HealthJanuary 30, 2020

Your first patient death: Preparing, processing, progressing

By: Manoj Jain, MD, MPH

Everyone knows that death is part of life. But for doctors, death is a part of our everyday work, and the first patient death is often the most unsettling. No amount of preparation can lighten the gravity of the situation.

Whether the death was expected or not, it can elicit a range of emotions. In the case of an expected death, such as the death of a terminally ill patient who was on the trajectory of a predicted decline, sadness and grief may encumber you. When an unexpected death occurs, you may find yourself filled with shock, self-doubt and even fear of malpractice. Why did I not see it coming? Am I incompetent? Did I commit a medical error? Will I be sued? What could I have done differently?

Our objective as doctors is to heal — to send our patients home to their families. As a result, with every patient death, there is no escaping a sense of failure. Knowing what to expect before and after a death can help ease the burden.

Having conversations about death

A conversation about death with families and patients, especially those who are critically or terminally ill, requires framing the topic in the broader picture of gathering medical information. Explain that you have this conversation with all your patients and that it's important for you to know their wishes. If their heart were to stop or they were to stop breathing, for example, what would they want you to do?

Patients want to hear a trusted doctor's opinion, but only after they themselves have been heard. Listen to their wishes without judgment. When appropriate, provide your professional opinion, such as explaining that attempting life-resuscitating measures might come with significant pain and suffering.

End the conversation with hope and reassurance. If the situation is not critical, say that you're glad to have had the conversation and that you're hopeful you can get the patient home soon. If death is imminent despite all medical measures, then tell them that you will make sure they are not in pain or discomfort.

Maintaining a meaningful presence

Keeping our patients alive is our utmost priority, so we need to exhaust all treatment options. Often, you are the patient's best and sometimes only advocate; you know their medical condition better than anyone else. If a consult with a specialized surgeon or a second opinion can offer hope, then you must make the extra effort. Doctors are fallible, and our pride must not hinder our judgment.

When there is little to offer medically, do not abandon the patient. Your presence with them and their family can help them through this difficult journey. Repeatedly ask if you can do anything to make them more comfortable, such as directing them to clergy, the palliative care team or the hospice team.

Following up with family and colleagues

After a death, you must speak with the patient's family and your medical colleagues. In lay language, explain to the family what happened and what efforts were made. Your colleagues need a medical reason for the death, and you may be required to discuss it during a morbidity and mortality conference. A few minutes of preparation for both encounters can ease an uncomfortable situation.

Beyond the emotions and explanations, a patient death comes with certain technical requirements. You must declare a patient dead and mark the time of death. This may not be so easy if a patient is on a left ventricular assist device and a ventilator with a flat EEG. You need to be familiar with your state's definition of death. You will also need to sign a death certificate with a cause of death. Sometimes, this may be simple as "myocardial infarction," but in an unexpected and unknown reason for death it may be vague, such as "sepsis" or "cardiopulmonary arrest."

Connecting with yourself

Lastly, after a patient dies, it's important to connect with yourself. Sadness and grief are natural emotions and are often determined by the depth and duration of the doctor-patient relationship. If you had worked with the patient for many years or if they were similar to you in age, gender, profession or ethnicity, you may experience deeper feelings of grief.

If indifference and detachment are the primary emotions you feel, use self-reflection to understand why. For example, are you trying to avoid grief, or are you burned out? A patient death can be a test of your own emotions as a provider. If your grief lasts more than a few days, it's OK to seek help from colleagues or a senior physician. Begin the conversation by explaining that you just have not been able to get this off your mind. Alternatively, find out if your hospital facilitates formal bereavement debriefing, an often beneficial support for doctors processing patient loss, according to the Journal of Pediatric Gastroenterology and Nutrition.

Every patient death is a deep learning experience — not just medically but in human emotions and the doctor-patient relationship. If we proceed with knowledge, self-awareness and self-reflection, we can grow with each experience.

Manoj Jain, MD, MPH