After Death

Social Engagements with Death and Dying

Examining Empathy Fatigue and Terror Management Theory in Medical Students

Sally Wolf

 

How do you picture the end of your life? Are you peaceful, in the comfort of your home, surrounded by loved ones? Or are you in the sterile white room of a hospital, connected to tubes and monitors, surrounded by medical professionals? More than likely, you are among the 90% of Americans who hope to die at home (Benson & Aldrich, 2012). However, 63% of people pass away in hospitals in the Unites States, and another 17% of people pass away in either nursing homes or assisted living facilities (Valente, 2017). Death has become increasingly medicalized since the mid-20th century, with a steady increase in the number of Americans dying in hospitals since 1949 (Knight et al, 2004). What are the ramifications of this cultural shift? The medicalization of death has implications not only for aging populations who hope not to die in a hospital, it also means that medical professionals are having more and more contact with death in the course of their careers.  How are medical professionals handling this increasing contact with human mortality? Are they being properly prepared and trained for this stress? Or are rates of burnout reflecting inadequate supports and preparation for contact with death as part of the job?

One key aspect of burnout is called empathy fatigue, which refers to a sense of numbness and normalcy when encountering distress, suffering, and death because of prolonged job stress (Maslach, Schaufeli, & Leiter, 2001). It’s common in emergency room doctors, social workers, teachers, therapists, and nurses (Maslach, Schaufeli, & Leiter, 2001). Empathy fatigue is treated by making sure that people in stressful jobs take the time needed to destress, and refocus on what is engaging about their jobs. In recent years, there has also been expanding research on burnout and empathy fatigue in medical students. Burnout increases over the years of medical education, and may contribute to burnout and poor conduct during medical careers (Santen, Holt, Kemp, Hemphill, 2010; Dyrbye et al, 2010).

Many psychologists refer to Terror Management Theory, or TMT, to examine a person’s motivations to engage in a high-stress helping profession that leads to contact with human suffering. According to TMT, everyone has to come up with strategies to cope with the terror response to their own mortality (Cox, & Arndt, 2008). Experiencing more reminders of your mortality increases the sense of terror and requires stronger coping mechanisms. Many people point to their religious beliefs, contributions they make to their families, and investments in their community or broader involvements as ways to handle the knowledge that death in inevitable (Ernest Becker Foundation Staff, 2015).

To investigate empathy fatigue and TMT, I interviewed Sireen Yang, a dental student, Abdul Aasar, a second year medical student, and Lisa Jones*, a student who has been accepted into medical school but has not started classes yet. I asked them about their motivations to pursue medical professions, supports against empathy fatigue in medical training, and their first encounter with death in a medical context: learning anatomy with donor bodies. Medical schools accept donor bodies, or cadavers, from people who elect to donate their bodies to medical teaching after their death.

Lisa, Abdul, and Sireen all had somewhat varied motivations for joining the medical professions, but all expressed a longstanding interest in working in some area of healthcare, and a sense of connectedness to medical science. Social supports were another major theme. Abdul referred to his family:

“Well, I sorta grew up with medicine, because my dad, um,   like I was born during his training and he’s been a doctor all my life. So he always used to take me to the hospital and I always used to see how he worked and what he did and so… It was always just what I knew I wanted to do. It felt pretty natural to me.”

Family support both prevents burnout in medical students, and can help people cope with their fear of death. Feeling connected to a wider network, like a family unit, works against feelings of hopelessness and doubt (Weng et al, 2011).

When I asked Abdul about what he wanted to specialize in within the medical field, he explained how his interests have changed over his medical training thus far:

“ When I first started med school, I thought I didn’t care if the disease was, was worse or not. Like I would just try my best and it wouldn’t like affect me emotionally or it wouldn’t affect my job satisfaction. But I’m sorta starting to realize that that’s not true, and I might be happier in a specialty where there’s a problem, and I can fix it, and I can feel good about fixing it, and the patients are happy that I fixed it. Whereas some fields, a problem is chronic, and you like, sorta have to deal with the problem over the patient’s life time but you don’t have a satisfactory solution.”

Abdul’s experiences in medical school clearly changed his perceptions of what he will find stressful and draining as a doctor, supporting the research that found the medical students first encounter burnout in medical school (Santen, Holt, Kemp, Hemphill, 2010). In contrast with Abdul, Lisa referred to her experiences in pharmacy school and her academic interests. However, her answer didn’t address the emotional satisfaction or stresses of a medical career. Her early interests in different specialties also reflect someone who has not experienced empathy fatigue in the medical field thus far:

“Mostly when I think about specializing, at least currently, I’m focusing more on how interesting I think the field is and how good the lifestyle is. And so patient outcomes can influence, like, your lifestyle, depending on your personality. If you find it really draining to deal with patients who have really bad outcomes, or even chronic pain patients who aren’t necessarily going to die soon but who just have a bad quality of life a lot of times, that can be draining for some people, but I haven’t really experience that yet. So I guess the specializations I’m most interested currently are neurology or neurosurgery, because I really like the brain, it’s really cool. So neurosurgery outcomes aren’t very good, but the procedures are really cool and there’s a lot of growth in the field, so it’s still interesting.”

Sireen’s interests shared some overlaps with both Lisa and Abdul. She referred to her academic interests and narrowing in on a healthcare profession that fits her the best:

“I was kind of exploring different healthcare options as I got into college, and as I shadowed, what just really struck me about dentistry was how you can kind of get a lot done quickly in one appointment, because if you see like a cavities or caries, then you can ya know, fill it, instead of just prescribing something and waiting. So I really like that hands-on aspect.”

She also spoke about being influenced by her family and their experiences:

“And then, when my brother got braces, um, he used to have a really large overbite, and after that was fixed, like, his whole facial structure changed. And I noticed a difference in his confidence level. Like, people really seem to respect him more, which is kind of sad, that ya know, that that made a difference. But at the same time, I realize how big of an impact it can make on someone’s life.”

Sireen demonstrates two major forms of support and stress reduction: connecting her patients and her family experiences, and her intrinsic interest in the field.

I also wanted to understand how these medical students responded to their early encounters with dead bodies. Abdul described the process of changing between reflecting on himself, to reflecting on the donor body:

“We went in there really focused on our own selves, and we weren’t like thinking about people behind the donor bodies. I mean, we were all sort of nervous. But the moment of silence and the introduction to the process of how the donors sign up and stuff, sort of like, gave us perspective on the whole thing.”

Medical professionals must learn to balance their own self-care with focusing on their patients. Abdul’s thoughts exemplify the search for that balance. He also described the process of becoming familiar with the donor bodies as an impactful part of the experience:

“some donor bodies have tattoos, like ours had, I think a navy tattoo, and so you realize, you know, this man served in the military at one point. Or, you can even tell if the donor was a smoker when you look at their lungs, or like if they were on dialysis because they had marks on their arms where they—whatever they call that procedure, because they like join the veins or something. And some donors had like breast implants, although it’s not clear if that’s from like a previous mastectomy they had, or like actual cosmetic surgery. You just kind of speculate. But you do get to know about your donor.  Nothing about their specific lives, but you can get hints on how they lived their life. And when you figure those out, it sort of, it sort of makes you more relating to the fact that it’s a donor. Like, It’s important to have confidentiality for the donors, but at the same time, that sort of made it impersonal. When we started out, we just like, we didn’t know anything about the body, we don’t get to know anything about the body really. We didn’t even know cause of death and age at the onset, we learned those a couple weeks in. So as we progressed through the course, we sort of began learning more about the body and that made it more, more real.”

Medical professionals have a lot of knowledge about their patients’ lives, and depending on the specialty, may have long relationships with their patients. Familiarity can increase empathy fatigue. However, doctors often have to put aside their own emotional reactions to most effectively help their patients and avoid feelings of empathy fatigue. Abdul’s reaction demonstrates the challenge of emotionally reacting to knowledge about another person, even though he intends to be objective.

Sireen also described the process of adapting to the situation and overcoming a stress reaction in order to learn from the donor body:

“If you were not comfortable with interacting with the donor body, it’s okay to just stand on the side until you feel ready to get more involved. So, I know a lot of students did do that. There was one girl in my group who was just very pale, I think she talked to the professor about it afterwards, and the professor that we had was very available for that. And just, ya know, after a couple days, it became more familiar and she did fine during the course.”

It is necessary for doctors to become comfortable and familiar with their work environment. However, empathy fatigue emerges when they become excessively accustomed to and exhausted by death and suffering (Weng et al, 2011). Medical school is the first step for medical professionals to learn the balance between familiarity and numbness. For Abdul, the greatest challenge to his sense of familiarity and comfort was how personal the donor body became:

“I thought the hardest part of seeing the donor body would be the face, and the face was covered for most of the semester. But when I actually did see the face, it wasn’t that impactful or emotional, because… I don’t know, you think it would be, but the part that actually made you feel the most, in terms of, it being a real body, was when we worked on the arm and the hand. And every now and then the arm or hand would bump you or you’d touch the hand and it would feel like you’re holding a person’s hand. Maybe it’s because when you see the face or you see the rest of the body, you know that the donor is dead and you’re not alarmed by that, but when you touch the hand it feels real for a second. It is an emotional thing to hold someone’s hand. And that was the most surprising part, when you touch the hand or hold the hand, you get an instant feeling from that. One of our professors said that was the hardest part for him too, so that’s definitely a shared experience.”  (Abdul)

Abdul’s reaction to touching the hand of the donor body exemplifies an emotional reaction to the donor body that he had to overcome in order to complete his training. This is a necessary process, but it can also lead to empathy fatigue. Sireen was also impacted by knowing that her donor body was a unique, individual person:

“It just kind of drove home the point that after you die, you know, you can still use your body for what you value. Because those people donated their body for science, so that’s something they had in their life that’s kind of continuing after they die, where they’re still fulfilling, I guess, their desire to educate others, and that’s something that’s ongoing, even after they pass.” (Sireen)

Sireen’s reaction demonstrates terror management theory: fear of death is reduced by understanding a person’s connections to broader organizations that will continue to exist after their lives (Cox, & Arndt, 2008). Understanding her emotions in this way should minimize her feelings of empathy fatigue. Sireen’s focus on contributions being made to science to cope with emotional stress and fear of death also came up when I spoke with Abdul, and with Lisa, who said:

“I mean, the advantages of anatomy are huge. The more you understand anatomy and the way the body works, the better you’re able to improve procedures and treatments and health outcomes for patients. I think that’s more than worth it.” (Lisa)

However, Lisa’s answers to the questions about donor bodies had a notably more global focus, rather than reflecting her personal connections. She expressed a lot of academic interest in donor bodies, but because she’d had very little direct contact with donor bodies and no prolonged experiences, she hadn’t had the same intense emotional reaction to cope with:

“S: And what about the first time you encountered a dead body in a medical context?

L: Um, in some of my anatomy classes, I never, anatomy and physiology. I never actually dissected them, but we saw some throughout parts of our course. They were already dissected and pre-marked and everything.

S: Was that experience impactful for you?

L: Um…

S: Or just interesting?

L: It was interesting, I mean, it was strange to see it. The first… I mean, before that, I had actually held a human brain in one of my neurosurgery, er, neuroscience courses. So I feel like that was… I actually got to hold it and look at the different dissections and cross sections, and so that was sort of weird. More in that it wasn’t as weird as I thought it was going to be. It was just… I mean, the brain was out of context of the whole body, but it was a human brain, and I’d spent so many classes like, learning about it and thinking about it, so it was strange to see it. But it was in such a scientific context that that’s mostly what I was focused on.

S: Are you nervous about having to actually interact with the donor bodies?

L: No, I don’t think so.

S: Why not?

L: Because I know why I’m doing it, and I know the body has been donated for that purpose, and I know I need to learn how to understand human bodies before, as part of my medical training.”

In contrast, Abdul and Sireen both expressed emotional reactions to the questions, including self-reflection in response to their donor body. Both of them mentioned how their belief in life after death influenced their reactions to their experiences with donor bodies.

“If I believe in life after death, how does that effect sort of how I see the whole process. And also, I asked myself, would I ever donate my body? And I almost want to say no, which would be hypocritical, a little bit. But, it just feels like it would be such a weird thing to do, and like, I do want to educate med students, but do they have to dissect me to do it? I don’t know, it’s just an emotional decision. It feels like, if I had to decide now, I wouldn’t do it. Which seems, like wrong, because I got the opportunity to do it. And I think that decision might be influence by religious beliefs. Even though it’s not like wrong religiously, I don’t believe it’s wrong religiously to do it, I just feel like if I do believe that humans have a soul, I wouldn’t want to do it.” (Abdul)

Abdul’s discomfort with the thought of donating his own body is consistent with TMT, because he is thinking about what he would do in the face of his own death and wondering about his donor’s reaction to that situation. In dealing with this anxiety, he refers to his religious beliefs. Sireen also referred to her beliefs:

“I guess because, I believe there’s life after death, that their… I guess it didn’t seem like a final end to the donor. Like before, I mentioned how their intentions were still being fulfilled afterwards, but because of my religious belief, it didn’t feel like they were gone after and would never know.” (Sireen)

Sireen’s reflections on her experiences with donor bodies and her religious beliefs also reflects TMT. Her belief in the afterlife led her to believe that the people who passed away were aware that their bodies were contributing to science, using both religious beliefs and contributions to society to deal with fear of death. Contributing to society and wondering about the lives of the donors came up repeatedly throughout the interviews.

“Yeah, I guess I sort of wonder why they decided to donate their body, and if they really… I guess what their priorities were at the end of their lives. And, because, so like my donor died from kidney failure and I wonder if he…  what he was thinking when he decided to donate his body. Like, knowing that like, his life was ending soon. Was it more like, I might as well do it, or was it like, Oh, this is my last good contribution at the end of my life? It’s definitely a noble thing to do.” (Abdul)

Abdul also speculated about how his donor would have coped with his own death. This is also consistent with Terror Management Theory, with a focus on how others continue to exist and contribute after their own deaths.

“Just having that interaction with someone who was and is a real person drives home the importance of empathy and realizing that your patients will die. And that’s an important thing to realize, and that it’s okay. And it’s important to think about their family as you treat them, and think about what they want as you treat them. Like especially with dentistry, a lot, well not a lot, but some the patients you know are going to die soon, and it’s like, can I make them feel confident and able to go out into society again. Um, like can I take away their pain.” (Sireen)

Sireen also expressed a sympathy for others who are coping with the terror of death and an interest in how they cope, including their relationship with their families and their self-image, as one would expect from TMT.

Overall, empathy fatigue and terror management theory were useful psychological frameworks to understand these interviews. Medical students are struggling to balance a sense of comfort and normalcy in the environments they work in, while still keeping in sight the gravity of the work   they’re doing. Emotional burdens and stress increase throughout medical education, and the reality of these stresses may differ from what medical students anticipate. However, family connections and a sense of scientific meaning were central in how these students cope. Throughout medical education, the greater sense of purpose and the social supports should be emphasized to facilitate appropriate coping and reduce empathy fatigue as medical students transfer into their careers (Maslach, Schaufeli, & Leiter, 2001). Medical professionals deal with high levels of stress in order to improve the lives of others. For the wellbeing of both the doctors and the patients, society needs medical professionals to be familiar with and able to handle death and suffering, without feeling complacent or numb in the face of their patient’s suffering. After all, if you were going to pass away in the hospital bed instead of at home, wouldn’t you prefer a doctor who was calm, but kind and sympathetic? It is everyone’s concern that doctors are able to effectively handle their contact with human mortality.

* The interviewee’s name has been changed to protect her privacy.

References

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