The death of the patient or the analyst while participating in a treatment is an unmitigated catastrophe.
To think about death, potentially one's own, is so unwelcome as to lead generally to a lack of preparation for such tragedies. Such a professional omission can terribly exacerbate what is already a world-class misfortune. Practicing psychoanalysis or psychotherapy without instituting precautionary measures is, in my view, unethical behavior.
The paramount ethical responsibility to the patient is relevant to the complexities linked to the death of either member of the dyad while the treatment enterprise is in progress.
When a patient dies in the course of an ongoing treatment, the impact on everyone is considerable. The analyst or therapist feels a great deal, and not just from the loss of income. Less spoken about is the frustration of therapeutic goals, even objectives both parties have worked toward for years. Questions arise quite promptly, such as whether the analyst should attend the patient's funeral. Most do not, as the funeral is primarily an event designed for family and friends. Any fees due and owing are to be sought from the patient's estate.
How are issues of confidentiality encountered? Our guideline in most jurisdictions is that the information conveyed to the analyst by the patient remains the property of the patient while living and of the patient's estate after death. The physical record of that information is, however, the property of the analyst.
Legally one must have some sort of a “chart.” Its narrative and clinical judgment justify the treatment and the fees for it.
Process notes should be physically separate from the chart described above, whatever their form. They are assuredly no business for family to be privy to. With equal assurance in instances of deceased celebrities, notes may not be fashioned into a publication except with the express approval of the patient's estate. Strictly speaking, all the information pertaining to the patient is covered by the umbrella of confidentiality, even the very fact that the patient ever was undergoing treatment by you.
However difficult it may be for all concerned to cope with the complications attending the death of a patient, they are much less tormenting than what takes place when an analyst in full practice dies. How does this unfold?
Suddenly, with no warning:
This is the worst. Sudden catastrophic collapses put everyone into a dumbstruck condition. Of these, the most tormenting is suicide.
To think about death, potentially one's own, is so unwelcome as to lead generally to a lack of preparation for such tragedies.
In a circumstance of this character everyone is reeling from the shock. The decedent's family have their hands full taking care of themselves and all the details linked to funeral, interment, and other details of family welfare. It does not surprise us that in this hubbub there is little or no concern about the fate of the suddenly abandoned patients. In most such situations no one considers there is any ethical duty to attend to the practice of the departed analyst.
Gradually, providing some warning:
Analysts are like all other people when confronted with the unprecedented challenge of an altered health condition that will most likely conclude life. It is a maximum assault on self-esteem and composure. In one way or another they deny the seriousness of the dilemma, and that denial often takes the form of action, commonly to continue in active practice. They are not yet seriously afflicted, so why stop? It feels better to be busy, so why stop? Interruption will be bad for the patient, so why stop? Besides, the analyst is offering a good demonstration of how to address serious adversity.
There will be time to bring it up when the condition worsens, so why stop now?
A colleague whose condition was serious decided that it would be inconsiderate to inform his patients just prior to their summer vacation recess; he would attend to that unpleasant task at the time of autumn resumption. He did not survive until autumn.
This last illustration highlights that a very significant aspect of the analyst's denial is the failure to accept the fact that illness alters judgment, and that there is a need for the afflicted analyst to consult with an outsider as to what is best to do, for whom, and when. The consultant should not be a personal friend, as such a selection renders a difficult situation even more so.
If the analyst has informed his patient of illness and the prospect of interrupting practice, that analysis has ended, even if analyst and analysand decide to continue to meet.
Why is this so? An essential condition for free association has been eliminated. The patient can no longer feel free to say whatever comes to mind. Associations naturally gravitate to the condition of the analyst but are difficult or impossible to share out of fear of their impact, that they may make the analyst sicker. Working, it is assumed, helps the analyst feel better, or he would not do it. The patient and analyst have actually switched positions, the patient now taking the analyst as patient. Nothing—like leaving—is to be done that may distress the analyst and possibly hasten deterioration and death.
Moving to the next stage: The analyst has died, and the family is in no position to be concerned about patients, with whom they have no relationship. What are they to do, and who will help them?
Stephen K. Firestein, M.D., is past treasurer of APsaA and IPA. He is training and supervising analyst at the New York University Institute and clinical professor in the Department of Psychiatry at NYU Medical Center.
A number of years ago, in the wake of the death of a colleague, a small committee at the New York Psychoanalytic Society constructed a document called “The Professional Will.” It was, of course, fated to be forgotten until some years later I rediscovered and somewhat revised it.
Do you have a professional will? You should, and it should be placed where family members will know to look for it. My colleague, Rita Clark, and I urge that every institute and/or society have on file a sealed copy of your professional will, to be employed if the family's copy cannot be found or if there is no surviving family.
She and I are moving toward the recommendation that it be regarded as unethical to practice without a professional will. Here is a sample:
In the event I am unable to continue my psychoanalytic practice because of illness or death, please refer to the following recommendations and requests.
I designate the following psychoanalytic colleagues (at least two, one of whom should be younger than you) to inform my patients promptly by telephone, to cancel appointments, and so to protect my patients against the distress of arriving to find the office door mysteriously locked. I have discussed with these colleagues my wish to list them for these purposes. They have agreed to help and, additionally, to offer to my patients the prompt opportunity for consultation to decide how best to meet their continuing clinical needs.
These colleagues are fully aware, in instances in which the patient is a candidate at an institute, of the need for collaboration with the chair of the Education Committee in arranging for the continuity of analysis. To assist my colleagues with these tasks, the names, addresses, and phone numbers of all patients are listed in the fee account record book kept in my office, and my appointment book indicates those with whom I am currently working. (List colleagues' names, addresses, and phone numbers here.)
My answering machine message should be changed immediately, with wording such as, “Dr. A.'s appointment schedule has been canceled. Please telephone Dr. Colleague at (telephone number) for additional information.” (Experience suggests strongly that this task should be taken over by the colleague and not left as a burden for family members, who understandably are preoccupied with their own distress. They cannot be expected to empathize suitably with the dilemmas of patients.)
On the office front door—just in case—place a note that reads, “Dr. A.'s schedule has been canceled. For further information telephone Dr. Colleague at (telephone number).”
Instruct the doorman, elevator operator, or front desk to say to inquirers, “The doctor's schedule has been canceled. Here is a telephone number to call for more information.”
Keep all my financial records, appointment books, and related records for the duration of the statute of limitations in our state (e.g., six years in New York). If a patient requests substantiation of a claim for insurance benefits and needs a listing of appointments and fees paid, that patient should be asked to repeat the request by letter. The signed letter becomes that patient's authorization for the release of information that is otherwise kept confidential.
As in the case of financial records, keep my clinical records for the duration of the statute of limitations in our state. Some of these records, such as evaluative diagnostic or progress summaries, may be requested by successor analysts or therapists. Only copies may be forwarded to the successor analyst, and only upon receipt of a signed letter of authorization from the patient. The original of the record should be retained.
Hopefully this discussion and the model professional will are sufficiently persuasive to convince you of the correctness and simplicity of these measures for smoothing what otherwise can become a disastrous intrusion into proper clinical care.
The key resistance to attending to this matter is our reluctance to pause in contemplation of the prospect of our own deterioration and death. An ethical concern for our patients' needs that survive us should shift the balance benevolently.
Process notes are a different matter, as they were comprehensible and useful to me alone. They can be destroyed after a relatively brief interval. (They should usually not be shared with anyone, including the successor analyst, unless specific instructions are left to do so. The Committee on Confidentiality of APsaA, after lengthy discussion of the Anne Sexton celebrity case, recommended a statement be published that no posthumous disclosures may be made without the patient's specific prior consent and/or instruction.)
Keep any agreements and copyrights of written works, either in progress or already published. You can obtain advice about these from my colleagues.
If a patient seeks family contacts beyond extending condolences, my standby colleague will furnish guidance concerning such requests.
As to obituary notices, the usual notice inserted in the newspaper by family, the funeral director, or the institute or society is entirely at your discretion.
Please notify the following list of organizations that have been important to me. (List.)
Dues to professional organizations and unexpired journal subscriptions should be refunded in a prorated manner. The journals in my library will list their administrative addresses. You need only notify the organizations and the journals. (List.)
My professional library should be donated to (name of institution). (List designee and second, third, and fourth choices in case the designee does not require additional copies of volumes already owned. I plan to donate mine to my institute library with the proviso that unneeded volumes be sold to candidates and others, the proceeds to go for future acquisitions.)