I remember my first death. He was my patient, a 59 year old who suffered an episode of asphyxiation. His story was tragic, a reminder of the frailty of human life. After choking on a food bolus at home, he had called 911.

Unfortunately, he suffered a prolonged cardiac arrest that resulted in irreversible brain damage. He spent two weeks in the intensive care unit in hopes of a recovery, but the outcome was not positive. When I went to see him, tubes were coming out of every orifice in his body. He was intubated and unable to be weaned from the ventilator to breathe on his own. His body had become progressively more swollen by the day, and now his face was barely recognizable.

Pictures of a younger, healthier man lay perched at his bedside, and every day that I went in to examine him, I made it a point to take a moment to appreciate the vitality that these pictures represented. As time went on, it was determined that there was no sign of cortical function and that the machine was still doing most of the breathing for him. In essence, he was brain dead. After several family meetings to determine goals of care, we decided to put him through as little pain as possible. He was extubated, and his death came slowly and gradually over the next several days.

The morning he died, I had to be pulled away from 9 a.m. teaching round to pronounce him. My senior resident guided me through the protocol. I auscultated his chest, felt for carotid pulses, checked for reflexes.

Time of death: 9:35 a.m.

The sobs of his family members penetrated the once silent room. I froze, unsure how to console them in this moment and chose to give them the privacy they deserved. I quickly exited, attempted to compose myself, and rejoined my team to continue on with the day’s tasks as if nothing had happened. There I was, standing in a hallway, talking about discharge plans for the rest of my patients with my senior resident when all I could think about was this patient, his family, and the loss of life I had experienced.

Medicine is a profession defined equally by healing as by loss. This experience, I would learn, was not in isolation. Throughout my three years of training as a resident in internal medicine, I would experience death and its accompanying grief a countless number of times. In fact, physicians in every specialty deal with death at some point during their training.

Though the experience is so prevalent for doctors, some would argue that grief in the medical context is considered shameful and unprofessional. Even though they wrestle with feelings of grief, many physicians hide them from others because showing emotion is considered a sign of weakness. Data on grief and its impact on physicians and patient care are sparse.

In a recent study in the Journal of the American Medical Association, researchers reported the impact of unacknowledged grief on oncologists dealing with the death of their patients. What they found was that when these physicians did not have an outlet for their grief, it undeniably resulted in an increase in inattentiveness, impatience, irritability, emotional exhaustion and burnout. Furthermore, the oncologists who reported unacknowledged grief provided more aggressive plans of care for subsequent patients, resulting in more chemotherapy, surgery, and clinical trial enrollment for patients with an already poor prognosis. Unacknowledged grief not only affected the physician; it also significantly affected patient care and resulted in unnecessary health care costs at the end of life.

Though few studies have explored the prevalence and intensity with which physicians experience grief reactions due to patient death, the data that we do have suggests that physicians are more likely to experience grief when faced with the death of a patient under their own care. Some studies support sudden, unexpected death as more grief provoking while others suggest that physicians experience the strongest emotions in death when caring for a patient for a longer period of time. Women have also been shown to have more intense experiences with grief in the aftermath of a patient’s death. The majority of studies relating to experiences of death and grief for physicians have focused on medical students and trainees. Far fewer studies have explored the effects that patient death and grief carry on the experienced attending physician.

This suggests that perhaps as physicians progress further into their careers, the less likely they are to experience significant grief reactions to patient death.  This may be due to the development of more efficient coping mechanisms or perhaps to an emotional detachment that some physicians describe later in their careers.

Understandably, each physician has his or her own unique perspective and experiences with death that result in different ways of processing a patient death experience. Some health care providers have offered suggested mechanisms for physicians to cope with grief. These include: death talks, professional grief support, didactics regarding end-of-life care in medical school, death rounds (educational tool designed to address the emotional needs of the trainee caring for a dying patient), narrative medicine/writing, personal awareness of feeling of grief and loss, and mindfulness meditation. The commonality between all of these coping mechanisms is the idea that a physician experiencing grief should not have to experience it in isolation. Healthy dialogue about grief and its effects on physicians will ultimately lead to a more empathetic work environment and hopefully to an expectation that physicians, though more frequently surrounded by death, are still human. Creating space for physicians to grieve will likely promote physician wellness and support them in their experience of caring for the dying patient.

For me, grief has never been predictable. In dealing with a tragic death in my personal life, I have paralleled many of the feelings that I have experienced to the feelings of my patients and their families. I have learned that we as a health care community must understand that it is important to embrace grief and to never shame our colleagues for the emotional burden a patient death may bring. If we recognize that grief is a universal experience and support each other through the processing of our emotions about it, we will become not only more empathetic to our patients but also to each other and ultimately to ourselves.

As a medical student, I believed that a physician had to be stoic and composed, never showing emotion in public out of fear of clouding the revered analytical decision-making skills that the good doctors undeniably possessed. Today, with each new patient encounter, I am certain that the opposite is true. Emotional vulnerability on both sides of the doctor-patient relationship is a cornerstone of good care. Opening the lines of communication can only come with the compassion that vulnerability brings to the equation. My experiences with grief have given me that irreplaceable skill.

I remember my last death in residency.  He died in the opposite way from my first patient, though the circumstance was equally as tragic. There were no tubes, no beeping of machines, and no sense of urgency to get back to the daily tasks. I auscultated his chest, felt for pulses, checked for reflexes, pronounced … and then I grieved.

Rashmee Patil is an internal medicine physician.

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