How do Doctors Cope with a Patient's Death?

[Archaeopteryx]

I was wondering about this issue, and I Googled it and couldn't find anything helpful. So I thought you guys might have some ideas about it.


Do medical schools train students how to deal with situations when they fail to save a patient's life? or how to break the news to the family?
Yes, I know medical schools are supposed to select and build strong characters. But I can't imagine it to be an easy task for any person to cope with death after being trained for years to prevent it.

So back to the original question, do they have some sort of a class for that? or do they leave it for experience?

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[Porfirio]

Booze

 

[Bacchus]

There's no education at all. It happens in rotations if you're lucky.

(My experience)

 

[itsMileyCyrus]

There's no education at all. It happens in rotations if you're lucky.

(My experience)

What happened? (if you feel comfortable sharing)

 

[Bacchus]

I wasn't taught how to cope with a patient who's coding, dies, or takes a turn for the worse. Medical students shouldn't deliver that news and as such my school does no formal training in it. It really isn't something that can be standardized because each patient interaction is unique. I was just hoping there was some way to learn it before being placed in one of the situations above. It doesn't seem appropriate to screw it up a few times and then finally realize what to say.

Luckily, I've only been responsible for one patient who coded and I only saw my first death pronouncement on Friday after 10 months of rotations. My resident and intern in the code and subsequent aftermath did not handle it appropriately IMO. They appeared cold to the family, not tuned into their emotions at all.

 

[Archaeopteryx]

I wasn't taught how to cope with a patient who's coding, dies, or takes a turn for the worse. Medical students shouldn't deliver that news and as such my school does no formal training in it. It really isn't something that can be standardized because each patient interaction is unique. I was just hoping there was some way to learn it before being placed in one of the situations above. It doesn't seem appropriate to screw it up a few times and then finally realize what to say.

Luckily, I've only been responsible for one patient who coded and I only saw my first death pronouncement on Friday after 10 months of rotations. My resident and intern in the code and subsequent aftermath did not handle it appropriately IMO. They appeared cold to the family, not tuned into their emotions at all.

Thank you very much, this was very insightful. But see the thing you said about the resident and the intern is what I was wondering about. I mean I can't judge because they might have seemed cold because they were trying to suppress their feelings, but I could easily see myself being very emotional when delivering news like these, which is not good either.

 

[PMPMD]

I was wondering about this issue, and I Googled it and couldn't find anything helpful. So I thought you guys might have some ideas about it.


Do medical schools train students how to deal with situations when they fail to save a patient's life? or how to break the news to the family?
Yes, I know medical schools are supposed to select and build strong characters. But I can't imagine it to be an easy task for any person to cope with death after being trained for years to prevent it.

So back to the original question, do they have some sort of a class for that? or do they leave it for experience?

I will tell you about my experiences - I'm a critical care (ICU) fellow so I deal with this fairly often. I suppose we got some training on this in med school but it's not really something that goes easily into a powerpoint lecture.

The magnitude of my emotional response to a patient's death seems to depend on how long I've been caring for them, the severity of their illness (how much I could see it coming,) and other factors, such as their age. I'm not saying one death is better or worse than another (or more or less sad), just that some factors seem to produce a larger emotional response. Obviously, the longer I've known the patient, the more I've connected with them and their family. If a patient has a terminal illness that has been progressing over months, we can prepare for the likelihood/inevitability of their death. And it tends to be easier to rationalize/intellectualize deaths in older patients. I'm not saying it's still not sad. So it tends to be that the most emotionally upsetting deaths are in young, previously healthy patients. I am thankful that I only care for adults - I don't think I could handle the death of a child.

I think it's good to feel a range of emotions. Would it be inappropriate to feel good when a sick patient gets better? Why should it be bad to feel sad when one dies? As long as it doesn't keep you from caring for other patients. It's hard to say if it gets easier to deal with death over years of a career. I had deaths that were upsetting as an intern. Five years later, I've also had patient deaths that were upsetting to a similar degree.

People become doctors because they care about human life and want to help people. I think it's a natural reaction to have a range of emotions when someone who you want to help dies. I don't think it would be good to ignore or suppress that. I prefer to acknowledge it, think about it in context, and reflect on what could have been done differently.

Most of the deaths I've dealt with in the ICU were incredibly ill patients - multisystem organ failure, on ventilators, multiple pressors (drugs to keep the blood pressure up), dialysis, etc. Their outlook was very poor. In the unlikely event they had ended up surviving their illness, they would have faced a poor quality of life. I can look to these facts to help ease (rationalize) the impact. But then I talk to their famly and no longer see numbers or machines, I see the human impact on the loved ones who are affected.

I think the best I can do as a doctor when someone is going to die (after all medical options have been exhausted) is to try to allow them to die with some dignity, and keep the family informed to how their loved one is doing.

 

[IlDestriero]

Death is an inevitable part of life. If you're end stage and you die through no fault of mine, I can't say I take it very badly. I feel bad, but it's not something I bring home with me. It would be very different if I felt that my actions, or inactions lead directly to your harm or death. It's an ongoing concern of mine as I'm an academic anesthesiologist and work with trainees. You can't be there all the time to see exactly what's going on.
I do find the pediatric oncology clinic procedure room too depressing a day. When I, rarely, find myself scheduled there, I usually swap assignments with another staff. They're more than happy to switch as it's technically a very easy assignment.
If one of your patients dies, make sure you go with the staff to see how they handle this with the family. We had a total of 2 lectures on the topic in medical school. One on breaking bad news and part of another one about limiting liability.
One thing to note, it's usually considered perfectly acceptable to show remorse, apologize (generally) about the bad outcome. That's not admissible as an admission of guilt/fault/malpractice. You don't want to say "it's all my fault." A CA surgeon learned that the hard way recently. The CA supreme court ruled that it was an admission of guilt and not protected like the "I'm sorry". As I recall, it wasn't even clear that he had done anything wrong. Sad but true.

 

[Archaeopteryx]

I will tell you about my experiences - I'm a critical care (ICU) fellow so I deal with this fairly often. I suppose we got some training on this in med school but it's not really something that goes easily into a powerpoint lecture.

The magnitude of my emotional response to a patient's death seems to depend on how long I've been caring for them, the severity of their illness (how much I could see it coming,) and other factors, such as their age. I'm not saying one death is better or worse than another (or more or less sad), just that some factors seem to produce a larger emotional response. Obviously, the longer I've known the patient, the more I've connected with them and their family. If a patient has a terminal illness that has been progressing over months, we can prepare for the likelihood/inevitability of their death. And it tends to be easier to rationalize/intellectualize deaths in older patients. I'm not saying it's still not sad. So it tends to be that the most emotionally upsetting deaths are in young, previously healthy patients. I am thankful that I only care for adults - I don't think I could handle the death of a child.

I think it's good to feel a range of emotions. Would it be inappropriate to feel good when a sick patient gets better? Why should it be bad to feel sad when one dies? As long as it doesn't keep you from caring for other patients. It's hard to say if it gets easier to deal with death over years of a career. I had deaths that were upsetting as an intern. Five years later, I've also had patient deaths that were upsetting to a similar degree.

People become doctors because they care about human life and want to help people. I think it's a natural reaction to have a range of emotions when someone who you want to help dies. I don't think it would be good to ignore or suppress that. I prefer to acknowledge it, think about it in context, and reflect on what could have been done differently.

Most of the deaths I've dealt with in the ICU were incredibly ill patients - multisystem organ failure, on ventilators, multiple pressors (drugs to keep the blood pressure up), dialysis, etc. Their outlook was very poor. In the unlikely event they had ended up surviving their illness, they would have faced a poor quality of life. I can look to these facts to help ease (rationalize) the impact. But then I talk to their famly and no longer see numbers or machines, I see the human impact on the loved ones who are affected.

I think the best I can do as a doctor when someone is going to die (after all medical options have been exhausted) is to try to allow them to die with some dignity, and keep the family informed to how their loved one is doing.

Wow, thank you very much for sharing!
I could understand why the death of younger people could be more upsetting.
True, doctors could only help so much, it is sometimes better to let patients die peacefully.

Again, Thank you

 

[oldbearprofessor]

So back to the original question, do they have some sort of a class for that? or do they leave it for experience?

Some schools, including the one I work at, do have formal educational sessions about this. However, there is only so much you can learn from simulations, discussions and lectures, especially about this.

Neonatologists deal with death all of the time. Typically I have at least 1 or 2 deaths every month that I work in the NICU, sometimes more. I've been at this as an attending for over 20 years, so I've done it a lot.

What I've learned is that dealing with the impending death, actual death and the post-death discussions with families, although not enjoyable, is one of the most rewarding aspects of my job. My view is shared by many of my colleagues and some even have focused on things like neonatal hospice care and bereavement.

Why? Well because like everything else we do, and in some ways more than many things we do, the attitudes, caring and skill of the physicians, nurses and others in this situation makes a huge difference. Done properly and compassionately, families have a very different experience than when not done this way. They tell us this over and over again.

A simple example to help understand this. In telling a family that there is no benefit to (more) CPR on a baby who is now certain to die, saying things like "We've done all we can for your baby and more things like chest compressions will not be helpful, now we want you to hold your baby while we give {insert baby's actual name} medicine to make sure {insert correct gender pronoun} is not having any pain." beats the heck out of "Is it okay with you if we stop doing chest compressions on {insert wrong gender pronoun} because they aren't working. Your baby is going to die anyway."

Satisfaction also comes from doing autopsy discussions with families months after a baby's death and answering all of their questions.

In the end, training in these things takes time, experience, comfort with ones one medical practice, and a real understanding of the blessings to a family that compassionate care surrounding the time of a baby's death means to them.

Trainees at every level learn this as they do everything else. See one, do one, teach one. Or more than one.

 

[Archaeopteryx]

Death is an inevitable part of life. If you're end stage and you die through no fault of mine, I can't say I take it very badly. I feel bad, but it's not something I bring home with me. It would be very different if I felt that my actions, or inactions lead directly to your harm or death. It's an ongoing concern of mine as I'm an academic anesthesiologist and work with trainees. You can't be there all the time to see exactly what's going on.
I do find the pediatric oncology clinic procedure room too depressing a day. When I, rarely, find myself scheduled there, I usually swap assignments with another staff. They're more than happy to switch as it's technically a very easy assignment.
If one of your patients dies, make sure you go with the staff to see how they handle this with the family. We had a total of 2 lectures on the topic in medical school. One on breaking bad news and part of another one about limiting liability.
One thing to note, it's usually considered perfectly acceptable to show remorse, apologize (generally) about the bad outcome. That's not admissible as an admission of guilt/fault/malpractice. You don't want to say "it's all my fault." A CA surgeon learned that the hard way recently. The CA supreme court ruled that it was an admission of guilt and not protected like the "I'm sorry". As I recall, it wasn't even clear that he had done anything wrong. Sad but true.

Pediatric Oncology? People who work in that department are brave!

So do doctors usually not admit mistakes? Is it the fear of a lawsuit? or are there Hospital rules that apply to such circumstances?

 

[Praefectus]

Pediatric Oncology? People who work in that department are brave!

So do doctors usually not admit mistakes? Is it the fear of a lawsuit? or are there Hospital rules that apply to such circumstances?

I assume you wouldn't want culpability for any legal action, foreseen or unforeseen.

 

[IlDestriero]

Pediatric Oncology? People who work in that department are brave!

So do doctors usually not admit mistakes? Is it the fear of a lawsuit? or are there Hospital rules that apply to such circumstances?

Bad things happen, somebody's got to be the 1:1000 or 1:100,000.
You can be sorry, you can show empathy, you can be scientific and explain the details, but admitting a "mistake" is just going to get you sued. That's why you can say "I'm sorry" that doesn't mean you're admitting to an error. If you really did make an error, it's best to work with risk management. That's what they get paid to do.

 

[Archaeopteryx]

I started this thread thinking I was going to get some simple answers about whether medical schools prepared students for such incidents (which I got). But the replies were also amazing and went some places where I haven't anticipated. You all have given me a lot of things to think about. Thanks to everyone who replied.

 

[Neurosis]

I'd imagine that medical schools don't teach people how to deal with death, how a doctor copes with death is probably dependent on two things: (a) experience (b) emotional competence. The former can obviously be learned/gained, the latter however is mostly innate.

 

[Neurosis]

Pediatric Oncology? People who work in that department are brave!

I could never imagine why people would go into oncology. I feel like it's the most depressing specialty (with neurology a close second).

 

[235788]

I could never imagine why people would go into oncology. I feel like it's the most depressing specialty (with neurology a close second).

well maybe its not for you. I can see why someone would.

 

[235788]

Bad things happen, somebody's got to be the 1:1000 or 1:100,000.
You can be sorry, you can show empathy, you can be scientific and explain the details, but admitting a "mistake" is just going to get you sued. That's why you can say "I'm sorry" that doesn't mean you're admitting to an error. If you really did make an error, it's best to work with risk management. That's what they get paid to do.

you gas, correct?

In surgery, the physician responsible for the death talks to the family about it? Or does the surgeon always do it? How does that all work out?

 

[dfk228]

I could never imagine why people would go into oncology. I feel like it's the most depressing specialty (with neurology a close second).

Onc can be a difficult specialty, but there are so many different kinds of cancers it is difficult to generalize too much. Some have very good prognosis such that you can truly make an amazing impact on someone's life.

 

[Gut Shot]

I was wondering about this issue, and I Googled it and couldn't find anything helpful. So I thought you guys might have some ideas about it.


Do medical schools train students how to deal with situations when they fail to save a patient's life? or how to break the news to the family?
Yes, I know medical schools are supposed to select and build strong characters. But I can't imagine it to be an easy task for any person to cope with death after being trained for years to prevent it.

So back to the original question, do they have some sort of a class for that? or do they leave it for experience?

Coping isn't bad, provided you have at least 30,000 BTUs and three burners.

Gallows humor helps.

 

[druggeek]

The human race has an amazing ability to adapt and "get used to it." Same idea basically for doctors, it becomes part of the job. Of course the magnitude also changes... ex. being a pediatric oncologist is certainly worse than being a neurosurgeon.... Just cause with the former you're seeing KIDS (who have years ahead of them) die slowly vs. seeing someone who's going to die in 6 months anyway of x disease die in the OR.

 

[oldbearprofessor]

So do doctors usually not admit mistakes? Is it the fear of a lawsuit? or are there Hospital rules that apply to such circumstances?

This is a complex issue. In general, it is appropriate and necessary to tell a family what happened, e.g. "the central line perforated the right atrium causing a pericardial effusion and a cardiac arrest" is a factual description. It is not okay to say "We goofed up and put the central line in the wrong place and then we ended up having to code your baby."

If it appears that the situation was not unquestionably a usual complication of care (e.g. intestinal perforation in a tiny preterm which is a known typical event) or if the family appears to be putting blame, etc, then it is MANDATORY to contact risk management immediately or sooner and start getting advice from them and following that advice.

They will investigate, ask about what happened and then make recommendations for dealing with the family. They will not generally want you to take responsibility for a medical error, but want you to simply explain to the family what happened in honest and direct terms. The reason for this is that assignment of responsibility is itself a complex task that should not be done by one physician - responsibility for major errors often is shared amongst a number of people, not just one or more physicians ("sentinel events").

BTW, it is not true that if you fess up to a mistake, families won't sue. Of course it is best to be compassionate and straight-forward and try to keep on a family/patient's good side, but if one makes a (perceived or real) mistake leading to brain damage in a baby, don't expect the family to ignore the possibility of millions of dollars in a lawsuit just because they like you.

 

[LaEsponja]

Great thread and amazing responses.

 

[tenndoc]

the surgeon i followed this summer told me you have to get back on the horse and keep on going. not forget it, but use it to better yourself. we had a biker come in this summer and he had broken nearly every bone from his neck down and was bleeding out pretty badly. they tried to save him but he was just too unstable to really do anything to. long story short... he died on the table. i went home and got a text from my doctor that night. "we try to win them all but there are some we just can't get. it happens. see you thursday." it was a little blunt but it really helped me see the pointlessness of getting hung up on a single person's death (although it was a very sad event). you just have to move on and try your best on the next case

 

[O2Doc]

While my med school also had some Powerpoint and standardized interviews on breaking bad news, you don't really learn until you're on the rotations. And then you learn at first by observing your residents and attendings. You won't be the one breaking bad news right away, you should have plenty of time for observing.

Most likely you'll see some older and/or chronically/terminally ill people die and their family get the news, long before you have to be the one to break it. You might or might not see the same for an otherwise healthy person's sudden/accidental death - hopefully you will, because breaking the news in that case is much more traumatic. When I was on my IM rotation we had some elderly DNR patient die every couple of nights or so, just in their beds (the nurses would find them and call us to declare), and there really was a rather comforting, routine way to break the news. But these were expected deaths.

That said, my very first solo declaration was on my second intern rotation, in the middle of the night for one of these old expected deaths. I was flummoxed and making my way through all the required paperwork, and one of the paperwork checkmarks was to notify the attending. I paged him.

Let me tell you, sweet kindly palliative types are not that kindly at all when you wake them at 4am on their on-call-for-emergencies-only night for a patient who was an expected death.

 

[deleted393595]

Great question OP, and certainly one that doesn't cross our minds that often.

I don't know very much about this, but from the tidbits that I've learned, we differ from other countries in that our healthcare system views death as a failure. Unlike us, doctors in Japan view it as natural and unavoidable. So I guess that US docs would blame themselves for the death.

On the other hand, this might also be how they feel:

 

[Bacchus]

The declaration I saw on Friday was expected. Family was in the room for the declaration and chose not to leave. I didn't find the situation awkward, but it wasn't an acute kind of situation. It also helped that the patient wasn't one I was familiar with or the intern for that matter. She had to make the declaration, but wasn't caring for the patient.

The US as a whole has set too high a standard for physicians and thus doesn't realize the inevitable. Sigh.

 

[Medical Muse]

The only formal training I remember receiving was about what not to say. How to actually tell the family we learned on the wards from the residents and attendings. What I found was helpful to the family was inviting them in the room when we were at the tail end of a code. I've never had a family member ask us to continue a code after seeing it.

The worst time for me was telling a family member over the phone. I remember his son picked up and said, "hey doc, how you doing?" in a cheerful voice, and then I had to tell him that his father was dead. The family came in, and I had to tell them again. This death still pisses me off because I don't think he should have died. I won't get into the details, but be very, very careful giving oxygen to someone with COPD.

One of the things that helped me the most in residency, and I say this in all honesty, was the show Scrubs. It's the most realistic medical show out there. Plus, it's good to laugh in medicine. It keeps you sane.