Death is part of life in hospital. Indeed, half of all deaths in England occur in these hives of activity, where we help many to evade the end for a little longer . Death is such a frequent part of our work in fact, that it can become routine. Last week a man died before we got to see him on our morning ward round. He died some time between having his breakfast and the 9am observations round. He was old, had been unwell for a long time, and his death was expected, although no-one predicted it would be that morning. It caused hardly a ripple. Nurses, doctors and physiotherapists exchanged surprised glances, then shrugged and immediately focused their attention on their next tasks. His death became an admin task, as the junior doctors planned when they would find the time to complete his death certificate, discharge summary, and paperwork for our departmental morbidity and mortality meeting.
Every so often a death causes much more than a ripple. Every so often a death sends waves crashing through the hospital and beyond. When we witness a death that is unexpected, or traumatic, it shatters the illusion that death is routine. It reminds us of the tragedy of every loss and shakes us to our all-too-mortal core. I was in charge recently when our team had such an experience. The patient was young and previously well. On admission they appeared to have a straightforward illness, and received appropriate treatment. We saw them on the morning ward round, made a plan for home at the end of the day, discussed staying off work and resting at home. No one predicted they would be dead just a few hours later.
In the days and weeks that followed we tore ourselves apart asking what we could have done differently. We pored over the charts, rechecked blood results, and reanalysed the x-ray in minute detail. We compared notes on similar cases that had had better outcomes, and of other cases that had ended in death despite our best efforts. We talked of the rapidity of this patient’s deterioration, and of the timing of multiple treatment escalations. We replayed the day to ourselves over and over, and relived it unexpectedly whilst waiting for the bus, or standing in a supermarket queue. We felt guilt and shame when we laughed, or discussed our evening plans. We hesitated when making what should have been straightforward decisions, and we over-investigated, over-monitored and over-treated our other patients.
The literature suggests that too often healthcare environments are ill equipped to acknowledge the psychological distress that occurs in response to a patient death  and that grief may be considered shameful and unprofessional . Thankfully this was not my experience. We had a debrief a few days after the event where we spoke of the patient. We discussed our identification with the pain felt by their family members, and how this brought out fears for our own family and friends. Nurses, HCAs, junior doctors, Consultants and resus officers shared feelings of personal responsibility, guilt, vulnerability and distress. We also talking practically and identified aspects of the system that could be improved. Spoken aloud in a safe space our emotions lost their paralysing power and we allowed ourselves to feel legitimate in carrying on in our professional roles.
A number of researchers have identified the fact that healthcare professionals experience a grieving process after a significant patient death, but that this is different to that experienced when losing a loved one. Grieving is complicated by self doubt, helplessness, guilt, or failure, and professionals fear criticism for their role in the patient’s care [3, 4]. Many suggest there is a ‘hidden curriculum’ or ‘conspiracy of silence’ in physician training that encourages a repression of emotional reactions, and that training inadequately prepares students and doctors to process their own reactions. “Emotional processing can be set aside in order to ‘functionally disconnect’ from personal emotional reactions and remain focused on the technical aspects of the physician’s role….The balancing process of reconnection needs to become as integral a part of physician training and role expectation as the functional disconnect” .
An ‘open culture’ is something healthcare organisations aspire to, but achieve all too rarely. On more than one occasion in conversations after our patient’s death, the spectre of the Bawa-Garba case loomed large . Doctors and nurses feel that they are just one overworked, under-supported shift away from criminalisation and censure. Thankfully the debrief was expertly convened and facilitated. In addition the formal hospital investigation into an unexpected death was almost entirely blame-free and learning-focused. This not only made it less painful for those involved, but meant we were able to identify personal and organisational learning points, and the process will therefore positively impact future patient care. This process required us to go over the events multiple times, as various meetings took place over several weeks, and it was challenging to re-confront emotions which were necessarily suppressed in order to get on with day to day clinical tasks.
“…the grieving experienced by health professionals occurs as a process of an ongoing fluctuation between experiencing grief reactions by focusing on the loss experience, and avoiding or repressing grief reactions by moving away from the loss experience. This fluctuation from one pole to the other is necessary, adaptive, and healthy” .
Shared grieving and team support have been identified as vital as social acts of meaning making, which allow a degree of acceptance and integration of the traumatic experience into part of professional identity.
“When a professional is able to make sense of a patient’s death… then he or she experiences a sense of integration that allows him or her to further invest new relationships, professional goals, and clinical interventions… Any form of meaning provides health professionals with a sense of mastery, and helps them overcome any state of confusion, of doubt, or of meaninglessness” .
In order to continue to expose ourselves to death and dying on our work, we need to be able to process any particularly traumatic deaths, and come out of the experience having learned something we can use to help others in the future. This processing is facilitated by sharing, and it is vital that time and space is created for this amid the needs of a busy clinical service.
When my patient died, I was mid way through Kathryn Mannix’s book ‘With the end in mind’ and found these words particularly poignant:
“Bereaved people…often need to tell their story repeatedly, and that is an important part of transferring the experience they endure into a memory, instead of reliving it like a parallel reality every time they think about it. And those of us who look after very sick people sometimes need to debrief too. It keeps us well, and able to go back to the workplace to be rewounded in the line of duty.”
My wounds are healing. I hope yours are too.
- PHE. End of Life Care Profiles. Feb 2018 update.
- Kasket E. Death and the doctor II: a phenomenological investigation. Existential Anal 2006;17.2:385–96
- Davies Marika. Death is part of a doctor’s job BMJ 2016; 355 :i5597
- Whitehead PR The lived experience of physicians dealing with patient death BMJ Supportive & Palliative Care 2014;4:271-276.
- BMJ coverage of the Dr Bawa-Garba case.
- Papadatou, D. (2000). A Proposed Model of Health Professionals’ Grieving Process. OMEGA – Journal of Death and Dying, 41(1), 59–77.
Thank you for reminding us that deaths, some more than others, have an impact on clinicians. By the end of a medical career we have dealt, somehow or other, with hundreds of deaths. Both the deaths you describe were relatively unexpected. But one was the unpredicted death of an old frail man for whom death was anticipated, though nobody though it would happen that morning. The other was the sudden, premature death of a young person. Not surprising they affected hospital staff so differently. But for the families, both deaths may have been unexpected and precipitated the maelstrom of numbness, anger, guilt, blame, despair, and loss that do not necessarily follow the neat sequences ascribed to Elizabeth Kubler Ross, but swirl around, sometimes dragging in the clinical team who were trying to do their best for each patient. The understandable responses of families to the death of a loved, or hated relative also affect clinicians. They too make us question our actions, our inactions, our decisions, our clinical competency, and it is right that they should. Such reflections can lead us to become better clinicians, or become disabling ruminations. Like you I have always found peer support helpful. It would be terrible if the fall out from the Bawa-Gaba case meant that teams could not talk, think and support one another after a death. Thank you again for writing this.