It was during the busy Christmas season when I turned my car into the parking lot of the funeral home. This patient was my third to die in the past few weeks, and tonight was my second wake in three days.
It was not easy to make the stop that evening. The holiday season is a difficult time for me to practice medicine; patients are more lonely and depressed, families are under greater stress, and tonight, the bittersweet juxtaposition of holiday joy and the sorrow of death were stressful. I had second thoughts as I got out of my car, but I continued up the steps to the front door and went inside.
As I walked into the viewing room, I could hear a loud whisper, "Dr. Irvine is here!" Whether because of my imagination or innate shyness, the situation felt like the television commercial for an investment firm, in which everyone stops to look and listen. Close family members recognized me immediately and came over to greet me, saying, "It was nice of you to come." Then they introduced me one by one to sons, daughters, grandchildren, neighbors, friends, and clergy. "Tell the priest to wait with the prayer," I overheard a voice say. "This was Dad's doctor."
It wasn't easy for them either. My presence brought tears to many eyes. Perhaps I was a painful reminder of the events of the past week in the intensive care unit. Indeed, it did not take long before they asked their questions: "We really shouldn't have... What did you think about that catheter?... Did we do the right thing? ... Do you think he would have had a chance if we had ...?" Most were careful questions, but they were clearly laden with hints of self-doubt, guilt, curiosity, and fear.
This was a rather typical visitation for me. I started attending them a few years ago; why, I can't even remember. In those years my experiences convinced me that my participation was essential, and for many reasons. It gives families an opportunity to talk about their experiences surrounding the death. They have questions about what happened in the last days. Second thoughts need to be discussed when the pressure is off. They want to know about the autopsy. They need reassurance and help with their guilt; no one can do that like the physician.
The doctor's visit does two other things that I have come to believe are very important. Our presence adds credibility to the sense of worth that family members gather about their loved one. (He was important enough that his doctor came to the funeral.) It is a very consoling thought. And secondly, family members regard the physician's attendance as a demonstration of caring for the person who died -- that the doctor views his patient as more than a business client, consumer, or scientific curiosity with an unusual disease; that the patient had value as another human being.
The visitation is also personally important to me. My feelings need resolution just as the family's feelings do, and society's rituals help me with that as well. Interestingly enough, family members often console me as when I hear myself say, "I'm sorry we couldn't do better," and they respond, "But you did your best doctor, thank you." They are so appreciative.
I am reluctant, almost embarrassed, to bring this up with colleagues. When I do, they look a bit distant and become quiet. They haven't thought about it much, or so they say. Few with whom I have talked have ever attended a patient's funeral, and those that have attended have usually done so under special circumstances. A prominent clergyman friend told me that among literally hundreds of funerals he has conducted, he could "count on one hand" the number of physicians who attended the visitation or funeral. In one survey of physician behavior toward death, only 6 percent reported that they routinely contacted the family after the death. Fewer than 10 percent reported that they sent cards or flowers or attended the funeral.
Does our behavior reflect the objective approach toward patients that we learned in our training? Does it remind us of our own eventual death or of our professional failure? Or are we simply insensitive to family needs? I doubt that it is any of these, but rather our failure to appreciate how important physician participation is to the process. Perhaps the lack of education about dying patients in our medical schools and continuing medical-education courses is partly responsible. Somehow, we must come to realize that our responsibility does not end with the pronouncement of death.
Most of all, the funeral helps me bring "living" and "medicine" into proper perspective. In a special way, it gives me perhaps my best understanding of how that person fit into his or her community, and how medical care fit into his or her community, and how medical care fit into that life -- on the patient's own ground rather than my medical ground -- away from the demeaning patient gowns, the sterile professional uniforms, and the white lights of the intensive care unit. The funeral brings that person back home to the community to rest; we are part of that community too.