PracticeUpdate: Why is grief management important for healthcare providers?
Dr. Schwartzberg: Traditionally, the role of the healthcare provider was paternalistic by delivering the news and staying at an emotional distance from the patient. You do have to do that to a certain degree, or you can't function; but, we know that, particularly in oncology, patients are going to die and not infrequently, depending on which area of oncology you pick. And you have to be ready to acknowledge your grief.
There are two extremes, and both are unhealthy. The one extreme is when you have no feelings at all when your patient dies. This is a terrible manifestation of burnout, I think. It's not typical, since people who go into oncology tend to be very empathetic in general. But seeing enough patients die can put you into a state of denial, and that's bad. Also dangerous is being so involved with every patient that you experience a death or a serious adverse event like it occurred to one of your close family members. You can't do that either, or you can't function. So, you need to find that middle ground where you remain empathetic.
Some patients are closer to you than others. I've had patients who I've taken care of for years and felt like they were like a father or brother or a sister, or like a son or daughter to me. And those relationships are very challenging when something bad happens. And it's okay to grieve. An important lesson for young trainees is that it is okay to grieve. It's okay to cry with patients. You're still the person who's delivering the news, but it's okay to show emotion. It's not okay, however, to break down totally in front of a patient, because that might impact the trusting professional relationship. So, you need to find that middle ground where you remain professional, you remain the source of information, but you're empathizing with the patient's pain, the family's pain, and what is going to come, the potentially existential uncertainty.
Lillie Shockney: We realize that not every patient is going to be a cancer survivor, although that certainly is our hope and our goal. Some of us specialize in patients who have stage IV disease, and that means we're going to lose every one of our patients at some point. I am a believer that, because we have entered this patient's life at the most vulnerable time of her life, the most profound moments of her life, we have bonded with her, and, goodness knows, she has bonded with us. And I don't want to pull back toward the end; I still want to be in it for her, absolutely there and supporting her, and helping her to orchestrate a good and peaceful death.
When I lose a patient, I need to grieve. And even though I may be more prepared for it than the family may be, because I've gone through it many, many times, it doesn't make the grieving process less difficult or less important. If we don't grieve, we can end up traveling the road of compassion fatigue and burnout, and we can't help other patients if that's the condition we're in. But, if we take care of ourselves, and the grieving process is part of taking care of ourselves, then we're able to help the next patient just as well as the one we just lost.
PracticeUpdate: Do you have any strategies that you find can help to cope with patient loss?
Dr. Schwartzberg: Burnout's a real phenomenon, one I think that almost everybody experiences at some point in his or her career to a lesser or greater extent. It tends to be associated with excessive working or excessive emotional onslaughts, which can happen with an unrequited grief. If burnout goes unrecognized and you don’t address it, then the interactions with your patients are not going to be as effective. You don't function as well at work. You tend to be withdrawn. Moreover, you get physical manifestations, anxiety, insomnia. Grief that is unaddressed is just one factor; it's an important one, but not the only one, and those factors that lead to burnout tend to be synergistic. A few of them together can really make your working environment very difficult.
One strategy that I have found to be effective once a patient has died is asking the family to come back in and have a discussion from two aspects. One is to go over the medical care. The families tend to feel guilty. They're not guilty of anything, but they tend to feel, "Well, did we do everything? Did we do it right? When we missed that appointment one day and went to the beach?” And giving them an opportunity to ask these questions or reassuring them that, “No, going to the beach had no effect on her survival,” is a huge relief for families, and this sort of discussion really helps you with your own grief as well.
Secondly, a meeting like this gives you the opportunity to acknowledge to the family how much the patient meant to you. And, typically, frankly, the family acknowledges the same thing to you, how much your relationship with them meant to them and how much your relationship with her meant to the patient. It really helps. I won't say closure, which is kind of a cliche, but it's more of acknowledging the grief and revisiting the whole experience and remembering that everyone was in it together.
Lillie Shockney: When a patient dies, I like to take a nature walk and think about that individual. I keep a journal. I'll just put in the patient’s first name and then some things I want to remember about her; it might be some life lesson that she taught me. I also write down how we were able to make a difference for her in her journey to the end of life.
I try to find gratitude each day: What am I grateful for today? I lost her, but I knew I was going to lose her; this isn't a surprise. But what was good about today? What can I be thankful for today? And I may just write two words in that journal and know exactly what I meant later when maybe I am down in the dumps, and I go back to that journal and think, "Oh, yeah, I remember that now." That is healing.