Death, Dying

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Death, Dying the Medical Student

• Towards good practice via awareness self-care
• Frank McDonald
• Consultation and Liaison Psychologist
• The Townsville Hospital
• 2006
• Download this linked materials at
  www.fmcdonald.com

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Overview

• Background to this presentation
• Nature of the problem
• What can we achieve today?
• Stressors associated with working with death and
  dying
• Which medical students more likely which less
  likely to cope constructively with their grief
  loss experiences?
• Loss, grief bereavement coping skills - sharing
  some ideas

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Background

• One of the more difficult aspects of medicine
  allied professions can be witnessing the dying
  process for both uninitiated students
  experienced practitioners
• Few curricula literature reports address how
  you are to behave, manage emotion confront
  cope with your own distress grief when pts die
• But what if only a few of your guides mentors
  (e.g. snr residents consultants) talk about
  death dying, or teach much about thanatology
  (the study of grief surrounding death), why
  should you bother?

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Background

• Lets hear from 1st to 4th year medical students
  who seem to be in tune with a genuine, practical
  need whose requests for change can hopefully
  influence those at the top, combined with the
  voices of community needs and experienced
  practitioners (e.g. Cairns Yates 2003) (we
  feel) inadequately prepared to communicate with
  terminally ill patients, as well as being poorly
  equipped emotionally to deal with matters of
  death and dying. This is important to us on a
  personal level as we face dying patients almost
  daily on the wards. (Am. Med. Students
  Assoc. website 2006)

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Background

• Understand your own personal feelings about death
  Most people have a vague belief of death or what
  happens after death. For isnt it the uncertainty
  of it all that scares us most? We are so used to
  dealing with concrete physical deformities that
  we can test and probe and examine, so when we are
  faced with the ambiguity of death we suddenly
  feel helpless. So we skirt around the issue and
  leave the room in a moment of awkwardness when
  the news is broken to the patients family It
  helps to think about these things (our coping
  strategies). The more we know ourselves, the more
  evident it will be to our patients. Jemima
  Tagal, third year medical student, University of
  Cardiff (Student BMJ 2006)

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Background

• Quite rightly, medical students receive training
  on how to break bad news to patients and
  families, but medical students who experience the
  death of a patient or a distressing case get
  little support students may receive a small
  amount of counselling to help them deal with bad
  news or bereavement. A confidential counselling
  service available 24 hours specifically for the
  medical profession, so they may deal with death
  in an appropriate way (both at a personal and
  professional level) would surely be appropriate.
  It is vital that the "medical culture that
  defines death as failure" ends.Simon Clausen,
  fourth year medical student University of Leeds
  (Student BMJ, 2003)

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Background

• Students who have witnessed death thru personal
  experience of family, friends, or volunteer or
  other work report a range of experiences . . .
  from the traumatic . . .

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Background

• . . . to lack of emotion . . .
• (Too much of this can suggest denial problems
  or other, eventually costly, defences. Meier et
  al. JAMA 2001, found unexamined physician emotion
  may interfere with pt care lead to physical
  distress, disengagement, burnout/cynicism, poor
  judgment. Medicos dont have good record with
  emotional self-care.)

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Background
. . .Others who have yet to experience their
first pt death anticipate a gamut of affects
concerns sadness, confronting mortality,
frustration, guilt, self-doubt, blame,
helplessness, a sense of failure, and most
frequently quoted of all - FEAR . . .
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Background

• . . . some, wisely, are concerned about becoming
  too inured to death that this excessive
  detachment would numb their sensibilities
  necessary for good medical practice . . .

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Background

• . . . Individual constructions of death can
  depend on the context whether they had a good
  relationship with the pt. who is dying at
  what age.
• Many fear the unexpected death, as well as
  the death of a child or young adult . . .

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Background

• . . . but upon reflecting upon the death of any
  hypothetical first patient, anxiety about death
  re-emerges as a major theme . . .

13
Background

• One student sums up the need for self-care,
  for medical education to get involved with the
  need for coping strategies, when confronting the
  dying pt.

Quotes extracted from C.M.Williams et al., 2005,
J. Palliative Medicine (Highlights mine)
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Nature of the problem

• Before discussing some self-care/coping skills,
  some exercises to begin establishing these, it
  can help to understand the nature of the problem
  of working with dying pts.

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Nature of the problem

• 1. In Medicine generally physical psychological
  demands high. Working with death dying is work
  of a special nature. Places additional unusual
  demands on coping skills
• making breaking bonds repeatedly
• need to grieve deal with effects
• pressure to develop realistic expectations (e.g.
  balancing self-care with care of dying pt.)
• coping with conflicting demands (pts, families,
  social, workplace, personal needs)
• dealing with ethical issues (when does preserving
  life become prolonging death?)
• limited time to interact with colleagues (e.g. to
  debrief)

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The most stressful jobs

• Teacher high school, inner city, higher primary
  grades
• Police officer
• Miner
• Air traffic controller
• Junior hospital doctor
• Stockbroker
• Journalist
• Customer-service/Complaints Dept worker
• Waitress
• Secretary/receptionist
• Machine-paced worker
• Bus driver
• Nurse
• Solicitor
• Professional groups with responsibility for life
• International airflight crew
• Unskilled semi-skilled worker
• Common thread/s?

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Nature of the problem

• 2. Easy to miss signs symptoms of bereavement
  overload (term refers to effects of serial
  losses originally applied to experiences of the
  elderly)
• can be very insidious
• old emotional reactions can be triggered w/o you
  knowing
• expectations of what you can do to support can be
  unrealistic

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Nature of the problem

• 3. You risk costs of excessive stress if you
• Ignore usual stress grief reactions
• Dont take sufficient time-out / try to do too
  much
• Lack organisational social support
• End up hurting yourself reducing your ability
  to help others

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What can we achieve today?

• Examine discuss how medical staff recognise
  cope with the stress of their grief, as distinct
  from that of those they care for
• Help prevent bereavement overload
• Legitimise the experience of grief-related stress
  in your work your emotional needs

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What can we achieve today?

• Heighten awareness of how losses, in the course
  of your work, can affect you
• Discuss some ideas for better management of
  stress of grief
• Raise awareness of early experiences and their
  influence on our reactions
• Discuss how we can draw on our experiences with
  adversity to help ourselves and others at times
  of death
• Being prepared for stress or demand is one of the
  best ways to mx it. Reflecting on the death of a
  hypothetical pt

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Stressors of care-givers grief

• 98 of 6,000 surveyed who work with the dying say
  they experience significant difficulties
  (Kavanaugh, 1974)
• 3 types of stress identified
• Forces to look at own mortality losses
• Multiple bereavements without closurefailure to
  grieve bereavement overload
• Unrealistic expectations about helping dying
  person alearned helplessness

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Stressors of care-givers grief

• More on bereavement overload - some causes of
  failure to grieve
• Social negation of loss of patient - often not
  defined as appropriate loss to be grieved
• Cut off from collegiate support
• Strong one role bound up with doctoring (
  other jobs like army personnel, nurse, minister
  etc)
• Easy to over-identify with others in crisis of
  loss because its a universal experience - can
  avoid reawakening old losses if suppress grief
• Overwhelmed by multiple loss

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Who copes?

• Those who understand grief bereavement theory.
  See How to tell if grief is progressing
  normally (Exercises to follow deepen this
  understanding)
• Complete bereavement tasks (those who work
  through grief)
• Use available support
• Can choose from a range of constructive coping
  strategies
  (Saunders Valente, 1994)

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Who doesnt cope?

• Environmental and personal factors predicting
  general distress in interns residents(Daly and
  Willcock, 2002)

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Preventing bereavement overload

• Description of personal coping strategies tip
  sheet for bereaved care-givers

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Some resources hyperlinked

• Supplements section of eMJA on medical student
  stress MJA 2002 177 (1 Suppl) S1-S32
• While written for individuals going thru a
  relationship break-up, this book - mostly in dot
  point form - gives generalisable insights into,
  hope for working thru, grief How to Survive
  the Loss of a Love
• Text only from the illustrated book for
  childrens questions about death The Fall of
  Freddie the Leaf

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Some resources hyperlinked

• Buddha and The Mustard Seed - parable about
  universality of death, sorrow suffering,
  tragedy loss. May help someone who is stuck
  in movement towards acceptance.
• Harpers (1977) 5 Stage Model helps reflect on
  where you are in your emotional progress of
  personal and professional maturation towards
  being helpful to pts facing death, mindfulness
  of your own needs

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Exercises - hyperlinked

• Exercise 1. - Worden's "History of Loss
  Questionnaire".  
•  
• To be discussed in a dyad or triad. This
  raises awareness of how early experiences with
  loss at least and (perhaps in some students'
  cases) death leaves us with messages, feelings,
  fears and attitudes that influence our response
  to the dying and the bereaved. Awareness raised
  by this exercise prevents becoming controlled by
  these reactions.
•  
• Exercise 2. - Your psychological, social and
  physical responses to the three most difficult
  situations in your life. 
•  
• A handout structures this exercise. It
  illustrates that we all have some experience with
  grief that we can draw on to assist us in dealing
  with others' and our own reactions to the dying
  patient.
• Share with a classmate who actively
  listens/paraphrases and responds.
• Exercise 3. - Reflect on how you might respond to
  the death of a hypothetical patient. (Handout to
  help generate pt profiles prompts for ways in
  which you may respond). Discuss in small groups
  of 2 or 3. Written reflection exercises improve
  skills.

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Glasbergen on the dual scientific humanitarian
focus of Medicine