Death and Coping Strategies
by Joe Allwood

Reflection

Having worked as a health care assistant on an oncology ward I've received many invaluable insights into the varying strategies people employ when coming to terms with terminal illnesses. It was a great privilege to be involved in people journeys, and one particular patient's journey has stayed with me. Roy had been battling cancer for nearly a year when I started my job. He was single, isolated from his family and struggling to cope with his illness. The medical dictionary defines cancer as any malignant tumour arising from the abnormal, purposeless and uncontrolled cell division of cells that then invade and destroy the surrounding tissues. This definition doesn't even scratch the surface as cancer affects so many aspects of a person's life, not only the physical being but their and social and emotional state as well. In Roy's case the lack of family support meant he felt isolated. He not only had to physically care for himself but he had no one to discuss his feelings with. This is a very important part of coming to terms with a terminal condition. This situation naturally reduced his resilience and therefore compromised his health further. Roy's condition was gradually deteriorating, because of his decreasing physical health he was unable to go out and socialise with friends; compounding his isolation.

Roy's story illustrated the importance of hearing a patient's narrative. After some time I noticed a change in Joe, he was more positive and even though the cancer was still progressing he seemed slightly better. Another thing I noticed was his unusual assortment of jewellery, at first it struck me as odd but after hearing his story I realised the symbolic significance of these items. Other members of staff and friends had conversed with Joe and encouraged him to seek help from his family. At first he was resistant to the idea. This reminds me of a quote from the poet Tagore's poem Stray Birds which goes Man barricades against himself. I believe this to be true of everyone. People try to protect themselves by sealing off areas of hurt when sometimes the most effective solution is to approach the problem head on. As time progressed, the nurses built up a strong trusting relationship with Joe and convinced him to seek the help of his family. By hearing the patient's story and building up a good relationship they had improved Joe's care. He had been going out shopping and spending quality time with his family and on some of these outings his young relatives had bought his some rings and other items of jewellery. He wore them as a constant reminder, keeping him strong when the disease was at its worst. By spending quality time with his family he had increased his own resilience and so was coping more effectively. When he was struggling he would focus on the happy times and this would calm and comfort him.

Sadly Roy's cancer was terminal and he passed away. An image that stays with me to this day is that of of his hand with all the rings on. It symbolised so much for me and that is why I chose to draw this image. Other aspects of his death are also prominent in my mind, for example how the healthcare team dealt with his death. In western society we have reached an unusual point where death has become a taboo topic. After reading the book On Death and Dying I tried to understand how self-care creates resilient practitioners. The focus in western medicine is on preserving life. While this is a key focus it should not be the only focus. Care for the patient should be, and usually always is, a key focus as well. In certain situations this focus can be pushed aside, partly so the doctor can work effectively to save the patient's life and partly so the doctor can protect their own mental and emotional state. It would become completely overwhelming if as a doctor you became emotionally attached to every patient you treated. The paper How Doctor's Deal with Death really demonstrated that although a doctor has a need to protect their own wellbeing (because self-care creates resilient practitioners), they also need to be able to empathise with a patient and have certain coping strategies in place to protect themselves. Dealing with Joe's death was hard for all members of the healthcare team as we had all developed relationships with him. Coming back to the quote from Tagore, I feel a common response is to completely wall away those feelings and not process them at all. But I had learnt from Joe that this does not work in the long run, I found the best way to cope with loss was to talk to my colleagues and share feelings on the situation. By talking it through I was able to increase my own resilience and therefore cope effectively with the situation and continue to perform my job.

Roy could not cope with or accept the fact that he was terminally ill. He needed to regain the sense of love and belonging in order to process and deal with what was happening to him.

English healthcare has become very target driven, mainly due to financial restrictions but this has many knock-on effects on good healthcare. A paper by Dr Rawlinson shows how detrimental target-driven care can be in an acute setting. Creating my drawing, I have realised how vital having time to talk to patients is in every setting. On the ward I worked on we had some incredibly busy days and some which were much quieter. Having the time to talk to patients and find out what was happening helped resolve many issues not just in the case of Roy, but in many other patients as well. Every effort needs to be made in future healthcare policies to protect time with patients, as it is being cut back more and more with every new target introduced. Producing this drawing really showed me how a simple image, the image of a hand, can tell you so much about a person's journey and how they cope with disease. Just having the time to ask questions can lead to some amazing discoveries. The rings weren't just a selection of trinkets; they represented all that kept Roy strong throughout the final stages of his life, improving his quality of life when he was physically very ill. By talking to him and sharing this story I improved my relationship with him and therefore could provide effective care. I understand that the NHS has many financial restrictions but every possible effort needs to be made when setting future targets to preserve time for doctors and healthcare staff to hear a patient's story and establish a relationship. Another conclusion I have drawn from doing my personal activity is the importance of having systems in place to look after not only the bereaved family but the staff who looked after the patient. This is even more important when they are long-term patients and a strong relationship has developed. This is one of the key drawbacks of becoming attached to a patient suffering from a terminal illness, although you are providing better care you will also suffer bereavement when the patient passes away. Therefore within healthcare settings there needs to be advice and training in processing emotions and the effective management. This will enable practitioners to cope and perform their roles to the best of their ability.

The artwork was by far my favourite part of this exercise because I have always enjoyed art and taken every opportunity in which to do it. The image of Roy's hand is one that has always stayed with me not just because of the interesting story behind it but because he was one of the first patients I built up a relationship with who subsequently died. His death was the first time I really felt upset, grief and loss for someone I had no personal ties too. By writing this project and exploring my thoughts and feelings I have learned a lot about myself and my own coping strategies. Developing the drawing made me realise how important self-reflection is. It shapes and influences all my future decisions. I feel that in future practice I will always try to talk with the patient and share all my thoughts and feeling with my colleagues in order to process them properly. The simple image of a hand with all these rings now holds a special place in my memory because of the connotations it holds for me. I chose pencil to try to keep the drawing simple yet striking. I hope that on viewing this piece of art people experience something similar to my own experience, confusion originally and then subsequent enlightenment after reading and learning of his story. Overall, I found this a very interesting way of exploring some issues I feel will be very important in my future practice. It has also helped me think about how I will try make myself the best doctor I possibly can be.

Joe Allwood

Whole Person Care, Year One, 2012

References

1 Concise Medical Dictionary Eighth edition. Oxford University Press, Oxford 2010

2 Read book online. Rabindranath Tagores Stray Birds. [Online] Available from http://www.readbookonline.net/readOnLine/1007/ (accessed 19/03/12)

3 Kbler-Ross E. On Dying and Death. Routledge, London and New York 2009

4 Reynolds F. How Doctors Deal With Death. Arch Dis Child 2006 91: 727

5 Rawlinson N. Harms of Target Driven Care. BMJ 2008;337:a885