As a hospice and palliative care physician, grief is a familiar concept to me. It is most often discussed in the context of loss of life. However, grief at the root is simply profound and agonizing distress caused by loss — any loss. In hospice and palliative care, we train to recognize risk factors for complicated grief and to refer for early intervention. The pandemic has been the ideal breeding ground for circumstances that place most of humanity at risk of complicated grief — long-lasting, severe grief and can negatively impact daily functioning. We are all subject to such grief.
Sudden, unexpected, and violent death is a known risk factor for complicated grief. If we apply the concept more generally, complicated grief might ensue from any loss that is sudden, unexpected, and traumatic. Additional risk factors for complicated grief include the presence of significant life stressors, social isolation, and a history of anxiety, depression, and post-traumatic stress disorder. According to NAMI, one in five U.S. adults experienced a mental health issue in 2020; one in 20 U.S. adults experienced a severe mental health issue. Those statistics are even higher for health care professionals, and health care professionals are extremely reluctant to seek help, making them an extremely at-risk population.
Like many health care workers throughout this pandemic, I was frozen in survival mode: fight or flight. One of our earliest pandemic-related experiences was anticipatory loss. We anticipated our health care system would buckle under the vast number of patients. We knew that health care workers would not be excluded from this illness. We would not have enough staff, and safety of care would be compromised. Many people would die. We soon lost our sense of safety in the workplace. This loss was multi-faceted. Health care workers were asked to work without adequate PPE and with unsafe staffing ratios — putting our physical safety in jeopardy. As we reported unsafe working conditions and compromised care, some of us were fired, humiliated, or faced retaliatory practices jeopardizing our psychological safety. Our financial safety suffered when surgeons could no longer operate, private practices closed due to lack of business, and hospital systems cut salaries. With deaths and resignations mounting, we suffered the loss of people. Not only did we lose family and friends to COVID-19, but we also lost co-workers. Some health care workers committed suicide while others joined the Great Resignation — unable to continue in this high-stress and traumatic environment. Like non-health care workers, we too became socially isolated.
Finally, the most profound loss I experienced was the loss of a sense of purpose and the death of a dream. I needed to feel necessary and valued to have a sense of purpose. While the pandemic intensified the idea that I was “essential personnel” and truly necessary, it engendered thoughts that robbed me of my sense of value. The pandemic elicited the best and the worst behavior that people had to offer. I can think of one poignant example that often resurfaces in my mind. Running interference for disgruntled patients became an all too familiar duty. One day a gentleman was asked to put on his mask for his outpatient clinical services to be rendered. In addition to the abusive rhetoric he used quarreling with me, he spit in my face. Spit in my face intentionally! I found out later he was physically aggressive with a nursing staff member. At that moment, I did not perceive that he recognized he needed the medical team or that he valued us. Working forced me to endure abusive and inappropriate behaviors.
Was I still actually living my dream? No.
A child’s dream of becoming a doctor sustained me into adulthood. My father is a beloved pediatrician in town. To this day, I encounter people who cherished the lifesaving care he often provided and who offer up their continued love and appreciation. I truly never expected to have that sort of impact as an inpatient physician since there is no opportunity for continuity of care. But I did expect to be treated with the same dignity and respect I offered my patients. My work environment stopped feeling like a hospital and started feeling more like a bar or nightclub where the patients were drunk patrons, and I was the bouncer. Finally, the COVID-19 pandemic became weaponized for political gain on both sides of the aisle. I naively believed my ability to provide evidence-based care was knowledge-based and within my control. But my ability to provide evidence-based care was less in my control than I realized. Subject matter experts bowed to political pressures or were muzzled at the institutional level and more broadly worldwide.
As a society, we routinely experience loss; the impermanence of everyday life ensures that it is a high-frequency occurrence. For health care workers, the COVID-19 pandemic has presented an additional circumstance well beyond everyday life where the loss has been concentrated, and we are that much more afflicted with grief. We suppress grief rather than process it for so many reasons. Grief is a scary unknown and takes time to process it; many of us believe we don’t have that time. We lack the knowledge of how to process this grief and be present and supportive of someone grieving. Most concerning, if we let these feelings in, we have no prior knowledge to suggest how we will cope and whether we will remain functional to continue caring for our patients. Within the COVID-19 pandemic, we have experienced a very unique circumstance.
Grief is an invisible wound that requires support for processing; it requires immediate care like other acute medical problems. Without treatment, grief becomes a festering wound that is long-lasting and severe, and it impacts our daily functioning. So process it, we must! Unprocessed grief results in prolonged suffering. Prolonged suffering engenders excessive stress. Excessive stress causes burnout. Can processing grief mitigate burnout? William Cowper said that “grief is itself a medicine.” I’d argue grief truly can be if we learn to allow and process it.
Cathi Whaley is a hospice and palliative care physician.
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