0
Editorials |

Our Responsibility for Training Physicians to Understand the Effect Patient Death Has on ThemUnderstanding Patient Death Effect on Physicians: The Role of the Intensivist FREE TO VIEW

J. Randall Curtis, MD, MPH, FCCP; Mitchell M. Levy, MD, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Dr Curtis), Harborview Medical Center, University of Washington; and Division of Pulmonary, Critical Care and Sleep (Dr Levy), Rhode Island Hospital, Brown University.

Correspondence to: J. Randall Curtis, MD, MPH, FCCP, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Box 359762, 325 Ninth Ave, Seattle, WA 98104; e-mail: jrc@u.washington.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(5):932-934. doi:10.1378/chest.13-2600
Text Size: A A A
Published online

Death can have a powerful emotional effect on physicians, whether they are medical students, postgraduate trainees, or those who have finished their training.1,2 Physicians at various stages of training and practice report similar emotional impact, with one-third reporting that a recent death had a “strong” emotional impact on them; they report similar symptoms of grief.1,2 Medical students and residents often describe a powerful and “haunting” effect that even expected deaths can have on them, with some of these deaths described as “just too awful.”2-4 Such deaths can have a lasting impact, and caring for the dying is one of the major predictors of burnout among physicians and nurses.5-8 Unfortunately, very little formal training in coping skills for dealing with death is offered to physicians-in-training. Medical students, interns, and residents are, for the most part, left to fend for themselves when working through their emotional reactions to the death of a patient.

In this issue of CHEST (see page 958), Fraser and colleagues9 report a randomized trial of 116 medical students at one university who were randomized to one of two simulated patient scenarios involving a critically ill patient with decreased level of consciousness. The two scenarios were identical except that in one scenario the patient was transferred to the ICU team, ending the case; in the other scenario, the patient died. Not surprisingly, medical students randomized to the scenario ending with patient death reported more negative emotions and a higher cognitive load after the simulation exercise. Interestingly, those medical students randomized to simulated patient death were also less competent to diagnose and manage a patient with reduced consciousness 3 months later during an objective structured clinical examination. The influence of negative emotions associated with death during this scenario apparently resulted in greater cognitive load, less learning, and lower performance.

What are the implications of this study for intensivists? The ICU is a common setting for death, with approximately 20% of all deaths in the United States occurring in or shortly after a stay in the ICU.10 In addition, for patients > 65 years of age, the proportion of deaths that involved an ICU stay in the last month of life actually increased between 2000 and 2009.11 In the training of physicians, medical students, and residents, one of the most common places where they care for patients who die is in the ICU. Proximity to death prior to medical school is unusual in our western culture. Many of us grow up with very little exposure to death or grief. Therefore, the ICU becomes an invaluable setting to train and support physicians in appreciating and understanding the influence of patient death on their own emotional health, the sustainability of their career, and, according to this new study, their ability to learn medicine.

How well do we do in teaching medical students and residents to understand the impact patient death has on them? Prior studies suggest that we are, in a word, abysmal.1-3 Medical students and residents report they are left to address and understand the emotions involved with caring for patients who have died in isolation and often without any help at all from their attending physicians.2,3 Put bluntly, we abandon them during these emotionally challenging moments of coping with their reactions to death. Consequently, trainees turn to each other much more frequently than they find support from attending physicians. On the rare occasion when medical students report that an attending physician discussed the emotional aspects of a patient death with them, they find it very helpful and express deep appreciation.3

These studies suggest that we have a moral imperative to learn to support physician trainees through the experience of a patient death. Our ability to provide this support will likely influence not only the emotional health of our trainees, but also their ability to sustain a career in medicine, learn the basic skills of medicine, and provide competent, reflective care for dying patients. In addition, our inability to help trainees understand and address the influence of these emotions on them creates a cycle of ineptitude with future generations of attending physicians who do not have these skills to support future generations of trainees.

What can we offer our trainees that might help? The ICU, with its frequent deaths, offers an opportunity to create a systematic approach to address these emotions. One approach that has achieved success and sustainability is “Death Rounds.”4,12,13 In Death Rounds, trainees, faculty, and other members of the ICU team collaboratively review the deaths in the ICU in the preceding 1 to 2 weeks with a focus on how things went in the care of the patient and family as well as the influence of these deaths on us. The goal is not to find fault but to create a safe environment where trainees can talk about their feelings and hear from others how they experience these deaths and how they keep patient deaths from having negative effects on the quality of their care, careers, and lives. If the faculty members are talking > 20% of the time during Death Rounds, they are missing the point of Death Rounds. There are many other methods to teach self-reflection and mindfulness and to share experiences that can help trainees understand and address these emotions and keep these emotions from having negative effects on their ability to care for patients as well as their own sense of job satisfaction and burnout.14-18 There is no single “best” approach to incorporate reflection and self-awareness into our lives and our jobs, and trainees should be encouraged to find an approach that works for them. It is a matter of acknowledging the inherent difficulties that arise when we are confronted with death—being honest and genuine with ourselves and our patients, being willing to share their pain and grief, and accepting that it never gets “easy.”

As intensivists, we care for more than our share of dying patients and, therefore, bear more than our share of responsibility for ensuring that we teach our trainees about the influence these deaths have on them. We cannot help others with this task if we cannot do this for ourselves.

References

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(7408):185. [CrossRef] [PubMed]
 
Jackson VA, Sullivan AM, Gadmer NM, et al. “It was haunting...”: physicians’ descriptions of emotionally powerful patient deaths. Acad Med. 2005;80(7):648-656. [CrossRef] [PubMed]
 
Rhodes-Kropf J, Carmody SS, Seltzer D, et al. “This is just too awful; I just can’t believe I experienced that...”: medical students’ reactions to their “most memorable” patient death. Acad Med. 2005;80(7):634-640. [CrossRef] [PubMed]
 
Vallurupalli M. Mourning on morning rounds. N Engl J Med. 2013;369(5):404-405. [CrossRef] [PubMed]
 
Whippen DA, Canellos GP. Burnout syndrome in the practice of oncology: results of a random survey of 1,000 oncologists. J Clin Oncol. 1991;9(10):1916-1920. [PubMed]
 
Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. [CrossRef] [PubMed]
 
Embriaco N, Azoulay E, Barrau K, et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007;175(7):686-692. [CrossRef] [PubMed]
 
Poncet MC, Toullic P, Papazian L, et al. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med. 2007;175(7):698-704. [CrossRef] [PubMed]
 
Fraser K, Huffman J, Ma I, et al. The emotional and cognitive impact of unexpected simulated patient death: a randomized controlled trial. Chest. 2014;145(5):958-963.
 
Angus DC, Barnato AE, Linde-Zwirble WT, et al; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32(3):638-643. [CrossRef] [PubMed]
 
Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309(5):470-477. [CrossRef] [PubMed]
 
Hough CL, Hudson LD, Salud A, Lahey T, Curtis JR. Death rounds: end-of-life discussions among medical residents in the intensive care unit. J Crit Care. 2005;20(1):20-25. [CrossRef] [PubMed]
 
Khot S, Billings M, Owens D, Longstreth WT Jr. Coping with death and dying on a neurology inpatient service: death rounds as an educational initiative for residents. Arch Neurol. 2011;68(11):1395-1397. [CrossRef] [PubMed]
 
Fins JJ, Gentilesco BJ, Carver A, et al. Reflective practice and palliative care education: a clerkship responds to the informal and hidden curricula. Acad Med. 2003;78(3):307-312. [CrossRef] [PubMed]
 
Jackson VA, Back AL. Teaching communication skills using role-play: an experience-based guide for educators. J Palliat Med. 2011;14(6):775-780. [CrossRef] [PubMed]
 
Yedidia MJ, Gillespie CC, Kachur E, et al. Effect of communications training on medical student performance. JAMA. 2003;290(9):1157-1165. [CrossRef] [PubMed]
 
Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293. [CrossRef] [PubMed]
 
O’Reilly KB. Using mindfulness to soothe physician stress. American Medical Association American Medical News website. http://www.amednews.com/article/20130107/profession/130109974/4. Published January 7, 2013. Accessed October 30, 2013.
 

Figures

Tables

References

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(7408):185. [CrossRef] [PubMed]
 
Jackson VA, Sullivan AM, Gadmer NM, et al. “It was haunting...”: physicians’ descriptions of emotionally powerful patient deaths. Acad Med. 2005;80(7):648-656. [CrossRef] [PubMed]
 
Rhodes-Kropf J, Carmody SS, Seltzer D, et al. “This is just too awful; I just can’t believe I experienced that...”: medical students’ reactions to their “most memorable” patient death. Acad Med. 2005;80(7):634-640. [CrossRef] [PubMed]
 
Vallurupalli M. Mourning on morning rounds. N Engl J Med. 2013;369(5):404-405. [CrossRef] [PubMed]
 
Whippen DA, Canellos GP. Burnout syndrome in the practice of oncology: results of a random survey of 1,000 oncologists. J Clin Oncol. 1991;9(10):1916-1920. [PubMed]
 
Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. [CrossRef] [PubMed]
 
Embriaco N, Azoulay E, Barrau K, et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007;175(7):686-692. [CrossRef] [PubMed]
 
Poncet MC, Toullic P, Papazian L, et al. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med. 2007;175(7):698-704. [CrossRef] [PubMed]
 
Fraser K, Huffman J, Ma I, et al. The emotional and cognitive impact of unexpected simulated patient death: a randomized controlled trial. Chest. 2014;145(5):958-963.
 
Angus DC, Barnato AE, Linde-Zwirble WT, et al; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32(3):638-643. [CrossRef] [PubMed]
 
Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309(5):470-477. [CrossRef] [PubMed]
 
Hough CL, Hudson LD, Salud A, Lahey T, Curtis JR. Death rounds: end-of-life discussions among medical residents in the intensive care unit. J Crit Care. 2005;20(1):20-25. [CrossRef] [PubMed]
 
Khot S, Billings M, Owens D, Longstreth WT Jr. Coping with death and dying on a neurology inpatient service: death rounds as an educational initiative for residents. Arch Neurol. 2011;68(11):1395-1397. [CrossRef] [PubMed]
 
Fins JJ, Gentilesco BJ, Carver A, et al. Reflective practice and palliative care education: a clerkship responds to the informal and hidden curricula. Acad Med. 2003;78(3):307-312. [CrossRef] [PubMed]
 
Jackson VA, Back AL. Teaching communication skills using role-play: an experience-based guide for educators. J Palliat Med. 2011;14(6):775-780. [CrossRef] [PubMed]
 
Yedidia MJ, Gillespie CC, Kachur E, et al. Effect of communications training on medical student performance. JAMA. 2003;290(9):1157-1165. [CrossRef] [PubMed]
 
Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293. [CrossRef] [PubMed]
 
O’Reilly KB. Using mindfulness to soothe physician stress. American Medical Association American Medical News website. http://www.amednews.com/article/20130107/profession/130109974/4. Published January 7, 2013. Accessed October 30, 2013.
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543