“That patient still haunts me,” I heard one of the PICU fellows murmur as he walked out of the auditorium. I wondered if I should have taken comfort after hearing that I was not the only one still struggling with this patient’s death. Despite months passing since this baby died, the memories of this family and their child continued to gnaw at me. It wasn’t until after that morbidity and mortality conference that I realized how raw I still felt. Why was I still so upset from this one patient? After witnessing a fair number of unfortunate patient outcomes in the first year of fellowship, I still struggled to process why this particular clinical scenario was burned into my memory.
As part of a non-surgical subspecialty team, I had felt partially removed from direct patient efforts when this patient was dying. The PICU and surgical teams had been the ones to trudge through the thick of it as the patient was slowly dying. They had been the ones working tirelessly at the bedside for over a week to try to save this infant. As the infectious disease team, it felt like we were limited in what we could offer in comparison. When minor adjustments in antimicrobials or a new clinical trial opening were not going to change the outcome for this child, it felt unfair to disrupt the family as they were grieving. It also felt unfair for me to continue to grieve this baby after they died when I hadn’t been the one managing some of the darkest moments at the end.
As a pediatric infectious disease fellow, my team would regularly see many of the sickest children in the hospital. Our daily list of patients included the child with leukemia dying from disseminated fungal infection, the rainbow baby with severe neonatal meningitis, or the previously healthy teen with toxic shock syndrome on VA-ECMO. Sometimes the predominant number of ICU patients on our list was staggering. There would be days on service when I felt relieved when one of the new consults was from the acute care team, simply because it meant it wasn’t another child acutely dying in the ICU.
Even when patients were clearly dying from a non-infectious etiology, teams asked for the ID team to be involved to make sure they were not missing a contributing infection. We could never be upset with the ICU teams for asking. Nobody wanted to miss something or be seen as throwing in the towel by doing less. Doing more, involving other teams, and leaving “no stone unturned” often made those teams feel better.
This got me thinking about what we do to feel better when we face death with our patients. What do we do to process the death of our patients? As a medical student, I remember discussing the topic of grieving with one of my geriatric patients. I was on internal medicine wards and caring for a woman with worsening congestive heart failure. She was one of the few patients I cared for who had made peace with her impending death, and I remember it being such a relief to me to have a real conversation with her. I asked her about her life and what was important to her. How did she want her family to grieve her when she passed? She told me that she had it all tentatively planned. She had had the difficult conversations when she first got sick and had detailed written instructions for her family to follow. Her children knew the phone numbers of the funeral home to call, the clothes she wanted to be buried in, and even what food to serve at her memorial. Perhaps she could see the surprise in my face when she elaborated on the details, but she explained that she didn’t want her family to be burdened with making decisions for her. She knew they would be grieving and said it wasn’t fair to them to stress over wondering what she would want. To her, this planning was her way of honoring her life, but it was also her way of allowing her family to have the mind space to grieve her death.
I haven’t encountered this same mentality during my training, but I wish I had. Shouldn’t we as physicians have the space to grieve the loss of our patients? The time to process shouldn’t just be the time it takes to walk down the hall to the next crisis or the time it takes to splash cold water onto our face in the staff bathroom. We deserve the support to stop and grieve. We should not struggle in silence. In the moment, we compartmentalize so we can continue caring for the next patient. Weighted down by a suffocating cloak of despair, we push ourselves like we were trained to do. But we need to mourn. Take the time to honor your patients and reflect on your role in their lives. Nobody is going to grant you the space you need to recover, so you must take it yourself. We must recognize and process our grief if we don’t want it to haunt us.
Natalya Beneschott is a pediatric infectious disease fellow.