A post on processing and grieving the deaths we experience as we learn medicine in residency, with tips for handling the debrief after.
A pediatric intern I follow on Twitter led me to write this post today. During your residency you will see death. Sometimes it is in the ICU with a patient who has had a chronic illness, or cancer, and for some of us it is easier to process this “expected” outcome – but not for all of us. And there are many deaths we see that are not expected. In the ER there are those we cannot save after car accidents, gunshots, drownings. In OB deliveries don’t always end with parents holding their new baby, but with grieving. On the floor we see COVID, infections and sometimes death we don’t understand, death without clear cause.
It is incredibly hard to see, to process – and it always hurts the soul. But we’re often expected to keep working, moving, see another patient, finish our work. In my residency within 24 hours of a patient’s death the attending would find time to debrief the team. Sometimes it was the same day, sometimes the next day. But it always happened, even for the ones we expected. There’s no magic formula for this discussion, but the primary goal is not to turn it into an M&M or blame game. It is to acknowledge the emotional injury of experiencing death, the irrational guilt at “not being able to save them” and give the team time to process what has happened.
I tried to find research based resources for this article, and mostly found publications on how to talk to patients about death, not those caring for them afterwards. So, here’s what I remember from residency, for senior residents or new attendings who take on this role.
Five Steps for Debriefing Death
- Acknowledge the emotional injury of seeing a patient die, or of caring for someone who died overnight while you were off-service. Most importantly, NORMALIZE it. This is normal, and not something to be embarassed or ashamed of!
- Let the students and residents express any feelings they have, while guiding them away from M&M type “we should have done ABC procedure” and “if only we had run xyz test.”
- Know what resources are available for mental health support at your program and share these with the residents. Given continued mental health biases, I suggest you send these via email during/immediately after – don’t make them write it down.
- Make it clear that it is okay to mourn your patients, and normal to have a good cry at some point. I also think it’s important to remember not to center yourself in this situation, so a gentle reminder that crying in front of the family can be upsetting to them and if anyone feels they will struggle not to do so don’t force them to be part of that discussion!
- Everyone copes in different ways, but encourage healthier options (watch the movie you always cry during, have some ice-cream, call a friend, journal, rage paint – all generally better than drinking alcohol)
Interns, if you are in a residency that doesn’t do this type of debrief, feel free to share the post with your PD, chiefs and/or attending on service. If you are in a malignant/toxic program that has already proven they don’t care please reach out to the medical community on Twitter (#MedTwitter) for support in the virtual space.
- Patient Death Debriefing Sessions to Support Residents’ Emotional Reactions to Patient Deaths, Juliana Eng, MD* Elizabeth Schulman, MD* Sabrina M. Jhanwar, PhD Monika K. Shah, MD, Journal of Graduate Medical Education, September 2015 – https://medicine.okstate.edu/site-files/documents/gme/jgme-death-debrief.pdf
- Patient Death and Physician Grief, Prarthna Bhardwaj, MD, Insights on Residency Training, July 22nd, 2020 – https://blogs.jwatch.org/general-medicine/index.php/2020/07/patient-death-and-physician-grief/
- Death Pronouncement: Survival Tips for Residents, LUCILLE R. MARCHAND, M.D., and KENNETH P. KUSHNER, PH.D., LYNDA SIEWERT, M.D., Am Fam Physician. 1998 Jul 1;58(1):284-285. – aafp.org/afp/1998/0701/p284.html
- The GRIEV_ING MNEMONIC: A Simple Approach To Death Notification In The ED, Author: Sarah Sanders, MD (EM Resident Physician, PGY-2, NUEM) // Edited by: Kory Gebhardt, MD // Expert Commentary: Kathy Neely, MD, BLOG NUEM Emergency Medicine Residency Educationhttps://www.nuemblog.com/blog/death-notification