griefHeartbreaking patient situations are the backbone of Emergency Medicine. Whether it’s a new cancer diagnosis, telling a family member that their loved one has died, or the creeping dread that a mistake that we’ve made will negatively impact one of our patients, we all experience extraordinary stress in our day-to-day clinical practice. Most clinicians are not tasked with routinely sharing news about the violent, unexpected, and horrific life-changing situations that occur in the emergency department, and yet we are given so few tools to help us manage this firehose of grief. This article is intended to share some of the best practices of grief management with clinicians who are immersed in grief, even if unawares.

What Kind of Grief Are We Talking About?

Lots of different types of grief exist. We are focusing on grief related to the clinical practice of medicine: disenfranchised grief. Disenfranchised grief is a very relevant grief classification that describes what healthcare workers often experience, which is defined by grief researcher Ken Doka, Ph.D., as follows:

“Grief that individuals experience when they incur a loss that is not or cannot be openly acknowledged, socially sanctioned, or publicly mourned.”

For example, any time you have encountered a patient who died and weren’t sure if it was really “your place” to feel sad, or had trouble shaking thoughts about the patient. Most of us have felt overwhelming emotion during a particularly poignant death, or in the aftermath, but may have felt some embarrassment or confusion around next steps.

Learning about how to categorize and manage grief is really a key component of your ability to continue adequately moving through grief and moving on, rather than avoiding or burying these feelings. These skills are important for ED clinicians (and all clinicians, really) in general, but especially during a pandemic, when the scale of the tragedy, the resource limitations, and the capacity of any one provider are stretched to impossible limits.

How to Grieve: The Steps

Step 1: Identify your Grief

If you’re having trouble identifying the feeling of grief, it can feel like this in your body: tightness in your throat/neck, heaviness in your chest when you recall a patient or encounter, or mild nausea or fatigue. These are signs of grief, and it’s worth asking yourself if that might be what you are feeling.

Physicians often confuse grief for guilt or shame. It is much easier for many clinicians to focus on the clinical aspects of the situation (which central line was done incorrectly, which medication they should’ve ordered at what point, etc) rather than the underlying sadness. Think back to the last time someone debriefed with you about a tough case. What did they say? How much of that debrief was focused on medical errors, real or imagined? How much was framed as, “I wish I would have done X…” regardless of whether X was clinically appropriate, reasonable, or possible?

It’s important to recognize that grief and shame can happen simultaneously. If indeed you made a medical error, which we all know happens, you can be upset and ashamed and feel guilty about that. However, do not forget to unwind that component of your distress from the grief that happened simultaneously. For example, if you missed a diagnosis of aortic dissection and a patient died as a result, you can feel upset that you did not diagnose that patient correctly, but do not forget to recognize that you might be grieving the loss of connection you had to that patient as well. You may also be sad that a person that you liked died. Guilt alone for the medical error does not address the emotional breadth of that event.

Step 2: Process your Grief

How it Works in Hospice

This is not meant to be a direct translation of how grief processing will happen for emergency providers. However, hospice providers are very aware of grief, and work constantly and function well in that environment. It is useful to examine these practices.

Grief processing is an expectation in the hospice world. Clinicians are offered many different ways to approach grief processing, and are expected to either actively engage or passively listen through each of an array of different grief management rituals:

  • Services of remembrance twice a year for the patients who have died. This acknowledges the truly massive amount of death we confront day to day, and additionally, allows family members and caregivers of patients to remember them.
  • Short recollections on a weekly basis. These usually last 2-3 minutes and focus on either challenges or pleasant memories that team members had.
    • A moment of silence
    • A lot of poetry that discusses and engages with topics like grief and mourning
  • People are expected to reach if they are really struggling with a death or an interaction.
    • To supervisors
    • To one-another for one-to-one debriefs. This is especially true within disciplines (physician to physician, for example, or social worker to social worker)
  • Key characteristics
    • There is not an expectation that there is a one-size-fits-all modality for processing grief. There is the expectation that you will find a modality that works best for you.
    • Support of supervisors and of peers is key. Part of your role as a supervisor and peer is to assist in this grief processing.

How We Can Process Grief in the Emergency Department

Start Processing

As noted above, this can be whatever speaks to you and allows you to release your grief. Some people need to talk about it right away or later, so be aware if you are a person who needs time before you process. Don’t feel obligated to do so in the moment.

Many physicians process their grief by sharing. The decision of whom to choose for grief processing is an important one. Many clinicians turn to the obvious choice: the most supportive, loving, and receptive person in their lives, their partners. A note of caution here: some partners are enthusiastic receptacles of your grief. Some are happy with it for a period of time, only to later recognize the breadth of the sadness and loss, and realize they cannot commit to this long term. It is important to check in occasionally with your partner and gauge their willingness to be in this role. Colleagues, supervisors, or a therapist are all also excellent choices.

grief

Some people need to write about their grief. This doesn’t have to be lengthy, or particularly good writing, for that matter. It just has to happen. If writing is an important component of your grief process, make sure to protect patient confidentiality, and be careful with your audience.

Crying is really important for some people to release the pent up emotion, though be mindful of where and when you cry. I find that if I have not put aside time to cry about a patient or encounter that I am grieving, the crying will happen whether or not I want to, and sometimes at really suboptimal times

Most of us have some combination of the above that works for us. There is no obligation to do anything other than what brings your emotions to a more neutral place. It isn’t important what you do. It is important that you do something to acknowledge, rather than bury your grief—and that you do it every time some tragedy really impacts you.

Finish Processing

This is key. Part of managing the grief of our work is allowing it to draw to a close. When we grieve for a family member or loved one we must expect a longer, more unstructured period of grief. When we are grieving for work purposes, however, there must be a more structured, and frankly less intensive approach. That’s the only way we will continue to engage with it over time.

It’s important to create a boundary around what you will and won’t perseverate on, and you will create that boundary for yourself through trial and error. Some general guidelines:

  • Focus on what you know, not what you imagine. You know that the trauma patient that died had many broken bones; you don’t know what she felt before she was hit by the car. You can see the pain in a family member’s eyes when you share a death; you cannot see how they will go on after the death.
  • You may discover “hot spots” of grief that, for you, generate a downward spiral of emotion rather than releasing you from it. Those are your boundaries! Do not go there!
  • For many people it is helpful to set a deadline, for example: I’m going to feel really sad and awful about this for 48 hours, and then I’m going to try and wrap it up.
  • If you have trouble meeting your own deadline, and the grief and sadness persist for a long time in a disruptive fashion, you need to reach out to talk to a professional.

Caution: What if you’d rather have 3 post-shift beers?

Comradery, friendship, and good times can be had while drinking after a shift, but do not mistake them as a substitute for managing grief. Avoiding and/or ignoring your feelings is a short-solution to a long-term problem. If you don’t manage this flow of grief, and instead just kind of turn it off or bury it, you can suffer many negative consequences:

  • Burnout and depression. Unresolved grief can kind of hang like a fog over your work and your life.
  • Substance use/misuse/risky behavior
  • Difficulty feeling connectedness or getting joy from your work. This is perhaps one of the most painful consequences of unprocessed grief. If you have not been able to access and reconcile the painful patient interactions in your past, it is hard to desire deep engagement with the ones directly in front of you.
  • Chronic complaining. This is particularly interesting. If you desire empathy and compassion for the grief that you are holding but do not want to touch, complaining is a coping mechanism. It gets people to respond to minor annoyances with some of the compassion and empathy that you are craving. It also, unfortunately, can push people away, which is the opposite of what you’re hoping for.

Work Grief: A Summary

Witnessing tragedy and suffering is part and parcel to being an Emergency Medicine clinician, but it does not have to doom us to a life of burnout and apathy. If we can identify, process, and move on from our grief surrounding painful clinical scenarios, we have a shot at continuing to remain engaged and involved in our work, in our relationships, and with our colleagues despite the suffering.

Kai Romero, MD

Kai Romero, MD

Attending in Emergency Medicine
Kaiser San Francisco
Chief Medical Officer
Hospice By the Bay
Kai Romero, MD

@emergencypal

Emergency Medicine/Pall Care Trained @UCSF. Latina CMO @ Hospice By the Bay. Straight up mom. She/her/ella. Tweets are my own. Views are my own.
Kai Romero, MD

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