Content warning: This post may make you remember.
I remember the first time I saw a child die before 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 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 god-awful indescribable noise that the father, usually so quiet and 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 although these symptoms sound 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 are at the core of everything.
Are you allowed to cry for patients?
Tears are the normal biopsychosocial response to suffering. So why do we feel we need to hide our tears? Perhaps, as Angoff (2001) suggests, we fear appearing ‘unprofessional, weak, or emotionally unstable’ at 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 burnout, making us complicit in our 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 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 you will add to your slowly growing graveyard. They need to know that you care and 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 of 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 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, and 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 and then pack it away into a little box. They become experts at compartmentalization, and that box 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, and exhausted. They begin to doubt themselves and their judgement.
The grief experience seems harder on younger staff, and there are probably many reasons. 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 suffer all the more for that. 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 identifying 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 more intense and more prolonged grief.
Our grief is compounded by our need to prioritize the best patient care over our 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 acceptance. Instead, we often leap to anger or depression, then detour via self-pity city before finally reaching acceptance.
Researchers have used the BriefCOPE tool 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 individual’s adaptive and maladaptive coping strategies. We use problem-based, emotion-based or avoidant strategies to deal with grief.
Many medics consider coping with a patient’s loss 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, coping can be easier. This is easier in the setting of anticipated or expected death. When they come, those final breaths 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 seek emotional support from their work colleagues as they progress toward acceptance. They use humour, often dark humour, to deflect or 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, throwing themselves into new projects or jobs. 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 make 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 for ourselves. It is important to recognise that grieving for a patient is normal. That crying is normal. It is okay to be upset, but if it becomes intrusive, that is not okay. We should not pathologise grief but recognise when it becomes maladaptive and morphs into something else.
Many of us have received training on delivering bad news to families and perhaps some training related to their grief. But very few of us have had any training on how to manage our 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 guilt and shame that they cannot do the seemingly simple job of keeping their children safe. As Plante and Cyr (2011) eloquently state, “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 checked the surgical scar and made sure our physical pain was dealt with. Then she sat 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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