Content warning: This post may make you remember.
I remember the first time I saw a child die in front of me. It was twenty years ago. Or was it yesterday? The memory is just as fresh. It was, as most deaths in the emergency department are, unanticipated and unexpected.
The high pitched beep-beep-beep coupled with the disembodied voice from my pager informed me that a paediatric trauma was coming in. There were no details. It would arrive in ten minutes. I was the orthopaedic SHO. My job was to… Well, I didn’t actually know what my job was. It turned out that it wasn’t to look after broken bones. It was to bear witness.
Do you remember the first time you saw a child die? Do you remember the silence that followed the CPR? Do you remember the noise, that god-awful indescribable noise, that the father, usually so quiet, so strong, made as he saw that his beloved child was dead?
I am sure you do. Because you are human. Because you care. Because you bore witness too.
Unlike deaths in the ICU or on palliative care, death in the paediatric emergency department is uncommon. Our place of work is a place of distraction with bubbles and magic tricks. It’s a place where most children are well and the tattered spectre of death does not lurk. Until unbidden and unexpected, it peers over your shoulder at the small, greying bundle of someone else’s dreams.
This child was not yours. But still, you grieve.
What is grief?
Sometimes, it is easier to describe what grief is not. Grief is not depression. It is not a mental illness. As Johann Hari explains in his book, Lost Connections, grief is a completely normal response to very abnormal (in our case) circumstances. People who grieve feel set adrift, unable to sleep, to eat, to concentrate. They may not want to talk to anyone. They may be tearful, all of the time. And whilst these symptoms sound a lot like a mental disorder – depression – they are not. This is grief.
This post is not about the grief the parents feel, but the grief we feel, being mindful that the patient and their family is at the core of everything.
Are you allowed to cry for patients?
Tears are the normal biopsychosocial response to suffering. So why, then, do we feel we need to hide our tears? Perhaps, as Angoff (2001) suggests we fear appearing ‘unprofessional, weak, or emotionally unstable.’ In the moment, we are supposed to be there for the patient. This grief, this suffering, is not about you. It is about them. Over time the burden of this emotional labour weighs heavy. Many hard years of dealing with the suffering of others can add to our own burn-out making us complicit in our own suffering.
You could, of course, take the alternate view that crying is an overt display of empathy and compassion and, as such, should be lauded. Indeed, according to Wagner et al. (1997), 76% of nurses, 57% of doctors, and 31% of medical students have cried in the workplace. We cry, according to Kuluku and Keler (2006), to unburden ourselves and alleviate our own suffering.
For healthcare workers there appears to be little overlap in the Venn diagram between professionalism and empathy. You may be either professional or empathic, but not both. But for patients? They require you to be both. They need to know that this death is not just one more that you are going to add to your slowly growing graveyard. They need to know that you care, that you are not just some mindless automaton.
My grief is not greater than yours, or any less, because I do not shed a tear.
How do we cope with death?
If we make the fundamental assumption that it is okay to cry, to grieve perhaps, then should ‘good’ grieving be a part of our informal curriculum? When Chew et al. (2020) interviewed a group of student paediatric nurses, they painted a spectrum of emotions. Many felt emotionally scarred by witnessing death. They felt overwhelmed with no real idea how to process things. These feelings were coupled with a profound sense of self-blame. They felt guilty that they had not done enough, that if they had only spoken up sooner then things would be different. They chose to cope by either engaging, and talking with friends, family and peers, or disengaging and distracting.
Is it the same for doctors? A lot of the literature focuses on physicians that are exposed to death on a more daily basis – oncologists, palliative care physicians, intensivists. Davies (2016) suggests that maybe, just maybe, these doctors become used to death, if such a thing is possible. They experience the loss of a patient then pack it away into a little box. They become experts at compartmentalisation and that box then gets packed away, like all the others, in the warehouse of their mind. Unable to acknowledge the grief they feel it leaks out over time. They become impatient, irritable, exhausted. They begin to doubt themselves and their judgement.
The grief experience seems to be harder on younger staff and there are probably many reasons for this. It’s not that older clinicians have become desensitized to human suffering, but perhaps younger healthcare workers reflexively self-identify with grieving parents. They imagine what it would be like to have their own children lying in front of them and, for that, they suffer all the more. Whilst the Stoic, Seneca the Younger, would suggest premeditatio malorum – the premeditation of evils (such as contemplating the death of one’s child) – can make us more resilient, unbidden thoughts of the death of one’s children do not, and never will, breed strength.
If age impacts our death experience, so then, does our gender. Healthcare workers that identify as female are more likely to experience complex grief reactions than their male counterparts. A lifetime of cultural inculcation of the traditional norms of motherhood leads to both more intense and more prolonged grief.
The grief we feel is compounded by our need to prioritize the best patient care over our own self-care. Instead of looking after ourselves, we look for distraction. We don’t move through the Kübler-Rossian stages of denial, anger, bargaining, depression and finally acceptance. Instead, we leap, often, to anger or depression, then detouring via self-pity city before finally reaching acceptance.
The BriefCOPE tool has been used by researchers to look at how we do actually cope. It explores domains such as positive reframing, religion, the use of emotional support, self-distraction and venting to tease out an individuals adaptive, and maladaptive, coping strategies. We use problem-based, emotion-based or avoidant strategies to deal with grief.
A lot of medics look at coping with the loss of a patient as another problem to be solved, another task on the to-do list. Prospective training is rare, so actively coping with one’s grief means accessing external resources at the time of need. By positively reframing one’s view of a stressful situation it can be easier to cope. This is easier in the setting of anticipated or expected death. Those final breaths, when they come, may be positively reframed to signal the end of suffering and pain. This is often not possible in the emergency department where we have had little time to establish a relationship with the patient and their family.
As suggested by Plante and Cyr (2011) doctors and nurses tend to seek emotional support from their work colleagues as they progress down the road to acceptance. They use humour, often dark humour, to deflect or they vent and blame. An emotion-based approach to coping with grief is not good or bad. It just is.
Avoidant strategies are the least healthy. As grief becomes more intrusive the victim might deny its existence and disengage. Alternatively, they distract themselves, throw themselves into new projects or their job. They anaesthetise themselves with alcohol or drugs unable to provide the self-care they desperately need.
How can we cope better?
Death is inevitable. Experience, and time, makes it easier for us to cope if we take the opportunity to reflect. All too often we do not allow ourselves time to grieve. We lurch from tragedy to emergency without the luxury of time to for ourselves. It is important to recognise that grieving for a patient is normal. That crying is normal. That it is okay to be upset. But if it becomes intrusive then that is not okay. We should not pathologise grief, but do we need to recognise when it becomes maladaptive and morphs into something else.
Many of us have received training on delivering bad news to families, and perhaps even some training related to their grief. But very few of us have had any form of training on how to manage our own grief in these situations. As Soklaridis et al. (2018) point out grief training can “help physicians cope with feelings about and responses to suffering, loss and death in a way that improves both physician and patient/family wellness.”
How can we be better?
No matter how intense our grief for our patients is, it is nothing compared to that of the parents. Like us, parents are tortured by their feelings of guilt, of shame, that they could not do the seemingly simple job of keeping their child safe. As Plante and Cyr (2011) eloquently point out “grief overides logic.” Recognising this, it’s important to remember that you cannot coerce a person to feel less guilty. All you can do is acknowledge the injustice and, as Liz Crowe would say, sit in the rubble with them.
The other side
I have been in the truly unenviable position of being on both sides. I have witnessed the death of children of others and I have grieved for the death of my own daughter. I have very strong memories of our time in hospital, of being avoided and shunned, but I’m choosing to focus on the O&G registrar that came to see us. Their job was done, in a way. They had checked the surgical scar and made sure our physical pain was dealt with. Then she sat down, on the end of the bed and said, “I’m sorry,” before her eyes welled up with tears. She sat with us and acknowledged our profound loss, our grief. She didn’t try to justify it. She didn’t ask for us to comfort her. She sat with us, in the rubble of our deconstructed life.
We thought her no less professional for it but we did think her more human.
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