Time enough for tears?

Rounds on Saturday. Twenty-six patients to see. Thankfully the housestaff are working hard and well. Halfway through, I attend — it’s what I do — to a patient with severe lung disease. I ask how things are going, how he’s feeling, if he has worries or fears about the future. The patient starts to cry, quite unselfconsciously, despite being in a four-person ward. He speaks to the need for hope, to believe it is still possible to get somewhat better, and of the sense of guilt that the lung disease is self-inflicted. I listen intently, affirm his grief and attempt to alleviate his suffering: “When people started smoking when you did, no one really knew, and for some people it can be just so hard to quit. But you have.” The tears continued their course down his face, unchecked. I did not search for tissues. A few minutes later, I am thanked for staying at the bedside.

“The other doctor, he walked away when I started to cry, but you stayed. That means a lot to me. It really does.” I leave feeling humbled and grateful.

Tears are tricky though, no question. I saw the movie Alien in the summer of 1980, when I was too young to drive to the drive-in theatre. A motley crew, led by Sigourney Weaver in a breakout role, are trapped in a huge industrial spaceship, hunted by a terrifying alien whose bodily fluids, when spilled, burn through multiple steel decks, very nearly destroying the ship. Clearly projectile weapons are not an option. And let’s hope the alien doesn’t feel sad and start crying deadly, perhaps spaceship-destroying, tears.

I refer to the movie when talking to medical students about tears, tears that most students will both witness and create. They have been taught, they tell me, to be prepared, to make sure the little square box of scratchy hospital tissues is readily at hand.

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“What happens next when you hand a grieving patient or family member tissues?” I ask students or residents. A look of bewilderment usually follows.

“They dry their eyes?”

But do we truly want dry eyes? Of course physicians want and need to be empathetic and caring, but it seems that the act of handing someone tissues is all that is considered essential. When a patient or a family member is searching for tissues, or wiping tears on their shirt or hand, it makes undeniable sense to search for tissues. But I wonder if the unconscious message that is conveyed is that the time for tears is over. Now it is time for dry eyes. But why?

Because tears aren’t caustic or dangerous, not at all. Unlike blood, unlike the alien’s deadly fluids, they are not dangerous, they don’t need to be staunched. Sometimes they cannot be. I vividly remember, from 25 years ago as a medical student on rounds, watching a man convulsing in grief over his wife’s jaundiced body, her abdomen rigid and distended by a liver filled with still-living cancer. I remember being awed at the depth of his grief and love. Her body, I imagined, was as sacred to him in death as it was on their wedding night. He was overwhelmed with grief and tears, oblivious to everything and everyone. To have interrupted to hand him a tissue was not the thing to do; it was emotional to witness his grief, but it was right not to intervene.

At other, less dramatic times, tears are accompanied by an apology, and there is an expression of shame or embarrassment. Most of us, myself included, have “lost it” at some time; feelings of shame and embarrassment are hard. But shame and embarrassment after hearing of cancer, death or disability? When grieving patients or their families apologize for their expressions of grief, I will sometimes state the obvious: that there is nothing to apologize for and that I am sorry for their loss or to have to give them bad news. Surely there is a time to accept grief and tears. If not in the moments that we as physicians accept the privilege of caring for the suffering and the dying, then when is crying appropriate?

It is hard to watch people overwhelmed with grief, but if they accept their own tears, perhaps physicians should as well. It is possible to convey acceptance of grief by watching and waiting for what to do next, or perhaps waiting until the tears have stopped — could it take an hour?

Tears mean different things in different circumstances. A psychiatry colleague perceptively pointed out that for some patients, crying can be a way to avoid talking about issues that cause pain or discomfort. Judgment is required; when facing a grieving patient, it can be hard to know what to do. But before handing out tissues, it is useful to ask oneself: How, and who, are they intended to help?