Death is something to be avoided: the psychodynamics of end-of-life planning for the general practitioner

The seeds for this research were planted in the emergency rooms of a tertiary Metropolitan Hospital Emergency Department where I practise as an Emergency Physician. My aim in the research is to develop an understanding of the psychodynamic processes that limit general practitioners from involvement in the groundwork of end-of-life planning with their patients who suffer from chronic and terminal illnesses and the dependent elderly patient. The focus in this thesis is to communicate an understanding of the general practitioners’ perception of the community and their role within it to end-of-life plan. At the commencement of the writing I acknowledge my limitations in the academic spheres of sociology, philosophy, anthropology and social history but these aspects of the thesis are developed to contextualize the research within the community of work of the general practitioners. Over a period of days, a number of frail elderly patients were transferred from their Nursing Home by a mobile intensive care ambulance to the Emergency Department to be resuscitated. My feelings of concern for these individuals generated questions. Who decides? Who has the right to make life and death decisions for others. Where is choice? Are the patient’s wishes known at this time? Do the patients have any rights when they are incapable of making their own choices known? Does anyone know what their choices would be? Or, is ‘death something to be avoided’, no matter what the circumstances? So this research springs from a passionate concern for the rights of the other, with the desire for others to appreciate their personal autonomy and their capacity for choice, in dying and death, as in life. As Yalom puts it: If he doesn’t know he is about to die how can your patient make a decision about how to die? Yes, he must decide how to face death1. The research commences with a quantitative study using data derived from a survey of adult patients attending the Emergency Department in May 2002, to quantify if end-of-life planning is occurring in the community. It then moves to the process of purposefully selecting a group of general practitioners, as a series of case studies, with whom to explore and understand the concept and process of end-of-life planning within the community. Using an interpretive paradigm with a clinical method of in-depth interviewing, data are collected from these general practitioners. System psychoanalytic and psychodynamic theories and practice are applied for the analysis of the data. The dissertation reveals the factors that limit general practitioners in end-of-life planning. These factors include; emotional collusion with members of the community, the lack of clarity in the primary task, the inability to recognize and manage the emotional experience associated with the role and limited education in communicating issues of significance. Theory is generated depicting the context of the work, and recommendations are made for future participation in end-of-life planning by the general practitioner and members of society.