Doctors, death, and dying
What do doctors think about their own mortality?
When Breath Becomes Air, Paul Kalanithi’s poignant account of life and death as a young doctor diagnosed with terminal cancer, has been long listed for the Wellcome Book Awards 2017. The memoir, unfinished at the time of his death aged 37, is the latest of several recently published books by doctors musing on mortality.
But do medics think about death differently from the rest of the population? In this article, doctors from a variety of specialties explain how the impact of exposure to death has affected how they think about their own mortality.
“I don’t know how often the average person thinks about death,” says Louise Robinson, GP and professor of primary care and ageing at Newcastle University. She finds that awareness of mortality manifests for her as “really appreciating life,” having seen how quickly someone can go from seemingly good health to a terminal trajectory.
However, Richard Smith, former editor of The BMJ, disagrees: “I think doctors are as adept as everyone else at shoving it to the back of their minds . . . Death is something that happens to patients,” he says.
For Charles Young, an emergency physician at St Thomas’ Hospital in London, doctors’ sense that they have a unique insight is misplaced: “Lots of people come across death in one way or another . . . We see ourselves as having a particular kind of knowledge or understanding, and I think that’s quite wrong.”
A 2012 survey of GPs by ComRes, on behalf of the organisation Dying Matters, found that only 35% of GPs have talked to someone about their own end of life wishes. Just over half have made a will and registered as an organ donor, but only 7% have written down their own preferences for end of life care.
Catherine Millington Sanders, clinical lead for end of life care at the Royal College of General Practitioners and developer of the Difficult Conversations training programme, says, “Everybody talking about death and dying tends to find it very difficult. It’s easier when you’ve had a lot of practice, you feel more comfortable.” It’s something she’s done herself: “I’ve thought those things through and have been much more clear with the people I love about what I want, got a will sorted out, where I prefer to die—[the] final arrangements.”
Most of the doctors I spoke to said they knew which treatments they would or would not want to have at the end of their lives. Discussing chemotherapy, Keith Hopcroft, a GP in Essex, says, “I would have a very low threshold for saying no to any of it, and would let nature take its course.”
Does the specialty you work in change your perspective on mortality? Rob George, medical director of St Christopher’s Hospice in south London, moved from working in intensive care, which he describes as “the apotheosis of death denial,” into palliative care. “The primary goal [of palliative care] is that we help people to die well,” he says. “I’m recognising death is there and can face it full in the eye.”
This is perhaps less of an issue in general practice. Hopcroft says, “Statistically, death is a rare event in general practice. Five or six patients die per year. You’re seeing loads of people who are worried they are going to die, but they don’t. I find that very reassuring.”
Millington Sanders thinks that doctors vary as much as everyone else in how they think about death. “People are often profoundly affected by their own experience of bereavement. Doctors are humans and are going to have had death experiences that are personal. Personal experiences make up the majority of what they feel about death,” she says.
For doctors in emergency medicine, unexpected or sudden death is a more common event. Young says, “Often what I think about is the discrepancy between the type of injury and the outcome. I see people—not many, but I have seen them—who have thrown themselves in front of a tube train and come away with dirty clothes and a scraped elbow. Others trip and fall, or have something minor, and die.”
“You get used to the unpredictability of the event, but it’s more about the outcome,” he says. “The impact has been to make me understand that the process is not a rational one.”
Young doesn’t agree with the assumption that emergency medicine doctors are all obsessed with saving lives at the expense of a good death.
“Sometimes people come in with injuries that are not compatible with life. Sometimes they come in and don’t want to be cured or saved, just made more comfortable. People understand you can’t save everybody and it’s much more a partnership now. If someone comes in and says, ‘I know I’m going to die but the pain in my foot is bothering me’—we’ll deal with that. In my emergency medicine practice I absolutely don’t think I can save everyone.”
For dementia patients, the long decline towards death is often marked by a series of “false alarms,” says Robinson. “You think they might be dying, then a week later they’re sitting up in bed.” This plays havoc with the doctor’s much valued ability to predict dying, which can be difficult for patients to accept.
What’s a good death?
Two years ago, Smith caused outrage when he wrote in BMJ Opinion that dying of cancer was “the best death.”  He still thinks that it is “better” than an unexpected death.
“Everyone wants to die a sudden death. It’s not so good for the people left around you.” A slow death from dementia, however, “is a living death. A lot of doctors are more bothered about that than death.”
Robinson decided to study dementia after being told during GP training that getting a diagnosis for a patient with symptoms would make no difference. “That really struck me because we don’t do that with anything else. You don’t say, you might have lung cancer but we won’t bother giving you an x ray. You always do your best to find out what the cause is and to come up with the best management plan.”
When practising palliative care in the community, she was again struck by the disparity between the care given to cancer patients and those with dementia. Although research focuses on finding a cure for dementia, she thinks that care is neglected. Ageing of the brain, she says, “appears to happen to all of us. Are we finding a cure, or putting off death and dying?”
George concurs that many doctors see “cognitive failure or nerve degeneration” as the worst type of final illness. “There’s definitely a view among doctors that there are things not to die of and things they would be OK about.”
He is passionate about the importance of a good death, which in his view includes time to complete relationships, resolve conflicts, and come to terms with life—“the goodbyes, sorries, and thank yous.” He talks of seeing people who “in the last day of their life are so alive it’s unbelievable.”
Young observes that, “We’re not all brave, a lot of people are really scared and that’s important to acknowledge.” However, he says patients often surprise him with their pragmatism and sense of humour, right to the end of life.
Hopcroft muses,“I wonder how I’d cope,” having seen a variety of unpredictable reactions to a terminal diagnosis. For him, he says, “It’s not so much mortality, it’s not the dying, it’s the run-up to dying. The pre-mortal stage. That’s the thing that gets frightening.”
Is medical knowledge more of a burden than a benefit at that stage? “Maybe then having that knowledge . . . knowing how utterly miserable that stage can be [is a disadvantage]. Maybe I wish I didn’t know in quite so much detail what that stage is like,” he concludes.
But George says, “I have the experience and techniques and expertise to make a lot of difference in terms of symptom management, and that makes it easier for me.”
So are doctors more prepared for death? “We’re probably the best prepared—or should be—to know what to do and how to prepare for that eventuality. [But] being human beings, we’re not,” George says, ruefully. “I’m not frightened of dying because of my belief structure, not because of my technical knowledge.” He pauses, then says, “Death is a social phenomenon, not a biological one. People don’t die from a disease, they die from a life. It’s about lives concluding, not the biology of managing disease.”
For George, the concept of a good death is to continue living right up until the last moment— “to live as well as you can while you are dying.” This is echoed by Smith’s account of the death of film maker Luis Buñuel. Dying of pancreatic cancer, Buñuel stated, “I hope I will die alive,” with “[a death] that’s expected, that will let me revisit my life for a last goodbye.”
Doctors have more experience of death and dying than people in most other professions. Although this might not make it easier to accept the inevitability of death, engaging with the “rough edges” of life and death gives doctors the opportunity to observe and learn from people in life’s extreme situations. As Hopcroft says, the question GPs are frequently asked when patients face difficult end of life treatment decisions is, “Doctor, what would you do?” However you answer, it’s an important question to ponder.
Box 1: Doctors writing about death
Paul Kalanithi, When Breath Becomes Air 
A newly qualified neurosurgeon is diagnosed with terminal cancer. Despite having been trained to “grapple” with death, he struggles to work out how to live a meaningful life in the limited time left to him. During his final year of life he engages with cancer treatments, returns to neurosurgery, fathers a baby—and writes a book.
“I might live another 12 months, or another 120. Grand illnesses are supposed to be life clarifying. Instead, I knew I was going to die, but I’d known that before. My state of knowledge was the same, but my lunch plans were shot to hell.”
Atul Gawande, Being Mortal: Medicine and What Matters in the End 
One day, cancer surgeon and author Gawande ventured one floor down from his surgery clinic to the geriatrics clinic, which he had passed almost every day for years. This resulted in a masterful exploration of frailty, old age, and how we approach death in the modern medical setting. It is unsparing in its criticism of how medicine, by prioritising time over quality of life, can rob patients of the chance to have agency and dignity in the final act of their lives. “In ordinary medicine, the goal is to extend life. We’ll sacrifice the quality of your experience now . . . for the chance of gaining time later.” In contrast, “Hospice deploys nurses, doctors, chaplains and social workers to help people with a fatal illness have the fullest possible lives right now. . .”
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
- Kalanithi P. When Breath Becomes Air.Bodley Head, 2016.
- ComRes. Dying matters coalition survey of GPs and the public. 2012. www.comresglobal.com/polls/dying-matters-coalition-survey-of-gps-and-the-public/.
- Difficult Conversations. 2017. www.difficultconversations.org.uk/.
- Smith R. Dying of cancer is the best death. BMJ Opinion 2014; 31 December. http://blogs.bmj.com/bmj/2014/12/31/richard-smith-dying-of-cancer-is-the-best-death/.
- Gawande A. Being Mortal: Medicine and What Matters in the End. 1st ed. Metropolitan Books, 2014.