Grief is defined as an intrinsic, prevalent, and adaptive response to the encounter of loss.¹ Despite various studies investigating the grieving process of patients and their caregivers, physician grief is less explored. Among medical professionals, oncologists and especially palliative care specialists (PCSs) consistently encounter death and the complexities associated with end-of-life care. Oncologists and PCSs try hard to fulfill their role in providing comprehensive support to patients and their families, addressing physical, psychological, and spiritual needs. However, they often lack the opportunity to attend to their personal grief over their patients' deaths and distress, which necessitates a greater emphasis on understanding and addressing the grief experienced by these healthcare practitioners. If grief remains unresolved, it can escalate beyond control, leading to negative consequences, including compassion fatigue, a sense of failure, decreased effectiveness, poor decision-making, psychological impairment, early career burnout, and poor quality of life.^2,3,4

As a newly appointed fellow in palliative care, my initial experience was both tragic and unforgettable. I was responsible for a 32-year-old woman with advanced breast cancer, which had metastasized to her lungs, causing severe respiratory distress. She was urgently admitted to the palliative care unit, and discussions about her poor prognosis were deferred. Her condition deteriorated rapidly. Before I could complete the necessary prescriptions, she succumbed to her illness in the presence of her recently arrived mother and grieving husband. Paralyzed by shock and disbelief, I found myself unable to confront the profound grief in the room. While the nursing staff attended to tasks such as performing ECGs and documenting the time of death, I stood by, feeling powerless and overwhelmed by an unfamiliar fear. The patient was my age, a wife, a daughter, and she died from breast cancer. This encounter left an indelible mark on me. Subsequently, I was haunted by the memory of that moment and the family's reaction, a memory that replayed in my mind constantly. I felt guilty and increasingly isolated. This emotional turmoil impacted my professional duties, draining my energy and affecting my ability to care for patients.

It should be considered that physicians, as humans, experience profound emotions triggered by mortality and terminal conditions.⁵ Beyond emotional responses such as sadness, disappointment, irritation, guilt, and anxiety, fatigue and insomnia are the physical manifestations most frequently observed in doctors following the demise of a patient. Coping is defined as the thoughts and behaviors developed by physicians, like others, to facilitate the mitigation of bereavement. Consequently, understanding coping mechanisms is a cornerstone in assisting physicians to handle the emotional challenges inherent in the care of dying patients. The most positive and negative adaptive strategies include talking to colleagues, friends, and family; focusing on work; talking to the patient's family; exercising; meditating or spending alone time; consuming alcohol; writing; and seeking religious support.^2,5 Regarding the failure of coping mechanisms in response to patient death, approximately 10% of physicians exhibit profound reactions. Medical specialty, level of experience, and gender are known factors that influence the burnout rate.⁵

In a palliative care setting, specialists may face personal challenges such as burnout, compassion fatigue, and compromised quality of care. Although PCSs frequently encounter terminal patients, studies interestingly demonstrate that burnout rates are low among them due to three main causes. First, a multidisciplinary decision-making structure in the palliative care setting is a key factor for burnout protection as it distributes the pressure. Sufficient time for communication with patients and their families is the second key to preventing burnout. Anticipation of death is the third factor that decreases burnout rates; it seems that if a patient's death is anticipated, the physician may process grief more successfully. In contrast, the unexpected death of patients who are anticipated to be cured can be a challenging issue.^4,6,7,8

Regarding experience level, there is conflicting data. Balaban et al. concluded that the degree of discomfort was more pronounced in less experienced physicians.⁹ Contrarily, Moores et al. illustrated that experience level does not affect the strength of emotional reactions or the need for support, indicating that the impact of a memorable patient’s death is shaped more by individual character attributes than by the extent of medical training.⁵

In addition to medical specialty and experience level, there are suggestions of a relationship between gender and stress related to patient death. Redinbaugh et al. concluded that female physicians are more prone to psychological distress and are affected more strongly by a patient's death than male physicians.¹⁰

Despite the inevitable grief that oncologists and PCSs feel for dying patients, it is crucial to find an approach to protect against unintended negative consequences for patients. Self-awareness, which involves recognizing and accepting one's abilities and limitations, is a key intervention to avoid the negative impact of patient death, as introduced by Kearney et al. Regular interdisciplinary meetings and Balint groups create opportunities to discuss grief, mistakes, suffering, and personal challenges, thereby strengthening self-awareness and helping physicians realize they are not alone.^11,12 In fact, receiving support from colleagues leads to successfully navigating the grieving process and ultimately enhances job satisfaction.

Physician grief, particularly among PCSs, is a critical yet often overlooked aspect of healthcare. Highlighting the emotional impact of patient death on physicians and the need for effective coping mechanisms is essential. Self-awareness, interdisciplinary support, and open communication can mitigate negative consequences. Providing adequate support for PCSs and oncologists is crucial for their well-being and ensuring high-quality patient care.