Zambrano 2011

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Death Studies
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On the Journey with the Dying:

How General Practitioners
Experience the Death of Their
Patients
a b
Sofía C. Zambrano & Christopher A. Barton
a
Discipline of Psychiatry, Royal Adelaide Hospital ,
University of Adelaide , Adelaide, South Australia,
Australia
b
School of Population Health and Clinical Practice ,
University of Adelaide , Adelaide, South Australia,
Australia
Published online: 28 Sep 2011.
To cite this article: Sofía C. Zambrano & Christopher A. Barton (2011) On the Journey
with the Dying: How General Practitioners Experience the Death of Their Patients,
Death Studies, 35:9, 824-851, DOI: 10.1080/07481187.2011.553315
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ON THE JOURNEY WITH THE DYING:

HOW GENERAL PRACTITIONERS EXPERIENCE
THE DEATH OF THEIR PATIENTS
SOFÍA C. ZAMBRANO
Discipline of Psychiatry, Royal Adelaide Hospital, University of Adelaide,

Adelaide, South Australia, Australia
CHRISTOPHER A. BARTON
School of Population Health and Clinical Practice, University of Adelaide,
Adelaide, South Australia, Australia
A grounded theory study was undertaken to understand how general practitioners

(GPs) experience the death of their patients. Eleven GPs participated in semi-
structured interviews. The participants explained their experience of a patient’s
death using the ‘‘death journey’’ metaphor. This journey, the Journey with the
Dying, could be described from 5 different moments in the participants’ encoun-
ters with people who are dying: private acknowledgement, communication of
prognosis, continuity of care, the moment of death, and looking after the family.
Emotional responses for each of the stages, and coping strategies in general, were
outlined. GPs’ narratives about professional identity, learning about dying and
death, and death beliefs were also important in the Journey with the Dying.
The experience of death described by the GPs in this study was different from that
reported by medical doctors in other care settings. The 5 phases of the Journey
with the Dying identified here show the different adjustments and appraisals that
GPs undertake to comprehend and to be able to work in the presence of death.
Medicine and death have a close relationship. Whether preventing

death, postponing it, or preparing patients to die, death is fre-
quently present in a medical doctor’s day-to-day experience. Yet,
Received 12 September 2009; accepted 16 June 2010.

We are thankful to the 11 general practitioners who agreed to be interviewed and for
their willingness to discuss their experiences. This article presents the work completed by
Sofı́a C. Zambrano to fulfill the requirements of a master’s degree in grief and palliative care
counseling at the University of Adelaide.
Address correspondence to Sofı́a C. Zambrano, Discipline of Psychiatry, Level 4,
Eleanor Harrald Building, Royal Adelaide Hospital, The University of Adelaide,
Adelaide, SA 5005, Australia. E-mail: sofia.zambranoramos@adelaide.edu.au
824
Journey with the Dying 825
research on how physicians react and cope with death remains

scarce. Artiss and Levine (2007) reported that ‘‘few systematic
attempts have been made to deal with the accompanying phenom-
ena that occurs in the attending physician’’ (p. 93). The literature
that is available tends to quantify rather than try and comprehend
medical doctors’ reactions to death and dying.
Although emphasis is placed on the role that health profes-
sionals have on the well-being of patients and families when con-
fronting death, less research has focused on health professionals’

responses to death (Lyckholm, 2001; Serwint, Rutherford, &
Hutton, 2006) and self-care (Kearney, Weininger, Vachon,
Harrison, & Mount, 2009; Miller & McGowen, 2000). This lack
of research may lead to discounting the relevance of medical
doctors’ responses to death and, as Serwint et al. (2006) suggested,
of the support that can be provided to physicians to overcome
possible barriers in the care of the dying.
As primary carers of terminally ill patients, medical doctors
are required to guide the dying process, and to cope as well as
possible so as to be able to work as expected. Lyckholm (2001)
explained that physicians develop close relationships with patients
and families, which is a reason why medical doctors suffer their
losses too. However, physicians do not have time to recover, or take
the time to do so, and still maintain the position of being a helper.
Artiss and Levine (2007) explained that medical doctors have
great difficulty in maintaining equanimity when a patient is about
to die, and they have recognized that displacement and denial are
among the most common responses in physicians. Other quantitat-
ive studies suggest that medical doctors respond to the death of a
patient with feelings of guilt, distress, and sadness (Moores, Castle,
Shaw, Stockton, & Bennet, 2007).
Because it serves as the foundation for their professional experi-
ences with death, it is important to take into account the context in
which medical doctors begin their training. It has been found that
the initial experiences of physicians have an impact in how they
approach their patients. The first encounter with death for medical
students is when they work on cadavers (Rhodes-Kropf et al.,
2005). In those very early experiences, students are pressured to
withhold any emotional response, and thus they ‘‘attain a detached,
objective and casual outlook on death’’ (Rhodes-Kropf et al., 2005,
p. 634). Those first experiences are accumulated with what has been
826 S. C. Zambrano and C. A. Barton
called the ‘‘informal or hidden curriculum’’ (Rhodes-Kropf et al.,

2005, p. 634), which also shapes their responses toward death and
their way of dealing with it. The hidden curriculum is considered
to be a significant influence on the care of dying patients (Rhodes-
Kropf et al., 2005). It consists of all the attitudes, cognitions, and
behaviors that students learn in their interaction with physicians.
These qualities are then embraced as being relevant to being a medi-
cal doctor and are thus displayed in their career. Rhodes-Kropf et al.
(2005) concluded that ‘‘students view the medical system as ignoring

their emotions and avoiding discussions of death’’ (p. 638).
Other authors have found that the personal experiences medi-
cal doctors have with death can have a significant influence in their
later behavior. For example, Serwint et al. (2006) found that for some
physicians the discussion of death at home was avoided; therefore,
there were also personal issues, such as fear about dying, that made
the care for the dying patient more difficult. They also found that
medical doctors experienced guilt, resulting mainly in withdrawal.
The findings that are more commonly reported in the literature
are those of the acute medical setting. For example, most studies
account for the reactions to a patient death of undergraduate medi-
cal students (Ratanawongsa, Teherani, & Hauer, 2005; Williams,
Wilson, & Olsen, 2005), and residents (Kvale, Berg, Groff, & Lange,
1999; Serwint et al., 2006). Research has also been undertaken with
medical doctors working within different specialties in hospitals
(Jackson et al., 2005; Moores et al., 2007), specifically in oncology
(Jackson et al., 2008), cardiology (Aase, Nordrehaug, & Malterud,
2008), and pediatrics (Baverstock & Finlay, 2008; Mander, 2009).
However, only a small fraction of the literature (e.g., Field,
1998; Saunderson & Ridsdale, 1999) has concentrated on the reac-
tions of medical doctors in primary care settings. There are many
differences between medical settings, specialties, and among the
physicians practicing in these different environments. Even though
all medical doctors share a similar initial training, after medical
school their chosen fields may shape their responses to death in
a different way.
For example, care for people who are dying is an inevitable
part of the work of general practitioners (GPs; Field, 1998). How-
ever, very few research attempts have concentrated on the
reactions of GPs, when marked differences between them and hos-
pital physicians exist. One of the most noticeable differences is the
‘‘continuity of patient contact’’ and the fact that there is a relation-

ship with the patient and with the families, not only at the end of
life (Field, 1998). In the study by Field (1998), GPs emphasized that
prior to the diagnosis of a terminal illness, they would have known
the patients and their families, and that the nature of this rela-
tionship is very different from the one that physicians working in
a tertiary care environment experience.
Moreover, grief responses in medical doctors have been dis-
missed in most grief and bereavement research (Kaplan, 2000, as

cited in Shimoinaba, O’Connor, Lee, & Greaves, 2009; Papadatou,
2009). Most of the literature, although urging medical doctors to
take care of their patient’s grief processes, only addresses family
and patient grief (Kutner & Kilburn, 2009; Shanafelt, Adjei, & Mes-
kens, 2003). Somehow, the grief responses of medical doctors and
health professionals have remained largely ignored. For example,
Kaplan (2000, as cited in Shimoinaba et al., 2009) stated that dis-
closing emotions when a patient dies is considered unprofessional,
because losing a patient is not regarded as a loss that may cause
grief to a health care worker. Recognizing how medical doctors
adapt to their patients’ deaths, and how they understand and
experience them, can help to address training in end-of-life and
palliative care of patients in a better way.
Research findings continue to emphasize the need for medical
doctors to feel comfortable in the context of death and dying, but
little is known about how they approach a dying patient and what
impact it has in their lives. Although some studies have described
how hospital physicians, medical students, interns, and residents
react to death, little is known about the meaning of death in other
medical contexts and medical specialties such as general practice.
Therefore, the aims of this study were to understand how GPs
experience the death of their patients. The research focused on four
different areas: meaning of death, medical training, feelings when diag-
nosing a life-threatening illness, and support and coping mechanisms.
Method
Study Design
The study drew on the principles of social constructionist

grounded theory as devised by Charmaz (2006). Using an
inductive methodology to the creation of a theory, grounded

theory aims to understand the context in which the problem is
being observed and allows the researcher to draw conclusions
about relations in the studied phenomenon. Therefore, through
this methodology, understanding the study GPs’ responses to death
provided a way to explain how they experience the death of their
patients, and the impact it has on their practice and private life.
The study was approved by the University of Adelaide
Human Research Ethics Committee.
Participants
Criteria for recruiting the GPs were (a) place of practice within
Adelaide (South Australia) and (b) at least 5 years of medical
practice.
Participants were recruited initially by e-mail using a purpose-
ful sampling technique. The North Eastern Division of General
Practice and UniCare (University of Adelaide) were approached
and asked to promote the study with GPs with an interest in the
topic. As the response rate was not high, a snowballing technique
was used thereafter. That is, the medical doctors who agreed to be
interviewed at first would nominate people they thought would
be interested in participating. Finally, as the grounded theory
emerged from early interviews, theoretical sampling was used to
explore and confirm emerging concepts, until theoretical satu-
ration was reached and the sampling ended.
A total of 11 GPs were interviewed. The participants’ demo-
graphics are described in Table 1.
Data Collection
The interviews were all conducted and transcribed verbatim by the

primary author (Sofı́a C. Zambrano) who has an undergraduate
degree in psychology and was completing a master’s degree in grief
and palliative care counselling at the time of the study.
One-on-one interviews with GPs were conducted between
April and May 2009. All interviews were recorded. In addition,
the main researcher (Sofı́a C. Zambrano) took additional hand-
written notes during and immediately after the interviews to note
TABLE 1 Participant Demographics
Characteristics of the sample n %
Gender
Male 6 54.5
Female 5 45.5
Age (M ¼ 51 yr)
30–39 2 18.0
40–49 1 9.0
50–59 5 45.5
> 60 3 27.0
Years of medical practice (M ¼ 26 yr)
5–10 2 18.0
10–20 0.0
20–30 3 27.0
> 30 6 54.5
Marital status
Married 9 82.0
Divorced 2 18.0
Religion
Christian 2 18.0
Catholic 2 18.0
Agnostic 1 9.0
None 6 54.5
Workload as a general practitioner
Full-time 1 9.0
Part-time 10 91.0
Location of practice
Northern 3 27.0
Eastern 2 18.0
Central 3 27.0
Southern 3 27.0
City of training
Adelaide 8 73.0
Sydney 2 18.0
London 1 9.0
any significant nonverbal behavior and her reflections and feelings

about the interview.
The study GPs were asked to consider and describe a recent
case of the death of a patient. A semistructured interview guide
was then used to guide discussion of the participants’ feelings
and reactions after that particular death. Other topics covered were
the personal view about death, memories about training and
education in end-of-life issues, the discussion of death and its

impact, and coping strategies (Figure 1). The interview guide was
discussed with an academic GP of the University of Adelaide,
who made some suggestions according to the aims of the study.
All interviews went smoothly with the exception of one,
where the GP was upset while remembering some professional
experiences with death. As foreseen in the ethics application,
because the participant was experiencing minor discomfort and
FIGURE 1 Interview guide.

did not want to interrupt the interview, the interview continued

and some questions and reflections were made to reassure the
participant that this was a safe space.
The duration of interviews ranged between 17 min and 58 min
with a mean of 30 min. Of the 11 GPs, six were interviewed in the
Discipline of General Practice meeting room at the University of
Adelaide, three were interviewed in their general practice consult-
ing room, and two in a public cafe.
Transcription of the interviews and the first stages of analysis

occurred simultaneously. When possible, each interview was
transcribed before the next interview. From a grounded theory
approach, simultaneity helps to enhance the results, because the
interview guide and the analysis are complemented with other
preliminary findings (Charmaz, 2006).
Data Analysis
The analytical approach focused on developing an understanding

about GPs experiences around the death of their patients and how
they experienced death in this context.
After the first six interviews were transcribed, the process of
initial coding and categorization began. The software package
NVivo 8 (QSR International Pty, Doncaster, Victoria) was used
to facilitate the analysis. Initial analysis consisted of the generation
of free nodes through a word-by-word analysis of the data, fol-
lowed by line-by-line coding. All code labels remained faithful to
the data and described actions, as suggested by Charmaz (2006).
All 11 interviews were then coded through focused coding,
thus being able to integrate and explain larger portions of data
(Charmaz, 2006). This process was followed by axial coding with
the use of tree nodes that allowed an exploration of relationships
between categories and the emerging themes. Memos were written
from the beginning of the analysis and complemented the develop-
ment of axial coding, as relationships between the categories
emerged.
At this stage of coding, themes and emerging categories were
discussed between the authors. The coding process and the
relationship between codes allowed for the outline of a theoretical
framework to explain the experiences of these GPs with death.
At this point, the researchers presented the main results to the

GPs who had been interviewed. Out of the 11 participants, seven
GPs provided written feedback about the framework within 1 week
and stated their agreement with the main findings. Another phys-
ician communicated personally her conformity with the model. To
further validate the analysis, the emerging model was shown to an
academic GP who was not part of the research team and had not
been interviewed; this GP was also satisfied with the findings.
Results
The findings are presented in three sections. The first section is

labeled ‘‘A Journey with the Dying.’’ It is the core category that
describes the experiences of GPs with the death of a patient and
could be described as a series of phases that GPs encounter when
a patient is dying. In the second section, the ‘‘Contributing
Factors’’ illustrate factors that influence GPs in their encounters
with death. The third section, ‘‘Appraisal of the Death Situation,’’
embodies different characteristics that allow GPs to respond to
death in a particular way (see Figure 2).
A Journey with the Dying
The death journey was a metaphor that appeared frequently in the

GPs narratives regarding their experiences with the death of their
patients.
I think it is the biggest privilege for medical doctors to walk with their
patients through the death journey, especially if you have been looking
after them for a long time. (GP2, female, age 56)
The repeated use of this metaphor, and the GPs comments

about their reactions to different situations before the actual death
of the patient, suggested that GPs’ reactions to death are found not
only in the moment of death itself but also in the time before the
death. The Journey with the Dying begins as a private acknowl-
edgement in the moment of awareness that the patient has a
life-threatening illness and then progresses through communi-
cation of the prognosis, the continuity of care, the moment of
death, and then looking after the (patient’s) family. Each phase
FIGURE 2 A grounded theory model of general practitioners experiences with

death.
was accompanied by an array of different emotional responses,

some shared between phases and some others specific to the parti-
cular stage. These phases of the death journey and the emotional
responses are described in detail below.
PHASE 1: PRIVATE ACKNOWLEDGMENT OF A LIFE-THREATENING ILLNESS

Medical training provides practitioners with enough knowl-
edge to recognize how life-threatening an illness can be, in spite
of all hopes and possible treatments. It is the knowledge of what
the patient will go through that makes this phase the starting
moment of the Journey with the Dying. GPs usually find out the
diagnosis when they receive the results of previous tests and it is
the moment of seeing those results that releases a series of reactions
toward the anticipated death:
There is nothing worse than looking at that result and seeing that that per-
son has something incurable and that you are going to need to go and con-
vey that to them. You feel like you are a really bad person, this terrible
person that is going to tell them that they have got something incurable.
It is a really horrible thing that you have to do. (GP9, female, age 30)
Emotional reactions. The emotional reactions that medical doc-

tors expressed within this phase included feelings of sadness, guilt,
and shock, followed by acceptance. Participants often explained
that even though they feel prepared to have these discussions,
there is a feeling of uneasiness in having to be the bearer of bad
news. The discomfort of sharing the bad news seems to be resolved
when medical doctors evaluate that it is not their fault because they
have done their job properly (see ‘‘Appraisal of the Death Situ-
ation’’ section on self-evaluation).
I think there is probably some sense of guilt. You know, ‘‘should I have
picked it up earlier? Or could I have done something else?’’ . . . you think
‘‘well, this has happened, I can’t change it, yes it is very sad and it is awful’’,
but we just have to do the best we can. (GP8, female, age 51)
PHASE 2: COMMUNICATION OF THE DIAGNOSIS TO PATIENT AND FAMILY

GPs accept that it is their duty to notify the patients about the
nature of their illness. In this process, after finding out a diagnosis,
they open up a space where they can feel as confident as possible
to give information about what the illness is and where to go from
there (see ‘‘Contributing Factors’’ section on professional identity).
If you are able to do things that in a way help a person understand where
they are at, and you feel that you have communicated things clearly, that
you know, the next steps have been clearly set out. Those kind of things,
and the person appears to be sort of taking these things on, then that looks
like it was a job well done, satisfying if you have done a hard thing and it
seems to have gone well. (GP5, male, age 45)
Emotional reactions. At this stage, GPs’ feelings are varied in

their effort to balance the professional side of medicine and their
personal reactions. Although they are professionally informed
and prepared, they express this moment as a powerful encounter
that is a stressful, emotional, and difficult time. There was a trend
in the accounts of the younger and less experienced GPs, who were
more focused on the emotional impact of the news, rather than in
their self-confidence and preparedness to convey the news.
I think it is an emotional time but so you [are] in control. . . . When you have
to give bad news, you have to be serious, and you know, a little sad, and so,
you are really somber. Like a somber mood and sometimes you can get a
bit of an emotion, and I don’t think patients mind that. I think that’s okay
because you are a human too. (GP4, male, age 61)
PHASE 3: CONTINUITY OF CARE AS A TRANSITION PHASE

This phase begins when the GP refers the patient for treat-
ment. Most GPs would still see the patient for other health issues
and might be involved in the care of other family members. In
other cases, the participants stated that they like to maintain con-
tact with their patient, even when they were not the treating doc-
tor. They said that being present in those other medical settings
usually helps them to see how well looked after the patients are
and if there is anything they can do to make it better. In many
of the circumstances, GPs are still participants in this process. This
phase includes the last days of the patient’s life—by this moment,
some patients might be receiving hospice care or others can be in
nursing homes or hospitals; however, GPs try to keep in contact
even when they are not directly involved in the care of the patient.
I mean, he was obviously being well cared for. The staff all seemed very
kind and good to him and he felt that they were treating him well. They
were doing what they were very good at. I have no problem with that . . .
I mean, I was happy to sit there. When I visited him I was visiting him
more as a friend, or at least as a companion, than as his doctor. Although
I am still a doctor . . . but it also helps to establish some continuity so that
when they come out of hospital, they know that we can have communi-
cation about what ongoing care is better. (GP5, male, age 45)
Emotional reactions. In this phase, GPs have to let go of the

patient to let them be treated by other specialists. GPs agree that
referrals are a crucial part of their job when patients have
life-threatening illnesses. They recognize the limits of their care
and the need for other medical doctors to be involved. As long
as the patients are well looked after, GPs feel at ease.
If I have a good relationship with the patient I go and see them in the hos-
pital. I don’t charge them or anything but I do visit them in the hospital
within my capabilities. So a few patients have ended up in hospices and
I go and see them. The staff is very welcoming of me, and yeah, I am very
happy to do it, I mean it is part of the holistic care that I like to give as a
doctor. And it is very helpful for me, I say goodbye to the patient as well
which is also helpful. (GP2, female, age 56)
PHASE 4: THE MOMENT OF DEATH

This phase begins when the doctor has to write the death cer-
tificate or when the doctor receives the news that the patient has
died. Usually the GPs who were involved in the previous phase
would be prepared to receive this news.
I knew that she was going to die, and I knew it was going to probably hap-
pen in the next 24 hours. I had been looking after her probably a couple of
weeks at home in that final stage but the actual feeling of when she died was
one of actual relief for the family.(GP8, female, age 51)
Emotional reactions. The reactions toward the moment of

death depended on the nature of death. If it was a sudden death,
the reactions were those of ‘‘shock,’’ ‘‘frustration,’’ ‘‘sadness,’’ and
‘‘anger.’’ In a context of palliative care or when the medical doc-
tors had acknowledged that the death was imminent, the reaction
was usually a combination of ‘‘relief’’ and ‘‘sadness’’ (see
‘‘Appraisal of the Death Situation’’ section).
PHASE 5: LOOKING AFTER THE FAMILY AFTER THE PATIENT HAS DIED
Seven GPs stated that because of the nature of their medical
practice, they are involved not only with the patient but also with
members of the family, in some cases even sharing social situations
with them. Therefore, medical doctors recognize the appropriate-
ness and need for supportive care in the bereavement stage. They
are involved in looking after the family left behind.
It [the death] just seemed like a natural part of life, so it didn’t particularly
concern me. My concern was more for her husband that was left behind
and how he was going to manage. (GP1, male, age 55)
Emotional reactions. GPs’ accounts of their commitment with

bereavement support show that their frequent response is feeling con-
cerned for the well-being of the family left behind. Those GPs who
attended funerals were grateful for having had the chance to share that
celebration with families, but this was not explored in all interviews.
COPING MECHANISMS
Independent of the Journey with the Dying phase, the study
GPs reported different strategies to address their emotional reac-
tions when finding out life-threatening diagnoses, communicating
bad news, and when they are notified of the patient’s death. Eight
GPs reported that they would talk about it with colleagues, family
members, and=or friends. Five GPs also coped by trying to find
something positive from the experience and by allowing them-
selves some time to assimilate the experience. Finally, acceptance
of the fact of death was also important as a way to come to terms
with their own feelings. Three other participants mentioned that
drinking alcohol on particular hard days was another way of
handling these situations (see Table 2).
Contributing Factors
Contributing factors were other aspects of the GPs’ experiences of

the Journey with the Dying that were salient and made a difference
TABLE 2 General Practitioners’ (GPs’) Coping Mechanisms
Coping mechanism Example
Talking ‘‘I do feel sad about it and probably the time to deal with
that is afterwards, when I go to have a cup of coffee at the
back and talk to one of my colleagues, and say I just had
this awful experience but I don’t mention it to the patient,
just to a few of my colleagues.’’ (GP7, male, age 56)
Finding something ‘‘All the time you actually feel that you’ve become
positive enriched, and that you learn things . . . from every person
that you look after you’ve got to learn something from
them.’’ (GP3, male, age 60)
Accepting death ‘‘The way I do it is by looking at death in a completely
existential way. Yes, we all die, sometimes people die
young, and looking at humans as part of the natural
world . . . I look at it as a whole of nature kind of
perspective. And from a historical perspective, you know,
humans being have been around for thousands of years
and this is what happens and in our world.’’ (GP10,
female, age 39)
Drinking ‘‘And sometimes I have a glass of wine, to be honest, if it
has been a really bad day.’’ (GP9, female, age 30)
‘‘I had two whiskies that night, which is more that I nor-
mally do. I would normally have a maximum of one, that
night not. That really affected me, when I heard her
screaming.’’ (GP6, male, age 60)
in the way the participants experienced the deaths of their patients.

These factors helped them to differentiate settings and assume
appropriate roles according to the circumstances surrounding the
death of the patient. The factors involve issues regarding their pro-
fessional identity, their learning about death and dying, and their
death beliefs.
PROFESSIONAL IDENTITY
This category comprised all the characteristics that the GPs

mentioned that enabled an adequate doctor–patient relationship,
not only for the benefit of the patients but for the GP to be able
to work assertively. Within this category, participants named the
qualities that they considered necessary so that they could differen-
tiate their role from others and at the same time justify why they
reacted in one way or the other. Behind these qualities, the parti-
cipants found shelter to avoid confronting what otherwise would
be their natural emotions when someone dies.
The following subcategories were derived from the data (see
Table 3):
1. Distancing from emotions and attachments, where eight medical

doctors expressed their need to separate their work from their
emotions and stated that this approach allowed them to deal
with the hard side of medicine, so that they would not feel over
involved with the pain experienced by patients and families.
2. Caring for more than the dying patient was another factor that
seven GPs used to ensure that not only the patient’s experience
of dying was addressed, but also that of other members of the
family; this strategy helped them make sure that the dying
experience was a bearable situation for all.
3. Assuming all sides of medicine was another relevant quality that
allowed GPs to work with the dying. This quality was the ability
to recognize that medicine is not simply about finding cures and
saving lives. When GPs realized that the hard side of medicine
brings rewards and has the potential to have a positive impact in
patient and family, GPs accepted this difficult task and made it
part of their job.
4. Maintaining contact with patients encouraged GPs to support
their patients while they were being looked after in other
settings.
TABLE 3 General Practitioners’ (GPs’) Professional Identity
Subcategory Example
Distancing from ‘‘I feel sad for them and sad for the families, but I don’t engage because if I engage with every patient that got
emotions and sick or died, then I would be an emotional wreck and then I wouldn’t be able to do my job properly . . . So, I
attachment am able to distance myself from those feelings and have a professional approach. It doesn’t mean I can’t feel
sad, it doesn’t mean I can’t acknowledge the sadness.’’ (GP7, male, age 56)
Caring for more ‘‘I guess my role in that is to help people have the best death they can, and to perhaps also to help those
than the dying around them to help them deal with it as best as they can. I used to quite enjoy palliative care, because I
patient think if you could keep people as comfortable as possible for as long as possible, give them a good quality of
life and be part of that process of them saying their good-byes, and tightening up their loose ends, there was
a satisfaction in mind that you had done a difficult job well.’’ (GP5, male, age 45)
Assuming all sides ‘‘It’s part of being a doctor and it’s easy to be a doctor when everybody gets well. I think the test whether you
of medicine are really a doctor who is really able to practice medicine in a quality way, is how you handle what is more
difficult.’’ (GP2, female, age 56)
Maintaining ‘‘If I have a good relationship with the patient I go and see them in the hospital. I don’t charge them or
contact with anything but I do visit them in the hospital within my capabilities . . . it is part of the holistic care that I like to
patients give as a doctor, and I say good bye to the patient as well which is also helpful.’’ (GP2, female, age 56)
Keeping ‘‘If you ask me whether it upsets my life outside of medicine, the answer is no . . . in fact outside of the surgery I
boundaries don’t talk medicine at all.’’ (GP6, male, age 60)
‘‘So our job doesn’t just end when we walk out of the office.’’ (GP1, male, age 55)
‘‘When I get home I might think about it again. Even though we try to leave work at work, you can’t com-
pletely do that.’’ (GP10, female, age 39)
Being ‘‘I sort of go through how I would logistically do that [tell someone bad news] and a lot of that is making sure
knowledgeable that I have got as much information as I can have on me, so that I can answer questions thoroughly and find
839
a good spot to do it and a good time to do it, and all those sort of things.’’ (GP10, female, age 39)
5. Keeping boundaries was related to the different attitudes that GPs

assumed regarding the level of involvement that their work had
in their life outside the medical practice. As can be seen from
the extracts in Table 3, some GPs had strict boundaries, others
were so used to their role as physicians that they would not find
it feasible to separate their life in different contexts, and other
GPs would find themselves thinking of patients outside their
role as medical doctors but they were able to let go of those
thoughts.
6. Being knowledgeable was where the participants were aware of
and prepared for the need for information that families and
patients have, especially when disclosing a life-changing diag-
nosis, so that they could lessen the worries of the patients.
LEARNING ABOUT DYING AND DEATH

GPs have different encounters with death throughout their
lives and all those experiences are sources for their learning. Their
approach to death is not static, because they identify different fac-
tors that influence their responses and have been able to recognize
and adopt more adaptive responses from experience. For most
GPs, their first experiences with death were those in medical
school. For other GPs, it was their experiences before medical
school, when different personal situations and family deaths
showed them what death was about (Table 4).
The contents that the participants remembered from medical
school can be divided into implicit teachings, explicit teachings,
and no teaching. The implicit teaching includes their memories of
how death was dealt with by their attendants and mentors; six of them
remember that death was somehow avoided and how all through
medical school there existed the illusion of curing and saving lives,
up to the extent that most experienced doctors would leave terminally
ill patients behind so that they could concentrate on the living.
The explicit teachings were commented on by seven GPs.
They remembered that these teachings would usually cover the
identification of the stages of grief in patients and families.
However, the GPs stated that little was taught about how to handle
their own emotions and reactions. According to these GPs, these
teachings did not prepare them to face the actual challenges that
they found with dying patients.
TABLE 4 General Practitioners’ (GPs’) Learning About Dying and Death
Subcategory Example
Explicit teachings ‘‘Right through we talked about emotions. In

first year we talked about how doctors relate
to people’s feelings and that included
counseling things as an elective and we
actually had the very basics of reflective
listening and all of that. But I don’t feel that it
actually prepared you for actually dealing

with it very well.’’ (GP11, female, age 51)
Implicit teachings ‘‘In the general medical disciplines once
someone looks that there is no hope,
basically you just leave . . . really, the senior
doctors just lost interest and moved on.
Maybe as an intern you had to deal with the
issue of helping someone with symptoms of
dying, but the senior consultants and
everybody lived on the cases where there
was still hope of achieving something for the
patient.’’ (GP4, male, age 61)
From experience ‘‘I think that as doctors get older and have
more personal experiences with death
through family and friends, particularly
through close family members if that should
happen, then it does increase, the
understanding of what patients are going
through and I think that it does help in some
circumstances’’ (GP7, male, age 56)
As indicated by most of the GPs, it was their experience with

death that influenced how they deal with dying and death. The
experience included both personal exposure to death of a family
member or a friend, but it also included their professional experi-
ences. GPs recognized that what they learned from experience is
usually opposed to what they learned while being in medical
school.
DEATH BELIEFS
GPs’ concepts about death were defined from a personal per-
spective that was usually developed well before their medical train-
ing. In this sense, studying medicine did not contribute to changes
in their perspectives about death. Their beliefs and the meaning of

death were more related to their religious or spiritual point of view.
The participants also emphasized that they do not impose their
beliefs on their patients and that if a patient wanted to explore
different alternatives, then they would be there to help them with
honesty and respectfulness.
For my non-Christian patients, I really let them approach me about what

they want to talk about. I try and open up the conversation to include spiri-
tual things but I hope I’ve never pressured in any way. If they enquire me
as to my spirituality, I would share it with them. But I make it quite clear
that everybody has to go down their own path. (GP2, female, age 56)
Appraisal of the Death Situation
Appraisal of the death situation was an important process that

enabled the participants to make the death more acceptable. The
following are some of the factors related to the appraisal of
the death that participants frequently reported in the interviews
(see Figure 2).
TIMELINESS
The timeliness of death was one of the most important attri-
butes for the study GPs to assimilate the death of their patients.
Therefore, deaths that occur in the elderly, or after a very long ill-
ness where many treatments have been tried, can be easier to
understand. However, sudden deaths in the elderly or in the young
could be experienced with major distress.
I certainly have been upset when patients have died unexpectedly and I
have felt different emotions, but with the people that I have looked after
in the terminal phase of the illness, when you know that is going to happen,
I don’t feel profound sadness. It is usually a feeling of relief and that we
have taken this journey together and we got there, and you feel content that
it is now over for the family. (GP8, female, age 51)
FINALITY OF THE DEATH

The participants expressed that another factor that makes
death more comprehensible is when they have heard from their
patients that they have completed what they needed to do, and that
the patients have been able to achieve different goals as they go
through their journey. The finality of the death means that GPs
are able to witness the process in which patients find some closure
and are able to let go. When this occurs, it is easier for the parti-
cipants to make sense of that patient’s death and to learn from their
experience.
It was said you were going to die, it is just a matter of how long it will take to
get there, and whether you could get things in place like making sure that
you saw your daughter for the last time. Whatever it is, making sure you get
to do it and as long as you have done that, you have had, I guess, a good
death. (GP9, female, age 30)
SELF-EVALUATION
Another aspect that was salient in the interviews and that
allowed the study GPs to adapt to the death of their patients was
the evaluation of their performance, and if there was anything that
was not done that could have been done. Usually, this is reported
in the literature as guilt, and that was how it was initially inter-
preted and coded here. Although the participants would use the
word guilt, they would refer to it as an example, more for its
availability in their memory, but not strictly as the experienced
emotion. For example, in the quote below, the participant refers
to a ‘‘sort of guilt,’’ not guilt itself. Therefore, on further inspection,
it was evident this was a self-evaluation more than guilt itself.
I feel quite sad, quite anxious, sometimes it is sort of tied up with hoping
that I didn’t miss anything, going back to what happened to see if there
wasn’t something that I could have worked out earlier, it is unusual that that
happens, so it is that sort of guilt that I should have found something earlier,
but it is also trying to get the right doctor for them and the right treatment
for them. (GP11, female, age 51)
SELF-IDENTIFICATION
Four of the interviewed GPs mentioned that in some occa-
sions, the most difficult deaths to assimilate were those where
GPs could identify the patient with someone of their own family.
If it is somebody that reminds you of your grandmother, you might want to

call your grandmother and tell her that you love her and tell her to look
after herself. And if it is someone who reminds you of your dad, it is the
same thing. So, it makes you sad and it makes you really value your family
a lot and want them to stay well. (GP9, female, age 30)
DEATH AWARENESS
The awareness and anticipation of death allows GPs to be
prepared to deal with the death of their patients. In contrast with
other deaths that occur suddenly, the benefit of deaths that happen
over a prolonged period of time is that GPs can prepare, so that
by the time the patient dies, their emotional reaction is more
balanced.
We [the doctor and the family] had plenty of time to grieve because we
really knew . . . So if you are dealing with people who are dying, let’s say
of cancer, where it is a long process, then you go through that, anyway,
you go through all the grief. So, by the time they die it is not that bad,
and that’s with the majority of patients. (GP6, male, age 60)
Discussion
GPs’ encounters with dying persons occur not only at the moment
of death, but begin from the moment when death can be antici-
pated. The Journey with the Dying encapsulates the experiences
of GPs when confronted with the death of their patients.
Drawing together the categories developed during the analy-
sis, the emergent model shows that the Journey with the Dying
comprised five stages that describe the GPs encounters with death.
The stages were accompanied by salient emotional reactions and
general coping mechanisms that GPs used to assimilate their
experiences of death. In the process of assimilation, the appraisal
of the death situation was crucial for their response. The major
factors included in this latter category, were the timeliness of
death, the finality of death, the evaluation that GPs make of their
performance, and the awareness of death. The Journey with the
Dying was also influenced by an array of contributing factors such
as professional identity, learning about death, and death beliefs.
The model acknowledges GPs experiences mostly with patients
with chronic life-threatening illnesses, because those were the most
common experiences with death that GPs shared and that they
usually find in their medical practice.
The results suggest that GPs experience the grief of their
patients’ deaths from the moment of death as a prognosis. In grief
literature, the acknowledgment of death is called anticipatory
grief, and it has been associated as a protective factor because
individuals can use the moment to get ready for the loss. On the
other hand, it has also been associated with guilt, because when
the grieving process starts while the dying individual is alive, there
might be lack of response in the moment of death and the sub-
sequent days (Worden, 2008). Thus, GPs and other medical doc-
tors who are involved for a prolonged period of time with a
dying patient can start processing their grief before the death itself,
so that at the moment of death its impact is diminished. In contrast
with other contexts, GPs would have the opportunity to assimilate

the death from the early stages, as opposed to other acute care con-
texts where the contact with the patients and the patient’s family
may be minimal. For example, Baverstock and Finlay (2008)
reported that medical doctors in hospital settings when confronted
with the death of a child carry unresolved feelings of grief in spite
of their coping mechanisms. Redinbaugh et al. (2003) found that
hospital physicians were more vulnerable to emotional responses
of loss when the contact with the patients was for a longer term.
These findings are in contrast to our own results, which most likely
reflect the contact with the patients in a primary care setting.
Another manifestation of grief that GPs experience is disen-
franchised grief. The first encounter that many GPs had with death
was often as medical students. In those situations, GPs described
the need to hide their emotional reactions. Therefore, their grief
responses were disenfranchised from the very first moments of
their career. The professional identity of GPs that was described
by the participants in this study, and that enabled them to work
assertively, is shaped from their early years in medical training
and has a significant impact on how they approach dying and
death. Physicians learn to avoid emotions because from their first
experiences these responses are forbidden; their mentors did not
open a space for them to know that their feelings were adequate.
Thus, medical doctors’ grief is disenfranchised from their first
exposures and they incorporate this as a professional truth, where
it is unacceptable to display emotions. The mainstream view in
medical culture tells physicians to avoid their feelings, and those
teachings are engrained in them.
The question is whether that ‘‘objectiveness’’ is serving a posi-
tive purpose. Rousseau (2003) explained how this view became
accepted in medicine as the excuse to force medical doctors to
maintain clinical objectivity, professional distance, and neutrality,
and in that way allowed them to work in the ‘‘best interest’’ of the
patients. However, this had an adverse result; both patients and
medical doctors were depersonalized. If physicians were encour-
aged to share their emotions, they could be more open about their
feelings and be able to offer a care that feels right. The question is
whether it would be against the professional ethos to show that
sensitivity.
Another characteristic of the Journey with the Dying is that GPs
have the chance to follow-up in the bereavement stage with other

family members and that is a positive experience in the midst of
the most difficult tasks of their job as medical practitioners. The pro-
fessional relationship does not end with the death of the patient but
continues with the family. This extended contact with the extended
family may convey resilience, which is absent from other medical
contexts. It is noteworthy that the GPs in this study did not think
they were taught appropriately how to deal with death and dying.
Both in the implicit and explicit contents of their teachings, there
were factors that reinforced the medical doctor’s rejection of death
in the pursuit of preserving life at all costs. These findings coincide
with other results of research with medical students in the acute care
context, where students and residents believed that they needed
more support and education about their own emotional responses
(Jackson et al., 2005; Moores et al., 2007; Ratanawongsa et al.,
2005; Redinbaugh et al., 2003; Rhodes-Kropf et al., 2005). Accord-
ing to Ratanawongsa et al. (2005), medical students’ attitudes and
behaviors toward the end of life are strongly influenced by senior
attendants and residents. If it is experience and exposure to death
that teaches about death, it becomes important that students and jun-
ior physicians are effectively mentored in primary care to deal with
death and their grief in this unique context. Hospitals may not be the
best place for future primary-care medical doctors to learn about
death, because here care seems to be concentrated on the living.
The younger participants had different narratives regarding
telling patients about death. Although more experienced parti-
cipants are aware of the difficulties of the task, the younger parti-
cipants believed that they were blamed as the bearers of bad
news. This is consistent with the results found by Dickinson, Tour-
nier, and Still (1999) who found that after 20 years of practicing
medicine, medical doctors changed significantly their attitudes
toward the care of the dying.
The frequent exposure to death and the dying can have a sig-
nificant impact on a medical professional’s well-being. Therefore,
the coping mechanisms that they use should be helpful in amelior-
ating their emotional responses. Among the various coping
mechanisms mentioned by the GPs, the use of alcohol is worthy
of consideration. The GPs who disclosed using alcohol did so casu-
ally, when combining it with other adaptive responses, like talking
with friends or colleagues. Thus, they did not seem to rely on
substances as coping mechanisms and thereby disregard the

importance of managing their emotions. Furthermore, from a con-
textual viewpoint, according to the National Preventative Health
Taskforce (2008), in Australian contemporary society alcohol
serves the purpose of being a ‘‘relaxant’’ (p. 2); additionally, drink-
ing alcohol is regarded as ‘‘intrinsically part of Australian culture’’
(p. 2). This implies that, in Australia, the use of alcohol to reduce
stress would not be viewed as negatively as it is viewed in other
contexts.
However, in those cases where drinking and the use of other
substances are the only coping mechanism, and may even be con-
sidered abuse at times, it is important that GPs and other medical
doctors find more adaptive responses to go through their emotions.
For example, Meier, Back, and Morrison (2001) emphasized the
need for physicians to examine their feelings and to address them.
They suggested a four-step model that includes: (a) naming the
feeling, (b) accepting the feeling as normal, (c) reflecting on the
emotion to gain perspective of its possible consequences, and (d)
discussing the feeling=situation with an entrusted colleague. The
use of unhelpful coping mechanisms may lead to mental health
problems such as depression, substance abuse, and ‘‘burn-out’’
(Meier et al., 2001), and in other studies being a GP has been asso-
ciated with a high risk of suicide (Hawton, Clements, Sakarovitch,
Simkin, & Deeks, 2001).
Strengths and Limitations
The aim of this study was to understand the experiences of GPs

with dying and death; therefore, a qualitative approach was the
most suitable methodology to answer the research question.
According to Murphy and Dingwall (2003), the strength of quali-
tative methods resides in their potential to describe, understand,
and explain the studied phenomena. The process of qualitative

research is acknowledged as flexible, therefore allowing the
researcher to incorporate unexpected factors or issues that emerge
in the interactions with the participants and in the analysis of their
contributions (Murphy & Dingwall, 2003).
The nature of the method used for the study and the analysis
of interviews places some limitations on the generalizability of the
findings and of the model developed. Because the study only
explored experiences within the context of primary care, these

findings cannot be extrapolated to other medical settings. With
regard to the sample characteristics, because most of the parti-
cipants were part-time practicing medical doctors, this might have
had an impact in their outlook and exposure to death. Another
limitation of the sampling technique might be the self-selection
bias, where only those medical doctors confident in their reactions
to death might have offered to be interviewed. There is also the
potential for social desirability bias in the responses given by the
participants; however, the participants did not seem uncomfortable
with the interview topic. Further, the interviewer was non-
judgmental and the GPs were reminded of the right of confidenti-
ality. In relation to the potential for researcher bias, the audit trail
provides detailed information of the handling of the data and its
analysis. In addition, the researchers did not have a medical back-
ground, so there were no expectations from or comparisons with
personal experience.
Within these constraints, however, the results were indicative
of the way in which GPs approach and deal with death in their
daily practice. Their overall experience with dying persons is
satisfying as long as certain conditions occur, and being able to
recognize the good aspects of their job seems to be a protective
factor.
Conclusions
The experience of death described by the GPs in this study is dif-

ferent from that reported by medical doctors in acute care settings.
For example, guilt has been found to be associated with withdrawal
from the patients’ care (Serwint et al., 2006), which was not found
in this study. This might be because those medical doctors in the
hospital context have a different relationship with the patients
and might not be present for the whole trajectory of the Journey
with the Dying.
The five phases of the Journey with the Dying identified here
show the different adjustments and appraisals that GPs undertake
to comprehend and to be able to work in the presence of death.
Defining their experiences in terms of phases is useful to appreciate
that GPs’ involvement with death extends to more than just the
aftermath, as it has usually been explored in most of the literature.
Although death education is still permeated by the underlying

medical culture that rejects death (Kaufman, 2005), medical stu-
dents require ways to incorporate coping mechanisms to adapt
to the death experience. Teaching medical students about death
by using the metaphor ‘‘Journey with the Dying’’ may help young
GPs to make sense of death, whereas more experienced GPs may
find this useful as they encounter death in the future as part of their
professional practice. Another important attribute related to how
medical doctors experience death and that is still missing in most
literature is physicians’ grief responses. Normalizing the expression
of grief of medical doctors might be a way to allow the experience
of emotions that for a long time have been shunned in medicine.
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This article was downloaded by: [North Dakota State University]

On: 02 November 2014, At: 08:54

On the Journey with the Dying:

To link to this article: http://dx.doi.org/10.1080/07481187.2011.553315

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ON THE JOURNEY WITH THE DYING:

Discipline of Psychiatry, Royal Adelaide Hospital, University of Adelaide,

A grounded theory study was undertaken to understand how general practitioners

Medicine and death have a close relationship. Whether preventing

Received 12 September 2009; accepted 16 June 2010.

research on how physicians react and cope with death remains

fronting death, less research has focused on health professionals’

called the ‘‘informal or hidden curriculum’’ (Rhodes-Kropf et al.,

(2005) concluded that ‘‘students view the medical system as ignoring

‘‘continuity of patient contact’’ and the fact that there is a relation-

missed in most grief and bereavement research (Kaplan, 2000, as

The study drew on the principles of social constructionist

inductive methodology to the creation of a theory, grounded

Human Research Ethics Committee.

The interviews were all conducted and transcribed verbatim by the

TABLE 1 Participant Demographics

Characteristics of the sample n %

any significant nonverbal behavior and her reflections and feelings

education in end-of-life issues, the discussion of death and its

FIGURE 1 Interview guide.

did not want to interrupt the interview, the interview continued

Transcription of the interviews and the first stages of analysis

The analytical approach focused on developing an understanding

At this point, the researchers presented the main results to the

The findings are presented in three sections. The first section is

A Journey with the Dying

The death journey was a metaphor that appeared frequently in the

The repeated use of this metaphor, and the GPs comments

FIGURE 2 A grounded theory model of general practitioners experiences with

was accompanied by an array of different emotional responses,

PHASE 1: PRIVATE ACKNOWLEDGMENT OF A LIFE-THREATENING ILLNESS

Emotional reactions. The emotional reactions that medical doc-

ation’’ section on self-evaluation).

PHASE 2: COMMUNICATION OF THE DIAGNOSIS TO PATIENT AND FAMILY

Emotional reactions. At this stage, GPs’ feelings are varied in

PHASE 3: CONTINUITY OF CARE AS A TRANSITION PHASE

Emotional reactions. In this phase, GPs have to let go of the

PHASE 4: THE MOMENT OF DEATH

one of actual relief for the family.(GP8, female, age 51)

Emotional reactions. The reactions toward the moment of

Emotional reactions. GPs’ accounts of their commitment with

handling these situations (see Table 2).

Contributing factors were other aspects of the GPs’ experiences of

TABLE 2 General Practitioners’ (GPs’) Coping Mechanisms

Coping mechanism Example

in the way the participants experienced the deaths of their patients.

This category comprised all the characteristics that the GPs

1. Distancing from emotions and attachments, where eight medical

TABLE 3 General Practitioners’ (GPs’) Professional Identity

5. Keeping boundaries was related to the different attitudes that GPs

LEARNING ABOUT DYING AND DEATH

TABLE 4 General Practitioners’ (GPs’) Learning About Dying and Death

Explicit teachings ‘‘Right through we talked about emotions. In

actually prepared you for actually dealing

As indicated by most of the GPs, it was their experience with

in their perspectives about death. Their beliefs and the meaning of

For my non-Christian patients, I really let them approach me about what

Appraisal of the Death Situation

Appraisal of the death situation was an important process that