Have clear boundaries
Ollie Minton, Macmillan consultant in palliative medicine, University Hospitals Sussex NHS Foundation Trust, and national end of life adviser, Macmillan cancer support, says, “I don’t think it’s unreasonable to express emotion at work—within reason—and this should include grief. The death of a patient affects everyone in different ways. It’s important to be emotionally intelligent about it, recognise the need to debrief, and find your own coping mechanisms and support.
“Death is part of what I do and the methods I use to separate my professional and personal life are now so deeply ingrained that I’d be hard pushed to explain exactly what they are—except that they work, even and despite the pandemic.
“I also have clear boundaries when dealing with emotionally charged situations and I work with a great team who can be on hand when it becomes too much.
“You don’t have to have known someone for a long time to be invested in them, although perhaps treating someone for a long time builds a relationship that you should be more aware of when they die.
“Our patients are getting younger and younger. I find that when a patient dies who is younger than me or who has children younger than my own it can have more of an impact. That said, it’s often when you least expect it that the emotions and feelings creep in.
“How you deal with the death of a patient is a unique experience every time. For me, achieving what I perceive to be a ‘good death’ for my patients—and having a robust discussion when that isn’t possible—allows me to do what I do.
“I haven’t been to any funerals of my patients but have attended annual memorials and days of reflection and would hope people would do the same for me once my time comes.”
How we support each other matters
Jess Morgan, paediatrician and Dinwoodie Royal College of Paediatrics and Child Health fellow, says, “As doctors we are surrounded by death from the very start of our careers—it’s something we simply come to expect. Yet we rarely acknowledge the emotional impact that it has. There is a collective unspoken grief that we all carry.
“I was a newly qualified doctor when I first experienced the death of a child patient. Afterwards, when everyone else returned to their jobs, I hid in the drugs cupboard and cried. My senior colleague found me. He told me it was unprofessional to be upset and that to survive in the specialty I had to ‘toughen up.’ For years afterwards I felt ashamed that I got upset when children died. Everyone else just got on with it. What was wrong with me?
“Then, one night shift, there was a particularly traumatic resuscitation. The mother’s helpless cries still haunt me, as does the image of the little girl’s inert body. Later in the shift, I caught up with my registrar. ‘That was tough. Really tough,’ he said. ‘How are you feeling?’ With that one simple question, I burst into tears. He hugged me, and then, with gentle kindness, he looked at me and said, ‘Jess, the day you stop feeling like this is the day you need to stop being a doctor.’
“We spend years learning how to break bad news with empathy and understanding, yet too often we stumble across the news that our patients have died by a passing comment or a missing name on a handover sheet. How we support each other, both in the immediate aftermath and the ongoing weeks and months, matters.
“Reflective spaces such as Schwartz rounds have gone some way to helping staff process the emotional burden of care giving, but we cannot confine these conversations just to those spaces.
“By talking and modelling our own vulnerability, we give others permission to do the same. There is also a need to equip health professionals with the skills they require to look after themselves and their colleagues. They need to know when and where to seek more expert support. It’s not shameful or unprofessional to find the death of a patient difficult. It’s human.”
Talk to others who have cared for the patient
Kirsty Shires, salaried GP, GP appraiser, coach, and mentor, West Midlands, says, “As clinicians we may have learnt to switch off our emotions when a patient dies but, as humans, sometimes this isn’t possible. Some patient deaths can affect us more than others, particularly if we’ve looked after the person for a long time. We might need to grieve for them.
“We can give ourselves permission to express our emotions and find a way to say goodbye to that patient. I have only once attended the funeral of a patient and found that I could not contain my tears. I worried that the family would think that instead of being there to support them, they might need to offer me comfort.
“I haven’t been to a patient’s funeral since then, but I know that there are many doctors, nurses, and carers who do attend funerals. I know it meant a great deal to me and my family when some of the carers who looked after my grandma came to pay their respects at her funeral.
“Our patients’ lives matter and they touch us. Our humanity and feelings enable us to care, and sometimes caring hurts. Rituals and routines can help in times of grief. Acts of kindness such as sending a handwritten card to the family, or making a condolence call can be part of this.
“I often find it helpful to talk to other team members who have looked after the patient and in this way we can support each other. Sometimes discussing the patient at the Balint group I attend can help.
“We have to acknowledge the emotional labour of our work and find ways to process it so that we can maintain the compassion which forms part of our professionalism.”
It is normal to feel loss
Jonathan Leach, general practitioner, Bromsgrove, says, “Doctors are human and across our professional lives we see the highs and lows of humanity. We have the privilege of sharing the happiest times such as the births of children or watching a patient achieve a long term goal. We also see some of the most difficult times, and the death of a patient can affect the doctor who has cared for them.
“Many find that it is an unexpected death, often of a young person, that leads to an emotional response around the futility of death or a life unfulfilled. At the other extreme, when there has been a long term relationship between the patient, their doctor, and their family, it can be the death of that patient that most affects us.
“We are human and it is normal to feel a sense of loss. The recognition of this and how we deal with it to allow us to continue, to function, and care for other patients is key.
“Roger Neighbour1 describes ‘housekeeping’ as the final task of a consultation, but it can also be applied when a patient has died—in what state has the previous patient left me, in what state will the next patient find me, and am I in good enough shape for the next patient? Practical aspects may include taking time away from work, talking to colleagues, and at times (with permission) attending a funeral can be helpful. Key is recognising that we are not automatons and have our own emotions and thoughts.”
You don’t have to sacrifice your humanity
Salma Aslam, radiology registrar, East Midlands, says, “Fortunately, as a radiology registrar, the death of a patient is not something I have to face directly very often.
“As someone who may never see the patient I am helping and who doesn’t ‘own’ any patients, dealing with difficult emotions is slightly easier. I still find myself checking up on the patient involved in a road traffic accident who was brought in during my on-call, or the really sick patient in the intensive care unit. But there is something about seeing a patient every day and meeting their family that puts their loss on another scale.
“This is why I have so much respect for oncologists. It is a job I could never do. Of course, there is a professional boundary that needs to exist, but we are people too. I am a very emotional person. Things move me. I cry. I decided early on in my career that that was okay and I didn’t want to sacrifice my humanity for my job, which is one of the reasons I decided on radiology.
“I still think about the patients I cared for during my foundation training. I think about their families. Their grandchildren. Our conversations. Many of them changed my life, especially the patients I met when I worked in a hospice. I believe doctors should and can grieve for their patients. No, we don’t always have the luxury of having a break inbetween a loss and the next thing that needs to be done, but it is certainly okay. It’s part of caring.”