Medical training and practice exposes us simultaneously to the beauty and tragedy of life. As a resident, you are thrown into a strange world in which death will often sit as an unwanted companion in the room with you and your patient. Most of us enter residency entirely unprepared for the experience of witnessing a patient die. Feelings of grief are a normal and often unanticipated reaction for a doctor, complicated by guilt and a lack of validation. Emotions of loss for someone whom we had the responsibility of saving is confusing and extremely uncomfortable, further muddying our internal processing. We are told to believe that because we not a beloved family member or friend, we are not entitled to these emotions. Alternatively, grief can feel too difficult to deal with, hindering our ability to continue the hard work that needs to be done for other patients. Grief can feel non-objective and at odds with our role as an objective physician. In light of increasing awareness about the factors leading towards physician burnout, doctors need a new approach to process grief.
The trauma starts as an intern, when you will have to “pronounce” a patient. It is a job that no one wants to do. As a medical student there might have been some instruction on how to handle patient death, but it becomes reality for house staff. The scenario varies. Perhaps you never met the patient before your call and are now being paged to a really unpleasant task. Perhaps you have been working with the patient all shift, trying to hold back the inevitable and now losing ground. It might be time to let the family know that nothing more can be done and that they need to say their goodbyes. You may have developed a certain attachment to the patient and their family while witnessing the strength and dignity demonstrated during their illness and may not know how to let the patient choose hospice instead of the treatment you propose. Maybe the death comes after a medical error that might have been preventable, and so a sense of terrible responsibility is weighing on you. Maybe this death was due to violence and this person was an innocent victim; maybe this person was the perpetrator. Maybe this person is just like your spouse or parent or sibling or child and this hits too close to home. All of these factors, and others stemming from your past and your current emotional situation, affect a doctor when a patient dies. I encourage you not to ignore this nor suppress these thoughts and emotions.
We grieve too, but differently than the next of kin. A doctor may need to temporarily shelve feelings of loss and grief, compartmentalizing emotions while continuing to serve the patients who remain. However, I want to suggest that pulling those emotions back out as efficiently as possible is critical to healing. Our job requires us to communicate the frank possibility or reality of death; this is a terrible thing to have to do, but it is critical to learn to do it well, with empathy and authenticity. Our ability to be aware of our emotions and manage them healthily informs how we function in our role. Often we are not entirely aware of the impact of our words at these moments, but they are usually remembered by the recipients. Sometimes it goes very poorly, especially when we are still not very skilled; the patient and their family may react in unexpected ways you when tell them the grim news. I once had a patient’s son jump up and scramble over a conference table to attack me during a goals of care meeting. Sometimes impressive emotional strength is demonstrated, and it is the doctor who disintegrates into tears and feelings of guilt. When I was a fellow, one of my patients was admitted to the hospital after travelling many hours for a second opinion. He was barely conscious when the family rolled his wheelchair into the office. Over the course of the next 24 hours he slipped further away, but awoke briefly to tell his wife that he loved her and that the folks in the hospital would help her after he died. He died peacefully about an hour later. I later learned that they lived in rural Texas and had no family nearby; somehow, in his final hours, he had found to strength to reach a hospital and situate his wife in a safe and supportive location. There are innumerable examples that are seared in memory after my 20 years as a physician.
These incredibly difficult end-of-life conversations are to be expected as a physician and they will be upsetting. Accept that but do not make the mistake of letting the difficulty start to harden you. Do not push away the uncomfortable feelings. Miracles and tragedy get mixed up with the mundane: that is the work we do. The end of life is so complicated and confusing that unless you take the time to let yourself think and feel what you witness, you cannot continue to engage indefinitely. I agree with those who insist that a patient or family in the throes of a catastrophic loss may not want or need to suffer the emotions of their physician, but there are healthy ways to manage these very real responses to a witnessed tragedy. Physicians need to process these emotions to use the lessons of our grief and the traumas we experience to develop our skills in communication and empathy to serve our patients and ourselves.
So, I propose a few suggestions for processing our grief as doctors:
- When you have to pronounce a patient, talk to the person whose body is lying in the bed as you confirm the death. Acknowledge the humanity of the person who just passed and let yourself feel a part of the solemn transition that has occurred. At first, this might feel more difficult than self-protective detachment, but I argue that it is healthier. It might feel like you are talking crazily to yourself, but really you are just acknowledging the presence of the patient and letting them know that you care. With any other living patient, you would inform them what you are about to do and talk them through the exam.
- Talk to the rest of the team about the loss. Try to understand what happened and how it impacted the team. Debrief. Participate in morbidity, mortality, and improvement conferences in order to improve the quality of your practice, but not to place blame.
- Send hand written condolence cards. Take a moment and sit down and think of what you want to say to the family that is grieving this death. Reflect on what you learned from this patient and what you can keep as a memory that will help you do better with the next patient. Be sincere.
- Consider a remembrance tradition that can be done individually or as a team to acknowledge the patients who die over time. In our practice, our neuro-oncology team has a time set aside to be quietly contemplative and then read the names of the patients we lost in the interval since our last ceremony.
- Seek out a neutral party to talk to. This can be a professional counselor, the program director, a mentor, spouse or significant other or a trusted friend. Do not ignore your emotions or feel that they aren’t permitted or warranted. If you are still having difficulty processing grief, it is important to find help.
A program director’s perspectives on practical wellness in residency and how graduate medical education leadership can facilitate housestaff resiliency and self-advocacy.