American College of Physicians: Internal Medicine — Doctors for Adults ®

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A hard lesson: coping with the death of a special patient

Talking about patient deaths can help residents weather what can be one of the toughest parts of medical training

From the April ACP Observer, copyright 2004 by the American College of Physicians.

By Alison McCook

Crystal N. Wiley, ACP Associate, vividly recalls the patient death that most upset her. The woman was in her late 60s, very ill with lung disease and extremely anxious. She persuaded Dr. Wiley, then a first-year resident with the primary care internal medicine residency program at New Haven's Yale University, to sit with her through the night.

Between filling out paperwork and checking in on other patients, Dr. Wiley talked with the patient about the woman's fears of illness and death. Then the patient, who was white, turned to Dr. Wiley, who is black, and confided something she hadn't told many others: She had given birth to a biracial child—and then, because she didn't have the means to care for it, watched social services take the child away.

"We shared this exchange about race relations, stuff that was so amazing that I don't even know if her family knew," Dr. Wiley said.

A few days later, when Dr. Wiley returned to the hospital, she headed straight for the woman's room, only to find another patient there instead. She learned that the woman she had connected with had died the previous night.

"I was completely devastated," she recalled. "That was definitely the hardest death of a patient I've ever experienced."

Dealing with feelings that arise when patients die can be one of the most challenging tasks young doctors face during their training. Residents may feel frustrated with others' end-of-life care decisions, guilty for not uncovering a hidden diagnosis or just plain sad that they won't get another chance to see a person they've grown to enjoy.

Coping with these feelings can be especially tough given the time constraints residents face, but doing so is an integral part of medical training. Discovering strategies to help you deal with your emotions and continue to care for other patients is key.

Connecting with patients

Patient deaths can be particularly difficult when you become friendly or close.

A study in the July 26, 2003, British Medical Journal found that physicians, on average, rated the emotional impact of a recent death of one of their patients as 4.7 on a scale of zero to 10, with 10 representing a particularly intense reaction. But Robert M. Arnold, ACP Member, one of the study's authors, and his colleagues learned that physicians have a much harder time coping with a patient's death when they have been caring for that patient for a longer period of time.

Dr. Arnold, who is professor of medicine at the University of Pittsburgh, added that residents are sometimes surprised by how close they can become to patients in a relatively short period of time.

Although bonding with patients can make coping with their deaths extremely difficult, Dr. Arnold said that residents shouldn't let their fear of grieving hold them back from making connections.

"Much of what makes medicine worthwhile over the long haul are the relationships you build with your patients and the connections you make to them," he said. "Being there for them means that, to a certain extent, you're going to be vulnerable."

Taking care of yourself by coping with your feelings after a patient dies is extremely important, both for you and your patients. Just as residents wouldn't consider not calibrating or washing a tool used to measure hemoglobin, Dr. Arnold said, they should dedicate the same attention and care to their own well-being.

"Be open to those emotions," he said. "Realize they are OK and normal, and not to be ignored."

Questioning yourself

Some residents struggle with the deaths of particular patients because they think a patient's end-of-life care has been less than optimal. They often find it hard to accept that a patient spent his or her last days undergoing a series of ineffective procedures and exams.

Many residents harbor guilty feelings that they are somehow at fault for a patient's death. In the vast majority of cases, however, these fears are completely unfounded, said Susan Dale Block, MD, a palliative care physician and psychiatrist at Boston's Dana-Farber Cancer Institute and Brigham and Women's Hospital.

"It is very common for inexperienced doctors to believe themselves to have contributed [to] or be responsible for a death that is actually due to an inevitable disease process," Dr. Block said.

Even experienced physicians can feel guilt over how they handled the last days of a patient's life. Dr. Block, who has been practicing for 27 years, said she recently treated a patient who wanted to discuss her fears about dying. When Dr. Block visited her before going out of town, however, the patient was too sedated to talk about those fears.

The patient died while Dr. Block was away, and they never had a chance to have that conversation. "I felt like I had let her down," she said. She noted that talking with people on her team and sharing memories of the patient helped her realize that it was bad timing, not bad care, that kept her from respecting the patient's last wishes.

Sometimes, residents will feel guilty if a patient dies after being handed off to someone else's care. Robert S. Crausman, FACP, a former residency program director at Brown Medical School in Providence, R.I., recalled how terrible he felt during his second year of residency when a patient died while under the care of the resident on call. "I felt guilty that I wasn't there all night long," he said.

Residents can be particularly troubled by the notion that they might have prolonged a patient's life if only they had uncovered some insight or identified some obscure treatment. Ahmad J. Abu-Halimah, ACP Associate, for instance, recalled how guilty he felt when a patient died of a neurological disease before he could discover the underlying cause of the patient's condition.

For three months before the patient died, Dr. Abu-Halimah—who is completing an internal medicine residency at Memorial Hospital of Rhode Island and Brown Medical School—said he became "preoccupied" with his patient, "thinking about his disease and his condition every day, trying to find a reason, trying to find a treatment."

Carrying those feelings of guilt can be an incredible burden for young doctors. Because most deaths are largely unpreventable, Dr. Block said she encourages residents to speak openly about their concerns, so others can reassure them they are not to blame.

Dr. Crausman, now an associate professor of medicine at Brown Medical School and a practicing specialist in internal medicine, geriatrics and pulmonary medicine, said he dealt with his feelings of guilt by discussing them with a mentor. And Dr. Abu-Halimah was comforted when he raised his fears with the patient's widow. "She told me, 'You've done everything you can,' " he recalled, "and I started to realize that."

For many young doctors, losing a patient reminds them of the boundaries of their abilities—or of even more profound limitations.

"At a deeper level, death brings into sharp relief a physician's own mortality, that this will be us someday," said Auguste H. Fortin VI, ACP Member, assistant clinical professor of medicine and director of the psychosocial curriculum for the primary care internal medicine residency program at Yale. "And that can be difficult to deal with."

Finding ways to cope

Lori Wiviott Tishler, MD, a primary care physician at Boston's Brigham Internal Medicine Associates, said that when she talks to young physicians struggling with their feelings about death, she first tells them it is alright to feel something when a patient dies.

She also tells residents and medical students that they don't have to grieve for every patient. You do not have an opportunity to get to know every patient equally well, and some will touch you more than others. "Sometimes [residents] don't have feelings when patients die, and that's OK, too," Dr. Tishler said.

You also shouldn't worry that allowing yourself to feel grief for one patient will take you away from the patients who still need you. Dr. Abu-Halimah, for instance, found that dedicating himself to the patient who had neurologic disease, and then allowing himself to grieve when that patient died, inspired him to work even harder for his other patients.

If you think an attending can help you cope with your feelings, feel free to pull that person aside and ask for help, said Dana-Farber's Dr. Block. "It would be great for interns and residents to take the initiative, if the attending doesn't."

Who you talk to about your feelings is up to you, as is the decision about whether to share your feelings with dying patients and their families. Pittsburgh's Dr. Arnold, for one, said that he has allowed himself to cry with patients, and he said he believes it has contributed to their care. "It shows that you're there and you're present," he said, "and that you feel their sadness."

If you don't feel like talking about your feelings or the right people aren't available, it may help to maintain certain rituals of your own. If you have not yet discovered what works best for you, consider asking more experienced physicians what they do in a similar situation.

When Dr. Arnold realizes one of his patients is about to die, he said he tries to sit with that person for a period of time, acknowledge in his mind that he may not see them again and say a silent goodbye. Dr. Fortin said he tries to take the time to attend a special patient's funeral or write the family a condolence letter.

Dr. Tishler said she keeps a list of the patients who have died, as well as some information about them. She also knows of colleagues who collect obituaries or keep files filled with names and memories of favorite patients. And Dr. Wiley said she maintains a journal as an emotional outlet and often relies on her spiritual beliefs.

A few months after his patient died, Dr. Abu-Halimah found himself in the town where the funeral had taken place—and said he felt "very comfortable" stopping by the patient's grave. That final gesture helped him put aside his troubled feelings and accept that he had done everything he could to uncover the cause of his patient's disease. His purpose in making that last visit, he said, was "to show my patient that I am sorry for what happened."

Alison McCook is a freelance writer in Brooklyn, N.Y., who specializes in health care.

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Training programs now help residents take some time to grieve

Although experts say that talking about your feelings after a patient dies is essential, finding the time and support you need to do that can be all but impossible for many residents. According to Auguste H. Fortin VI, ACP Member, when a patient codes and dies, teams "rarely" pause to reflect on the loss of life but immediately resume work instead.

A study in the July 26, 2003, British Medical Journal found that less than one-quarter of interns and residents felt their attending physicians were helpful when coping with a patient death. And in an as yet unpublished study, Jennifer E. Rhodes-Kropf, ACP Member, and her colleagues at Montefiore Medical Center in New York found that 63% of the deaths deemed "most memorable" for medical students received no discussion by their teams. Of the cases in which the death was discussed, 40% of the conversations focused solely on the medical aspects of the case.

While doctors young and old may sometimes prefer to not dwell on the emotions that arise after patients die, it is important to take some time to think over what has happened, said Robert S. Crausman, FACP, former residency program director at Brown Medical School in Providence, R.I.

"It is certainly within the resident's ability to pull out for a minute or two," Dr. Crausman said. But coping with the death of a close patient, he acknowledged, "takes more than a minute, and this is where the program faculty and the institution are most important."

Physicians in the internal medicine residency program at Boston's Brigham and Women's Hospital, for instance, complete a required series of grief rounds during the oncology service. Approximately once every other week, interns sign out their beepers to residents and gather to discuss the emotional issues that arose while caring for dying patients. Typical topics include questions about a patient's end-of-life care, better ways to talk to dying patients and their families, and how to process their own reactions to death.

Psychiatrist and palliative care physician Susan Dale Block, MD, who helps lead the program, said that she and her colleagues have not yet systematically evaluated the benefits of grief rounds. She noted, however, that she has gotten positive "informal feedback."

At Brown Medical School, Dr. Crausman has organized seminars and yearly retreats to allow residents to discuss their feelings about patient care. He also instituted a support group for young doctors to talk about issues they were facing, including coping with patient deaths. Currently, the intern support group is in its sixth year, while the intern retreat is in its tenth.

And Dr. Fortin, assistant clinical professor of medicine at New Haven's Yale University, said he helps facilitate a support group for interns in the primary care internal residency program. During the first few sessions, many interns want to talk about their feelings related to a patient's death. "The first death is a major topic among interns in our group in the summer," Dr. Fortin said.

Having an institution publicly acknowledge the importance of coping with death helps residents do the same, said Crystal N. Wiley, ACP Associate, a second-year resident at Yale. "If it's built into the structure of programs," she said, "I think people will know that [institutions] are not just paying lip service. They will be more willing to come forth to talk about it."

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