, and the importance of religion in their lives,
years of medical practice, medical specialty, experience
treating terminally ill patients, academic training related
with death, personal formative experience related with
death, and personal fear of death, and the Physicians’ Views
about Death (PVD) questionnaire. This is a 5-point Likert
scale ranging from 1 (strongly disagree) to 5 (strongly
agree). Questionnaire items were developed from a review
of literature and from conversations with physicians. The
validity of each item was assessed by 23 judges using the
Lawshe formula (18). After discarding the items with low
validity, the instrument was piloted with five physicians.
396
Alvarez-del-R
ıo et al./ Archives of Medical Research 44 (2013) 394e400
The discriminative capacity of each item was calculated using the extreme group method (19). The final version
resulted in a 10-item instrument; nine items were concerned
with the respondents’ reactions with terminally ill patients
or the reaction that they would have in the case of physicians who have not yet cared for terminally ill patients
(Cronbach’s alpha 5 0.72). The remaining item asked
whether the respondent considered that physicians should
be offered seminars reflecting issues related with death.
Finally, respondents were asked if they would like to know
the truth if they were to have a terminal illness.
‘‘reflections about death’’, which refers to the need to
discuss issues related with death.
Finally, the ‘‘median’’ method was utilized to divide the
participants into two groups according to their scores in
each category described previously (one classification for
each category). The Pearson c2 test was conducted to determine the association between the number of participants
who scored below or above the median, and the number
of participants who claimed they would want, would not
want, or did not know whether they would want to know
the truth if they had a terminal illness. All probability
values !0.05 were considered significant.
Data Analyses
Results
The frequencies of participants who disagreed with each
item of the PVD (scoring, 1 or 2 points), who neither disagreed nor agreed (3), and who agreed (4 or 5) were calculated. Subsequently, a c2 goodness-of-fit test for each item
was calculated.
The participants were divided by gender, age, religious
beliefs, years of medical practice, type of medical specialty,
experience treating terminally ill patients, academic
training related with death, personal formative experience
related with death, and fear of death.
The Student t test for independent samples or one-way
analysis of variance (ANOVA) with post-hoc Duncan test
were used to test differences between groups. In order to
carry out these comparisons, PVD items were divided into
four categories and means were calculated for each category. These categories comprised the following: ‘‘guilt’’,
which refers to feelings of guilt when a patient dies;
‘‘evasion’’, which refers to physicians who do not tell their
terminally ill patients that they are going to die; ‘‘family
request’’, which refers to the physician being asked by
the patient’s family to hide the truth from the patient, and
Four hundred thirteen physicians were surveyed. Ages
ranged from 27e67 years (mean, 34 years) and they had
from 2e43 years of clinical practice. Characteristics of
the sample are depicted in Table 1.
Two hundred ninety nine physicians (73.3%) treat terminally ill patients frequently, whereas 88 (21.5%) treat them
occasionally, and 21 (5.1%) do not treat terminally ill patients. Although the majority of physicians treat terminally
ill patients, only 115 (28%) had received formal academic
training related with death.
There were 195 participants (47.3%) who had a
personal formative experience related with death, and
279 (69.4%) described themselves as not being afraid of
death.
Table 2 shows the percentages of physicians who agreed,
disagreed, or neither agreed nor disagreed on each of the
PVD items. According to the most frequent answers given
by physicians to items related with guilt, the physicians do
not feel guilty when a patient dies (items 6 and 10). As to
the items exploring whether or not they would avoid talking
about death with their terminally ill patients, their most
Table 2. Number and percentage of participants who agreed, disagreed, or who neither agreed nor disagreed with each items on physicians’ views about
death
Item
1.
2.
3.
4.
5.
6.
7.
8.
When I know that one of my patients is going to die, I think that I should inform him/her
In my clinical practice, I tell my patients the truth when they are going to die
If the patient’ relatives ask me to hide from the patient that he/she is going to die, I consent
I avoid the subject of death with my terminally ill patients
I hid from my terminally ill patients who already died that they were going to die
I think I failed when one of my patients dies
When I know that one of my patients is going to die, I prefer to withdraw from the case
Physicians should have special places to reflect about issues related with death
(seminars, workshops.)
9. Sometimes I think a patient has the right to know that he/she is going to die, but I feel
unable to inform the patient
10. I feel guilty when one of my patients dies
Disagree
(n) (%)
18
16
208
276
313
295
356
34
(4.4)
(3.9)
(51.0)
(67.5)
(76.3)
(71.4)
(87.5)
(8.2)
Neither agree nor
disagree (n) (%)
44
69
113
76
70
90
30
60
(10.7)
(16.9)
(27.7)
(18.6)
(17.1)
(21.8)
(7.4)
(14.5)
Agree
(n) (%)
351
323
87
57
27
28
21
319
p
(85.0)
(79.2)
(21.3)
(13.9)
(6.6)
(6.8)
(5.2)
(77.2)
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
214 (52.2)
80 (19.5)
116 (28.3)
0.0001
260 (63.0)
102 (24.7)
51 (12.3)
0.0001
Note: Most physicians prefer to inform their patients that they are going to die, and they do not feel guilty when a patient dies. Most of them would like
seminars or workshops to reflect about death.
Physicians Facing Death
frequent response was that they prefer to inform the patient
of his/her imminent death (items 1, 2, 4, 5, 7, and 9). When
the participating physicians were asked whether they would
hide the information from patients who asked whether they
were going to die, if so asked by the patient’s relatives,
approximately half of them disagreed, whereas the
remainder either agreed or neither disagreed nor agreed
(item 3). Finally, the majority of the physicians agreed that
they should be offered seminars or workshops that reflect
on issues related with death (item 8).
When we compared the results of each category among
the groups of participants, the sole variable in which there
was no significant difference was religious belief. Results
concerning the category ‘‘guilt’’ show that physicians
O39 years of age were less likely than younger physicians
to feel guilty when their patients die. This was also the case
for those who do not treat patients directly and for those
who usually treat terminally ill patients (compared with
397
those who do not usually treat terminally ill patients
and to those who usually treat both terminally ill and
non-terminally ill patients). Furthermore, physicians who
were afraid of death were more likely than the remaining
participating physicians to feel guilty when their patients
die (Table 3).
Items included in the category ‘‘evasion’’ indicate that
physicians aged O39 years were less likely than younger
physicians to avoid telling a patient that their death is likely.
Moreover, physicians with !6 years of medical practice,
compared to those with 6 or more years, were those most
likely to avoid telling patients that they will die. This was
also the case for those who did not have a personal formative experience related with death, for those with no academic training related with death, and for those with no
experience treating terminally ill patients (Table 3).
Regarding the ‘‘family request’’ item, the only significant result was that female physicians were more likely
Table 3. Results (mean and SD) of the four categories of the physicians’ views about death: guilt, evasion, family request, and reflections about death
Guilty
Gender
Masculine
Feminine
Age (years)
20e29
30e39
40 or over
Religion
Strong believers
Weak believers
Years of medical practice
1e5
6 or more
Type of medical practice
Does not directly treat patients
Does not usually treat terminally ill patients
Usually treats both terminally ill and nonterminally ill patients
Usually treats terminally ill patients
Experience treating terminally ill patients
Never
Seldom
Frequently
Academic training related with death
Yes
No
Personal formative experience related to death
Yes
No
Afraid of death
Yes
No
Family
request
Evasion
Reflections
on death
M
SD
M
SD
M
SD
M
SD
1.40
1.49
0.57
0.57
1.33
1.40
0.36
0.39
1.64a
1.82a
0.76
0.85
2.65
2.76
0.64
0.56
1.54a
1.43b
1.22a,b
0.60
0.57
0.44
1.37a
1.39b
1.24a,b
0.37
0.38
0.34
1.73
1.68
1.72
0.81
0.77
0.85
2.69a
2.64b
2.90a,b
0.61
0.68
0.31
1.45
1.41
0.57
0.56
1.36
1.36
0.37
0.39
1.73
1.66
0.81
0.77
2.72
2.65
0.60
0.63
1.48
1.38
0.58
0.57
1.39a
1.31a
0.37
0.36
1.70
1.70
0.79
0.80
2.69
2.71
0.63
0.60
1.05a,b
1.58a,c
1.51b,d
1.27c,d
0.16
0.60
0.62
0.43
1.44
1.38
1.37
1.30
0.38
0.36
0.38
0.37
1.79
1.83
1.75
1.54
0.79
0.74
0.81
0.77
2.63
2.75
2.67
2.77
0.68
0.55
0.64
0.55
1.50
1.52
1.41
0.59
0.59
0.56
1.65a
1.44
1.31a
0.40
0.38
0.36
1.86
1.79
1.66
0.73
0.77
0.81
2.57
2.76
2.68
0.68
0.55
0.63
1.40
1.44
0.59
0.56
1.30a
1.38a
0.34
0.38
1.71
1.71
0.78
0.81
2.69
2.70
0.58
0.62
1.43
1.44
0.59
0.57
1.30a
1.41a
0.34
0.40
1.63
1.77
0.77
0.82
2.77a
2.63a
0.57
0.68
1.57a
1.36a
0.60
0.54
1.41
1.34
0.34
0.39
1.76
1.69
0.80
0.79
2.70
2.69
0.64
0.61
SD, standard deviation.
Means in rows sharing subscript (a, b, c, d) are significantly different from each other at the p !0.05 level.
The results were compared by gender, age, religious beliefs, years of medical practice, type of medical specialty, experience treating terminal patients,
academic training related with death, personal formative experience related with death.
398
Alvarez-del-R
ıo et al./ Archives of Medical Research 44 (2013) 394e400
to consent to hide from the patient that he/she is going to
die than male physicians. With respect to the item on ‘‘reflections about death’’, physicians who were O39 years of
age as well as those who had had personal formative experience related with death were more likely to agree that
physicians should have places to reflect on death-related issues than younger physicians (Table 3).
Finally, physicians were asked whether or not they would
like to know the truth if they had a terminal illness. The majority of participants (90.6%) responded that they would like
to know the truth, whereas only 3.7% said that they would
not want to know that they were going to die, and 5.7%
did not know whether they would like to know the truth.
Discussion
This study explored the views about death of a group of
highly specialized physicians in Mexico City, providing
objective data on a situation that had been mainly viewed
through anecdotal information.
Of all physicians asked to answer the questionnaire,
!1% of these declined to complete it. This response differs
from that obtained in two previous studies also conducted
with Mexican physicians concerning other issues in which
|15% of physicians refused to respond to a survey
(20,21). A plausible explanation is that the subject of death
may constitute a concern in their daily work life.
Only one fourth of respondents had received some type
of academic training regarding the death/dying process,
even though the majority of these physicians treat patients
who are going to die soon. This fact was not unexpected
because the literature notes that physicians are not prepared
to cope with end-of-life care (2,7,8).
Nearly one half of the physicians reported having had a
personal formative experience related with death, which appears to be, together with the experience of being exposed
to terminally ill patients, how the majority of physicians
learn how to deal with death. Interestingly, in our study,
the respondents who would not hide from a patient that
he/she is going to die were either those who had acquired
learning through experience or those who do not treat
terminally ill patients. It could be stated that physicians
consider informing a patient of his/her condition as the
right thing to do, which is in agreement with the fact that
nine of ten of the participating physicians would like to
know the truth if they themselves had a terminal illness.
The problem arises when they have to provide this information to the patient in their clinical practice. One thing is
why physicians think they should do and another thing is
if they are prepared to do it.
However, it does not only concern informing. A recent
study with patients with incurable neoplastic disease
showed that the majority of these patients did not understand that they were receiving only palliative (not curative)
treatment (22).
Their misunderstanding may be due in part to the patients’ denial of their situation, a common response when
patients are informed that their illness is incurable. This
is a psychological defense described by K€ubler-Ross as
the first stage patients go through when confronted with
their prognosis, which is supposed to be temporary,
although many patients linger in it (23).
In the Weeks et al. study, patients’ misconceptions about
their prognosis were found mainly among those who graded
the relationship with their physician as ‘very good’ (22).
This may indicate that, even if physicians are keen on
providing rational expectations, they may not be sufficiently clear due to fear of hurting the relationship with
their patients. Reluctance to disclose prognosis and to
discuss advanced care planning has also been found in physicians with a higher fear of death (24), an emotion that in
our study was reported by the minority of respondents
(30%).
Physicians must recognize what information is needed
by patients and must assess whether they are ready to process it (17,25). For example, do patients understand that
their survival is in terms of months or weeks when offered
a specific treatment? Would physicians submit themselves
to these treatments? To give the correct information, physicians must feel comfortable with the fact that there is a line
after which prolonging life may be pointless.
According to Hughes-Hallet, ‘‘It’s about recognizing
that someone is dying, and giving them choices: Do you
want an oxygen mask over your face? Or would you like
to kiss your wife?’’ (26). The majority of participants in
our study value the need to provide information regarding
uncertain outcomes when standard treatments begin to
show their futility; however, this may be based on what they
think the correct thing to do is because the data obtained do
not allow us to know what they really do in their own medical practices.
It has been proven that patients with cancer are more
likely to receive optimal end-of-life care, consistent with
their preferences, when they have had the opportunity of
discussing their wishes with a physician (10). Communication between physicians and patients at the end of life is an
enormous responsibility for physicians, which can be hindered by different factors such as denial, hope based on
religious beliefs (disregarding actual facts), and fear. Physicians cannot have control of all of the aspects that may
obstruct communication, but they should be able to change
theirs. Miyaji found that physicians may not be aware that
they feel obliged to give hope and, although they may think
they give priority to what the patients need, they may be
actually giving priority to what they as physicians need
(27). Smith and Longo mention that self-deception may influence the way that physicians provide information, which
would be based on their desire to see things better than they
really are. It is not easy to inform a patient that he/she is
going to die and ‘‘most of us (physicians) choose not to
Physicians Facing Death
do it’’ (25). Could this be interpreted as guilt? In our study
the majority of respondents do not feel guilty when one of
their patient’s dies, but guilt can also be felt when providing
a poor prognosis and physicians may fear being blamed as
if they had caused it. After all, when people cannot handle
bad news, they tend to personalize this, blaming the
messenger and getting angry at that person (28). It is important for physicians to reflect on the difference between being responsible for giving bad news about an incurable
illness and being responsible for not being able to cure
the illness. This type of problem can be addressed in seminars related with death in which the majority of respondents in our study appeared to be interested.
Another finding was that more female physicians would
consent to hide from the patient that he/she is going to die if
asked to do so by the patient’s family. The fact that these
physicians were more empathic toward family requests
raised for a patient’s emotional well-being may be culturally based because women more than men in Mexico are
encouraged to be compassionate and sensitive (29). Indeed,
in other countries, it has been found that gender influences
pain management in emergency medicine because female
physicians are more likely to administer analgesics than
their male counterparts (30).
In conclusion, coming to know and quantify certain views
that physicians have toward death was important for confirming the need for specific training for these to feel better
prepared to face death and improve communication with patients and their families who would, in turn, be more satisfied with the care they receive. Furthermore, this would
promote well-being among physicians, an issue that is beginning to receive attention in the medical profession (31).
Burnout (emotional distress associated with health problems
or with decreased job function), which has been found in
physicians, can lead to serious depression, anxiety, and
addiction (32). Research has shown that physicians who treat
patients who may be facing death—such as surgical oncologists—present high rates of burnout (33). In contrast, palliative care physicians have low rates of burnout, presumably
because they learn both to consider death as a natural end
of life and to recognize their own need to cope with it (34).
Some limitations of the present study should be taken
into consideration. First, these results were based on selfreported information and, therefore, some participants
could have given socially acceptable answers. Additionally,
we do not know if our results can be generalized because
most participants were from public hospitals. Future
research is needed to compare the results between physicians from public and private hospitals.
Finally, we suggest that future research should continue
and explore physicians’ experience facing death in their
medical practice through qualitative research. In addition,
interventions to enhance knowledge and coping skills for
professionals who deal with end-of-life situations should
be developed.
399
Acknowledgments
The authors thank Alberto Lifshitz-Guinzberg for kind support in
the generation of ideas for this project, Gerhard Heinze-Martın
and Enrique L
opez-Mora for their support in the conducting of
the study, Rosa Lilia Castillo-L
opez for help in the data analyses,
and Maggie Brunner for English-language review of the
manuscript.
Funding: Financial support for this study was provided by
UNAM, INCMNSZ, and INCan.
Conflict of Interest
The authors claim no conflict of interest.
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