New Practitioners Forum
New Practitioners Forum Coping with death in the patient care setting
P
harmacy education is centered on teaching the hard knowledge and soft skills needed to practice as a pharmacist: knowledge of basic pharmacology, adverse effects, therapeutic guidelines, offlabel uses, and patient counseling and skill in public speaking and cultural sensitivity, among various other things. Many of these areas of knowledge and skills are patient centered—whether they are about improving patient care or having more
purpose of this article is to describe typical reactions to death and discuss ways to cope with the traumatic death or terminal illness of a patient. Reactions to death. A difficult situation can appear suddenly and unexpectedly (e.g., the death of a child in a motor vehicle accident, the death of a family friend from a myocardial infarction) or it can appear gradually and with forewarning (e.g., the death of a patient in a hos-
effective communication with patients. However, one aspect of patient care that is often underrepresented or even neglected in pharmacy curricula is how to deal with a sudden traumatic death or the process of dying. These events can be very difficult for a new practitioner unaccustomed to dealing with such situations.1 The twofold
pice program, the death of a patient in the intensive care unit who is declared brain dead after having a stroke during an extended hospital stay). Both situations can be difficult experiences for various reasons. Seeing a pediatric patient die is never an easy situation, can be devastating for someone inexperienced with such a trag-
The New Practitioners Forum column features articles that address the special professional needs of pharmacists early in their careers as they transition from students to practitioners. Authors include new practitioners or others with expertise in a topic of interest to new practitioners. AJHP readers are invited to submit topics or articles for this column to the New Practitioners Forum, c/o Jill Haug, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8821 or [email protected]).
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edy (if he or she is not prepared to handle it), and is difficult for even the most experienced clinicians.2,3 The first thing clinicians typically experience after a traumatic death is a sense of shock or emotional numbness that may be associated with denial. They might feel cut off from the outside world or confused about the recent experience. It might be difficult for an individual to accept the events that just occurred, and he or she might constantly relive the experience in his or her mind, allowing few other thoughts to enter for a period of hours or even days. After this initial period of shock, the next experience can be entirely variable. Some people become incredibly sad and overwhelmed by emotion; others may become scared that the traumatic event will happen to them again or to someone close to them, and yet others may become angry or disillusioned that such a traumatic event can happen to a child or someone close to them. Some clinicians may experience guilt, feeling that there was something more that could have been done. Many people will experience a combination of these emotions and feelings.1,4 During this period, one might also notice physical symptoms related to the grief or bereavement process. Difficulty sleeping or sleep interruption by abnormal dreams or nightmares may occur. This may lead to tiredness or exhaustion, and the ability to work may also be impaired secondary to difficulty concentrating and thinking clearly or impairment of short-term memory. Other physical symptoms may include headaches, change in appetite, physical aches or pains, and tachycardia.5 Coping with a traumatic death. Recognizing the emotions that occur when a patient dies suddenly is the first step in appropriately managing them. For residency preceptors, it is important to be aware of students’ and residents’ emotions if it is known that this is one of their first times encountering a traumatic death. The second step is to allow time to process the event; this might include taking a break, Continued on page 920
New Practitioners Forum Continued from page 918
going to lunch, or even taking the rest of the day off if necessary. Talking with others—a coworker, preceptor, mentor, or trusted friend—is often helpful. Additionally, using workplace resources can be helpful. A variety of resources to assist healthcare practitioners in coping with death and dying are available online (appendix). In addition, many hospitals have individuals, religious personnel, or counselors who have training and experience in working with healthcare professionals who encounter these situations. Such personnel can often offer a different perspective on the situation. Talking with more experienced clinicians may also be beneficial, as they have likely experienced similar situations in their professional life. There are also some things to avoid when coping with a traumatic death. The first thing to avoid is suppressing feelings, which may be a natural inclination, as some people might be embarrassed by or ashamed of their feelings and others people might not want to feel like they are burdening those around them with their feelings. It is important to avoid suppressing feelings, as they may become more intense, thus making the experience worse. Second, it is important to avoid using excessive distractions. It might feel natural to do things or take on projects to provide distractions from the feelings, but this is only a temporary solution. Intense feelings may still emerge while the practitioner is not busy or while he or she is sleeping. Coping with death due to terminal disease or chronic illness. While the sudden death of a patient can be a traumatic experience for healthcare professionals, the death of a patient due to a terminal disease or chronic illness also can be difficult. Although the death of a patient secondary to cancer or heart disease may not be sudden, it can cause the practitioner to experience many of the same emotions experienced after the sudden traumatic death of a patient, including sadness, grief, guilt, and, possibly, helplessness; however, these emotions may be stronger or more intense than they are in the former case. Redinbaugh et al.6 found that the longer the duration of the patient–healthcare provider relationship, the more intense 920
the emotions the provider may experience after the patient’s death. Depending on the clinical practice specialty, practitioners may experience the death of a patient with whom they have a close relationship or to whom they have provided care on a regular basis. Specialties such as oncology, palliative care, and hospice care often provide the opportunity to develop longer patient–provider relationships. Clinicians in these practice areas may also encounter patient death on a daily basis, and although the prognosis of the patient may be known, the patient’s death can still be devastating. Participating in a patient’s end-of-life care can be a rewarding experience, but his or her death can still cause distress to healthcare providers.6 Therefore, in specialty areas in which providers frequently care for dying patients, it is important to develop strategies to manage the feelings and emotions related to patient deaths. These strategies can be specific to the individual, or they can be group focused. One recommended strategy is to complete a “debriefing” on the emotional events7; this can be an informal process, such as a discussion with a colleague or mentor, or it can be a planned multidisciplinary discussion. One debriefing approach many hospitals have incorporated includes Schwartz Center Rounds,7 a multidisciplinary forum involving the presentation of a difficult patient case followed by an interactive discussion. These formal discussions provide an opportunity for practitioners to reflect while gaining insight and support. Other coping strategies include staying active, focusing on a healthy lifestyle, and maintaining meaningful relationships.8 Whether the strategy used is an individual-based strategy or a multidisciplinary discussion, recognizing and managing emotions is important when patient deaths are commonly encountered in practice. Closing notes. Responding to the death of a patient and managing the emotions that arise secondary to the experience can be difficult, and they are skills that require development. Unprocessed grief can lead to distress and burnout.9 Additionally, being in the early stages of a healthcare career can be a risk factor for burnout. Therefore, it is important to be aware of emotions and implement selfcare techniques, especially for new prac-
Am J Health-Syst Pharm—Vol 72 Jun 1, 2015
titioners. New practitioners often have underdeveloped self-care skills, and they have not received training on how to handle patient death, whether it is related to chronic illness or the result of a traumatic event. Death is an inevitable event in life, and, as pharmacy practitioners, we must prepare ourselves and know appropriate coping techniques. 1. Sansone RA, Sansone LA. Physician grief
with patient death. Innov Clin Neurosci. 2012; 9:22-6. 2. Treadway K. The code. N Engl J Med. 2007; 357:1273-5. 3. O’Malley P, Barata I, Snow S. Death of a child in the emergency department. Pediatrics. 2014; 134:e313-30. 4. Bruce CA. The grief process for patient, family and physician. J Am Osteopath Assoc. 2007; 102(suppl 7):ES33-40. 5. Zisook S, Devaul RA, Click MA Jr. Measuring symptoms of grief and bereavement. Am J Psychiatry. 1982; 139:1590-3. 6. Redinbaugh EM, Sullivan AM, Block SD et al. Doctors’ emotional reactions to recent death of a patient: cross sectional study of hospital doctors. BMJ. 2003; 327:185-9. 7. Penson RT, Schapira L, Mack S et al. Connection: Schwartz Center Rounds at Massachusetts General Hospital Cancer Center. Oncologist. 2010; 15:760-4. 8. Blust L. Fast fact #169: health professional burnout—part III (November 2006). www. capc.org/fast-facts/169-health-professionalburnout-part-iii/ (accessed 2015 Feb 22). 9. Sanchez-Reilly S, Morrison LJ, Carey E et al. Caring for oneself to care for others: physicians and their self-care. J Support Oncol. 2013; 11:75-81.
Appendix—Resources for clinicians • The Association of Death Education and Counseling (www.adec.org) • Survivors of Violent Loss Resources (www. svlp.org) • Trauma Information Pages (www.traumapages.com) • Journey of Hearts (www.journeyofhearts.org) • National Hospice and Palliative Care Organization (www.nhpco.org) • National Cancer Institute (www.cancer.gov) • The Schwartz Center (www.theschwartz center.org)
Bryan M. Bishop, Pharm.D., BCPS, Clinical Pharmacist St. Rita’s Medical Center Lima, OH [email protected] Lacey Shumate, Pharm.D., BCPS, Clinical Pharmacist Aultman Hospital Canton, OH
The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp140562
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
New Practitioners Forum Coping with death in the patient care setting
P
harmacy education is centered on teaching the hard knowledge and soft skills needed to practice as a pharmacist: knowledge of basic pharmacology, adverse effects, therapeutic guidelines, offlabel uses, and patient counseling and skill in public speaking and cultural sensitivity, among various other things. Many of these areas of knowledge and skills are patient centered—whether they are about improving patient care or having more
purpose of this article is to describe typical reactions to death and discuss ways to cope with the traumatic death or terminal illness of a patient. Reactions to death. A difficult situation can appear suddenly and unexpectedly (e.g., the death of a child in a motor vehicle accident, the death of a family friend from a myocardial infarction) or it can appear gradually and with forewarning (e.g., the death of a patient in a hos-
effective communication with patients. However, one aspect of patient care that is often underrepresented or even neglected in pharmacy curricula is how to deal with a sudden traumatic death or the process of dying. These events can be very difficult for a new practitioner unaccustomed to dealing with such situations.1 The twofold
pice program, the death of a patient in the intensive care unit who is declared brain dead after having a stroke during an extended hospital stay). Both situations can be difficult experiences for various reasons. Seeing a pediatric patient die is never an easy situation, can be devastating for someone inexperienced with such a trag-
The New Practitioners Forum column features articles that address the special professional needs of pharmacists early in their careers as they transition from students to practitioners. Authors include new practitioners or others with expertise in a topic of interest to new practitioners. AJHP readers are invited to submit topics or articles for this column to the New Practitioners Forum, c/o Jill Haug, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8821 or [email protected]).
918
Am J Health-Syst Pharm—Vol 72 Jun 1, 2015
edy (if he or she is not prepared to handle it), and is difficult for even the most experienced clinicians.2,3 The first thing clinicians typically experience after a traumatic death is a sense of shock or emotional numbness that may be associated with denial. They might feel cut off from the outside world or confused about the recent experience. It might be difficult for an individual to accept the events that just occurred, and he or she might constantly relive the experience in his or her mind, allowing few other thoughts to enter for a period of hours or even days. After this initial period of shock, the next experience can be entirely variable. Some people become incredibly sad and overwhelmed by emotion; others may become scared that the traumatic event will happen to them again or to someone close to them, and yet others may become angry or disillusioned that such a traumatic event can happen to a child or someone close to them. Some clinicians may experience guilt, feeling that there was something more that could have been done. Many people will experience a combination of these emotions and feelings.1,4 During this period, one might also notice physical symptoms related to the grief or bereavement process. Difficulty sleeping or sleep interruption by abnormal dreams or nightmares may occur. This may lead to tiredness or exhaustion, and the ability to work may also be impaired secondary to difficulty concentrating and thinking clearly or impairment of short-term memory. Other physical symptoms may include headaches, change in appetite, physical aches or pains, and tachycardia.5 Coping with a traumatic death. Recognizing the emotions that occur when a patient dies suddenly is the first step in appropriately managing them. For residency preceptors, it is important to be aware of students’ and residents’ emotions if it is known that this is one of their first times encountering a traumatic death. The second step is to allow time to process the event; this might include taking a break, Continued on page 920
New Practitioners Forum Continued from page 918
going to lunch, or even taking the rest of the day off if necessary. Talking with others—a coworker, preceptor, mentor, or trusted friend—is often helpful. Additionally, using workplace resources can be helpful. A variety of resources to assist healthcare practitioners in coping with death and dying are available online (appendix). In addition, many hospitals have individuals, religious personnel, or counselors who have training and experience in working with healthcare professionals who encounter these situations. Such personnel can often offer a different perspective on the situation. Talking with more experienced clinicians may also be beneficial, as they have likely experienced similar situations in their professional life. There are also some things to avoid when coping with a traumatic death. The first thing to avoid is suppressing feelings, which may be a natural inclination, as some people might be embarrassed by or ashamed of their feelings and others people might not want to feel like they are burdening those around them with their feelings. It is important to avoid suppressing feelings, as they may become more intense, thus making the experience worse. Second, it is important to avoid using excessive distractions. It might feel natural to do things or take on projects to provide distractions from the feelings, but this is only a temporary solution. Intense feelings may still emerge while the practitioner is not busy or while he or she is sleeping. Coping with death due to terminal disease or chronic illness. While the sudden death of a patient can be a traumatic experience for healthcare professionals, the death of a patient due to a terminal disease or chronic illness also can be difficult. Although the death of a patient secondary to cancer or heart disease may not be sudden, it can cause the practitioner to experience many of the same emotions experienced after the sudden traumatic death of a patient, including sadness, grief, guilt, and, possibly, helplessness; however, these emotions may be stronger or more intense than they are in the former case. Redinbaugh et al.6 found that the longer the duration of the patient–healthcare provider relationship, the more intense 920
the emotions the provider may experience after the patient’s death. Depending on the clinical practice specialty, practitioners may experience the death of a patient with whom they have a close relationship or to whom they have provided care on a regular basis. Specialties such as oncology, palliative care, and hospice care often provide the opportunity to develop longer patient–provider relationships. Clinicians in these practice areas may also encounter patient death on a daily basis, and although the prognosis of the patient may be known, the patient’s death can still be devastating. Participating in a patient’s end-of-life care can be a rewarding experience, but his or her death can still cause distress to healthcare providers.6 Therefore, in specialty areas in which providers frequently care for dying patients, it is important to develop strategies to manage the feelings and emotions related to patient deaths. These strategies can be specific to the individual, or they can be group focused. One recommended strategy is to complete a “debriefing” on the emotional events7; this can be an informal process, such as a discussion with a colleague or mentor, or it can be a planned multidisciplinary discussion. One debriefing approach many hospitals have incorporated includes Schwartz Center Rounds,7 a multidisciplinary forum involving the presentation of a difficult patient case followed by an interactive discussion. These formal discussions provide an opportunity for practitioners to reflect while gaining insight and support. Other coping strategies include staying active, focusing on a healthy lifestyle, and maintaining meaningful relationships.8 Whether the strategy used is an individual-based strategy or a multidisciplinary discussion, recognizing and managing emotions is important when patient deaths are commonly encountered in practice. Closing notes. Responding to the death of a patient and managing the emotions that arise secondary to the experience can be difficult, and they are skills that require development. Unprocessed grief can lead to distress and burnout.9 Additionally, being in the early stages of a healthcare career can be a risk factor for burnout. Therefore, it is important to be aware of emotions and implement selfcare techniques, especially for new prac-
Am J Health-Syst Pharm—Vol 72 Jun 1, 2015
titioners. New practitioners often have underdeveloped self-care skills, and they have not received training on how to handle patient death, whether it is related to chronic illness or the result of a traumatic event. Death is an inevitable event in life, and, as pharmacy practitioners, we must prepare ourselves and know appropriate coping techniques. 1. Sansone RA, Sansone LA. Physician grief
with patient death. Innov Clin Neurosci. 2012; 9:22-6. 2. Treadway K. The code. N Engl J Med. 2007; 357:1273-5. 3. O’Malley P, Barata I, Snow S. Death of a child in the emergency department. Pediatrics. 2014; 134:e313-30. 4. Bruce CA. The grief process for patient, family and physician. J Am Osteopath Assoc. 2007; 102(suppl 7):ES33-40. 5. Zisook S, Devaul RA, Click MA Jr. Measuring symptoms of grief and bereavement. Am J Psychiatry. 1982; 139:1590-3. 6. Redinbaugh EM, Sullivan AM, Block SD et al. Doctors’ emotional reactions to recent death of a patient: cross sectional study of hospital doctors. BMJ. 2003; 327:185-9. 7. Penson RT, Schapira L, Mack S et al. Connection: Schwartz Center Rounds at Massachusetts General Hospital Cancer Center. Oncologist. 2010; 15:760-4. 8. Blust L. Fast fact #169: health professional burnout—part III (November 2006). www. capc.org/fast-facts/169-health-professionalburnout-part-iii/ (accessed 2015 Feb 22). 9. Sanchez-Reilly S, Morrison LJ, Carey E et al. Caring for oneself to care for others: physicians and their self-care. J Support Oncol. 2013; 11:75-81.
Appendix—Resources for clinicians • The Association of Death Education and Counseling (www.adec.org) • Survivors of Violent Loss Resources (www. svlp.org) • Trauma Information Pages (www.traumapages.com) • Journey of Hearts (www.journeyofhearts.org) • National Hospice and Palliative Care Organization (www.nhpco.org) • National Cancer Institute (www.cancer.gov) • The Schwartz Center (www.theschwartz center.org)
Bryan M. Bishop, Pharm.D., BCPS, Clinical Pharmacist St. Rita’s Medical Center Lima, OH [email protected] Lacey Shumate, Pharm.D., BCPS, Clinical Pharmacist Aultman Hospital Canton, OH
The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp140562
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
