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Death is inevitable and may come with overwhelming emotions for those who witness it. It is known that the emotions experienced and how these are managed are individual, however, the effects of death are often overlooked by medical professionals. How doctors and medical trainees cope with death is a much-researched topic, with many studies associating these experiences with increased rates of burnout, stress levels, and mental health issues. Emotional responses differ between practitioners, with major contrasts between palliative and non-palliative care specialists. It has also been found that junior trainees mimic the coping strategies of senior doctors, which can alter their future interactions with colleagues and patients, as well as affect their own reactions to death. It is important to understand the strain that death has on doctors, and how different coping strategies can help or hinder emotional recovery.
Approximately one-third of practicing physicians stated that a recent death had a “strong” emotional effect on them; many exhibited similar grief symptoms (Curtis and Levy, 2014). A growing body of research indicates that the emotional drainage associated with caring for the dying (Curtis and Levy, 2014) and frequent exposure to death (Kearney et al., 2009) in a palliative setting result in high burnout rates, compassion fatigue, stress (Whitehead, 2012), and is a major predictor of depression amongst doctors. Deaths in a palliative setting elicit emotions of grief, sorrow, and heartbreak (Batley et al., 2017), attributed to the interpersonal connection formed between doctor and patient. Palliative physicians reported ‘being present with the patient’ in a way that provided calm reassurance and support when it was time for them to die (Whitehead, 2012). Palliative care workers coped via frequent debriefing sessions and giving themselves time away from work to mourn. They also sought to have a balance between ‘getting emotionally involved’ and ‘seeking emotional distance’ when it came to treating patients (Zambrano, Chur-Hansen, and Crawford, 2012). This allowed them the opportunity to experience emotions, whilst protecting themselves from long-lasting negative effects and allowed them to have a healthy work-life balance (Zambrano, Chur-Hansen, and Crawford, 2014).
Emergency doctors experience feelings of shock, powerlessness, and frustration in response to patient death (Batley et al., 2017), and are able to offer more vivid descriptions of patient death. In many cases it wasn’t the patient’s death that affected the clinician, but rather the imagery and seeing the reaction of family members; “seeing [the wife] crying was more disturbing than the patient’s death” (Batley et al., 2017). One study of emergency doctors found that 28% considered quitting their jobs, a further 32% contemplated changing professions, and 14% thought of counseling (Strote et al., 2011). Another 2005 study reported that 49% expressed distress as a result of patient death, 12% met the full PTSD criterion while 30% exhibited at least 1 of the 3 major symptoms categories (Mills and Mills, 2005), 73.1% reported crying during a clinical rotation after a patient’s passing (Angoff, 2001). Memorable cases appeared early in physician careers and caused physicians to question whether they had done everything they should have for a patient, often leading to career changes (Whitehead, 2012). Surgeons often preferred patient interaction devoid of ‘personal’ exchanges and coped with deaths by staying busy, keeping emotional distance, not discussing emotional impacts or providing debriefing opportunities, this allowed them to forget about particular patients (Zambrano, Chur-Hansen and Crawford, 2012).
Many students are surprised by the amount of death in the hospital setting and are caught off-guard by the rapid progression of disease (Ratanawongsa, Teherani and Hauer, 2005), with half stating that they do not feel emotionally prepared to handle death (Billings et al., 2010), and found that dealing with the deceased’s family was as equally distressing as dealing with dying patients (Tuckey and Scott, 2014). Medical students in a simulated patient death scenario were found to be less competent at dealing with similar situations in OSCE settings over 3 months later, and are found to have a greater cognitive load, less learning, and lower performance in response to the associated negative emotions (Curtis and Levy, 2014). Senior practitioners are role models to students (Shapiro, 2011) who wish to know that their mentors see patients as people, not as diseases (Ratanawongsa, Teherani, and Hauer, 2005). Ethics and moral development studies show that students may develop ‘ethical erosion’ over their training years (Feudtner, Christakis, and Christakis, 1994), as a result of teams discouraging student participation, clinicians unprepared to share feelings, and medical discussions devoid of emotions. These can make students feel disempowered, isolated, and frustrated (Ratanawongsa, Teherani, and Hauer, 2005). Isolation left students talking to nonmedical confidants, who struggled to understand the context of the situation, leaving students with only non-verbal outlets; with exercise being the most common coping strategy amongst students. Writing, music, therapy, and prayer sessions are also commonly cited (Ratanawongsa, Teherani, and Hauer, 2005). The lack of emotion sharing between clinicians and students has perpetuated a cycle in which withdrawal from patients, reclusive behaviors, and poor empathy are seen as appropriate coping mechanisms among physicians (Zambrano, Chur-Hansen, and Crawford, 2012).
The cumulative effect of dealing with death over a career leads to emotional fatigue, burnout, and depression among practitioners. It is important for medical professionals to develop an appropriate system for dealing with emotions, preferably one which contains frequent debriefing sessions, and which creates an environment of emotional trust between medical staff. It is also essential for senior physicians to work with junior doctors and allow them to share emotions and seek help when required.
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