The emotional toll on a surgeon or physician after the loss of a patient is an experience rarely spoken about freely. Perhaps the one exception is during the mandatory review at morbidity and mortality conference. We are often not prepared on how to deal with this experience. There is no grief counseling after the fact and sometimes no time to reflect on the depth of its impact. How one deals with a patients’ expected or unexpected passing is based on their perspective on life, the circumstances, and of course likely the manner in which they learned as trainees.
The conditions surrounding the loss will directly impact the spectrum of emotions felt. For example, if it is a patient with cancer that you have cared for and death is expected you might feel some loss but as it was expected you are more emotionally prepared for that likely outcome. However, the death of a trauma patient that you did not know previously might elicit sadness for the loss of a human life; but may not affect you profoundly unless it’s the first time that you have had the experience. Likely the hardest scenario is a patient death when the outcome was unexpected or intraoperative.
The range of emotions can range from no impact to a deep sense of loss, anger, astonishment, helplessness or worse an acute depression. Hopefully as you work through the reactions you will develop a deeper sense of appreciation for your profession and the role you play in saving lives. We are surgeons, we are brave and confident yet we must be prepared to deal with this inevitable occurrence.
How can you prepare? A family member once said to me “you are a surgeon you should expect that you would lose a patient.” But even still it’s hard to say that the expectation gives solace. Frankly it would leave us vulnerable to believe a patient can die as we invade the body wielding our knives, clamps and ties with confidence. To be effective the thought can never really be at the forefront of our mind during an operation. We focus instead on attaining the best outcome. We prepare the patient and our team for the case especially if it is a challenging one. If religious, we say a silent prayer for success.
What happens after you do lose a patient? From a systematic standpoint there really is nothing in place to help a surgeon through the grieving process. You grieve, you mourn privately. You turn within promising to be better, to learn and to not let that death be in vain. Every year 200,000 lives are lost due to medical error alone. We are not infallible; we are mere humans and can not save the life of every patient we treat.
Over my career I have had to deal with the loss of patients in all the scenarios I described. The ones that are closest to me are the most challenging but they have all been challenging. I hold the memory of all close so that their deaths whether expected or not can serve as an instruction on how to be the best surgeon, colleague, provider and teacher I can be. Fortunately it is not a frequent occurrence as I am moved quite deeply with sorrow when it does occur.
I have learned some lessons and coping skills that I will now share. You will have developed some on your own and I would love to hear about them (Twitter – @KMarieMD).
- Be there for the family – This is the most important recommendation. No matter how you are feeling (or not) they have lost a loved one. Even if it was expected it remains devastating. Show empathy, be truthful and be available.
- Seek the guidance of a trusted senior surgeon – Most if not all have had this experience at some point in their career. They will have likely found a way to cope that they might share. They will also be able to offer insight on what decisions could have been optimized for a particular case.
- Seek the support of your family/friends – However challenging the whirlwind of emotions you might face, remember your commitment to saving lives. You contributions to society are important. Mourn and seek comfort. Then return to doing what you do best.
- Perform an introspective analysis – Determine what lessons can be learned that will help you and your team to grow. Look for and be open to feedback.
- Support your team – Review the case with your team. Allow everyone to have a voice in expressing what occurred, how the case was managed and what can be improved. This is especially important in unplanned deaths. Model for your team empathy, kindness and openness to receiving feedback.
- Consider attending the funeral – This will be based on the closeness of the relationship with the patient and the family. I have personally attended a couple of my patients’ funerals. I got closure from the process and their family appreciated my presence.
- Write a personal note to the family if the death occurred outside of the hospital. Even if you took care of the patient a long time ago your note may help a loved one.
- Reach out to a colleague that has lost a patient – a kind word and advice will undoubtedly help.
- Seek professional help – If a case troubles deeply you might need to discuss the case with a grief specialist. An unexpected outcome can lead to post traumatic stress. Know you are not alone even if this result is not openly discussed.
- Prepare your patients – Death unfortunately will occur. Be mindful in setting expectations in the preoperative setting especially for challenging cases. If a patient has a terminal condition discuss early the potential of death. Obtain do not resuscitate (DNR) and do not intubate orders (DNI) early in the relationship. A prepared patient and family can make decisions with clarity if they have an accurate vision of the future and time to process.
I recommend the following publications for more advice and examples about how to deal with a patient’s death.