Time Stamps

• What is Clinician Grief?
• Types of Losses
• Loss of a close relationship with a particular patient 
• Loss due to a professional’s identification with the pain of family members
• Loss of one’s unmet goals and expectations and one’s professional self-image and role
• Loss related to one’s personal system of beliefs and assumptions about life
• Past unresolved losses or anticipated future losses
• The death of the self
• Coping

Show Notes

• Introduction
  • Dr Danai Papadatou, PhD
• What is clinician grief?
  • Clinician grief: grief that clinicians feel when a patient dies. 
  • Clinician grief is often disenfranchised: it is not recognized as legitimate by others (be that our peers, our loved ones, society, or even ourselves)
  • Clinicians may experience a range of emotions when patients die, but grief is distinct from emotions like burnout and secondary traumatic stress
    • Burnout: a constellation of symptoms defined by emotional exhaustion, depersonalization, and low self-efficacy
    • Secondary traumatic stress: emotional duress from hearing about or witnessing another person’s traumatic experience
• Types of loss
  • “Loss of a close relationship with a particular patient”
  • “Loss due to professional’s identification with the pain of family members”
  • “Loss of one’s unmet goals/expectations and one’s professional self-image and role”
  • “Loss related to one’s personal system of beliefs and assumptions about life”
  • “Past unresolved losses or anticipated future losses”
  • “The death of the self”
• Coping 
  • Dr Papadatou’s model of coping: clinicians cope with grief by oscillating between experiencing grief and avoiding grief. This process is affected by individual factors and team dynamics
  • There are a variety of interventions that can help clinicians cope with grief. Different people respond differently to grief and to the interventions available for coping. It’s worth exploring the resources that your institution offers, and trying a range of methods to see what could be helpful to you
• Conclusion

Transcript

Introduction

Dr. Margot Hedlin: I can’t share his name, but I can tell you what he taught me about grief. I met this patient a few months after graduating from medical school, and by that point he was already dying. I understood some of what I saw – a belly distended with malignant fluid, the pattern of labs that resulted from a liver full of metastases – but there was a lot I had to learn. I learned how to communicate through an interpreter, our stilted conversations translated from English to a rare West African dialect by a voice on a phone. I learned about his life, about the unspeakable horrors that took his family before he fled for a country where he was a stranger. And I learned what cancer can do to the body and the mind. There was a lot we could offer – palliative chemotherapy, pain control, blood transfusions – but there was nothing we could solve, and in the ritualistic comfort of ordering labs and calling consultants I lost sight of that fact. One day my attending brought the palliative care team in to readdress his goals of care. The delirium had started to encroach on his thinking, and as he pointed at each of us in turn we realized he was mistaking us for the loved ones whose murders he had been forced to watch. “If I die, will you be safe?” he asked.

I grieved for this man the way I’ve grieved for many patients: I found a supply closet to cry in for a few minutes before my pager went off. But in the years since, years in which I worked at the epicenter of the COVID pandemic, worked nights at a cancer hospital, and suffered personal loss, I’ve found that grief is too large to be stuffed in a supply closet: when left unaddressed, it keeps coming back, in ways and places that I couldn’t predict. So today I wanted to honor my patient, and the many dying patients I’ve had the privilege of caring for, by talking about clinician grief. 

Welcome back to At the Bedside. I’m Margot, a hospitalist at Harborview Medical Center in Seattle, and an Assistant Professor of Clinical Practice at the University of Washington’s School of Medicine.

Dr. Jafar Al-Mondhiry:  I’m Jafar Al-Mondhiry, a hematologist and oncologist at Inova Schar Cancer Institute just outside of Washington, DC, and an Assistant Professor of Medical Education at UVA School of Medicine.

Dr. Tamar Schiff: And I’m Tamar. I trained in internal medicine and am a bioethics researcher. 

Dr. Margot Hedlin: Guiding us today is Dr. Danai Papadatou. 

Dr. Danai Papadatou: I am an emeritus professor of clinical psychology at the nursing department of the National and Kapodistrian University of Athens. And I’m also the chair of a nonprofit organization for the care of children and families who are faced with a life-threatening illness or death. Over the past year, I have been chair of the National Committee for the Development of Palliative Care in Greece.

Dr. Margot Hedlin: Dr. Papadatou has published numerous studies and a book exploring how clinicians in a range of specialties care for dying children and cope with those deaths. Her interest in clinician grief stems from her work with seriously ill children. She volunteered in a children’s hospital as a student, and ultimately focused her PhD on children with cancer.

Dr. Danai Papadatou: My first job was in the pediatric oncology unit, in the early eighties. So I have had experience of accompanying more than a hundred children through their illness and to their death because at that time, most of these children were dying. So I had been affected by the death and the team that I was working with was affected. Dealing with our own grief and our own distress, in constructive ways and sometimes in dysfunctional ways. But that triggered my interest to better understand how individual clinicians and how teams cope with death.

Dr. Margot Hedlin: Today, we’ll define clinician grief, discuss the types of loss we can experience, and try to understand what it means to cope.

What is clinician grief?

Dr. Tamar Schiff: Almost everyone will experience grief in their personal lives, feeling heartbreak and the many other emotions of loss. And there can be some comfort in having the weight of that experience acknowledged. Dr. Papadatou started by talking us through how clinician grief can be a bit different. 

Dr. Danai Papadatou: Grief is a process that occurs when we experience a loss. It can be the loss of life, it can be the loss of a relationship, of an ideal, of a goal, or whatever. Now, unique to the grief of clinicians is that it is disenfranchised. What does that mean? That it is not openly acknowledged as being significant, whether this is by society, by the culture of medicine, or of nursing, by loved ones, and quite often by ourselves. And this is because, we are expected as health professionals to be in control of our feelings, to be strong and resilient in the face of death. So what happens is that we neglect all the suffering that is evoked when we experience one specific or multiple deaths of patients. 

And we spend a lot of energy on detaching ourselves from all these feelings and not only feelings with all these grief responses, because grief is not just feelings. It’s both behavioral, cognitive meaning making response and physical many times. And our culture, especially in medicine, assumes oftentimes an approach that reinforces a detached concern towards patients. So they need to be concerned and display some empathy, but at the same time, detached in order to protect themselves. So, yes, that kind of grief may be difficult to deal with. Now, one last thing I want to say about grief. It’s not only an individual process. It is also a team process because we are differently, within a team affected by death.

Dr. Tamar Schiff: There are so many emotions that arise for clinicians who care for seriously ill and dying patients. And these experiences are layered. Grief and burnout are not the same, and it’s important to name and understand each of these experiences separately.

Dr. Danai Papadatou: One thing we need to keep in mind is that grief is healthy. Grief unfolds in the face of loss, and it’s a suffering that we may be experiencing in the field that is unavoidable, but it is adaptive, and we need to come to terms with that. Burnout is not healthy: it is a state of physical, emotional, and mental exhaustion that results from being involved for a long time in demanding and distressing work conditions. And three other characteristics of burnout: emotional exhaustion, depersonalization – we become impersonal and cynical sometimes and detach from our patients that we treat as cases, disease cases rather than people. And the third is a reduced sense of accomplishment. In other words, we don’t feel that we are effective enough, and as a result we don’t invest a lot of energy in our work.

Dr. Tamar Schiff: Sudden and intense events may lead to experiences that are different from a gradual burnout. 

Dr. Danai Papadatou: Now, secondary traumatic stress is a condition that, unlike burnout that evolves progressively, it may occur suddenly. And this happens when we are exposed to work situations that are experienced dramatically. We don’t expect a patient to die. And then suddenly something happens, and then we experience intrusive thoughts, intrusive feelings associated with the event that we systematically because they are so intrusive that we systematically suppress as they remind us of the traumatic event. And at the same time, we remain in a state of hypervigilance and we are hyper alert. We are irritable. We have sleep problems. We have outbursts of crying or outbursts of anger. So we are in a peculiar state for some time. And if this is prolonged in time, then it may lead to PTSD. 

Dr. Tamar Schiff: We don’t have the longitudinal relationships, depth of connection, shared memories, or love that a family member or close friend had with a deceased patient. But clinician grief is complex and multifaceted for other reasons. I’ll turn it over to Jafar and Margot to walk us through some of the types of loss clinicians may experience. 

Types of Loss

Dr. Jafar Al-Mondhiry:  As the saying goes, grief has many faces. Seeing them, knowing them, and coming to terms with them can help us better understand our reactions and bring us to resolution on a loss. In doing so, we may even better understand ourselves. Dr. Papadatou outlines six types of loss felt in the clinician’s experience with grief.   

“Loss of a close relationship with a particular patient”

Dr. Danai Papadatou: The first is the loss of a relationship with a patient. And especially when we have developed a special bond, we have become intimate in that caring relationship. So we grieve the loss of the patient. 

Dr. Jafar Al-Mondhiry: We have many different kinds of interactions with patients – some are short and intense, others are long and longitudinal. Working as an oncologist has let me experience both, but some of the most powerful, lasting patient memories have come from my outpatient panel, where I’ve been there from diagnosis, through surgery, adjuvant treatment, sudden relapse, and multiple attempts at palliation. Those are the obvious milestones, but it’s also about time spent together through the years—holidays, a child’s graduation or wedding, sharing notes on each other’s summer vacations, cookie platters and thank you cards that fill the office. After they’re gone, they become too precious to throw away — memories like that become locked and final and, almost, sacred. 

I can remember caring for a woman approaching sixty, who had worked night shift doing menial labor stocking shelves as the sole financial support to her two children, children who would go on to finish graduate schooling and become professionals. She was one year from retirement when she was diagnosed with stage IV melanoma. One treatment after another failed us, but each transition met with what I can only describe as grace and fortitude. As a young attending, her struggles and my inability to stop her disease brought me tremendous anxiety, but her kind & accepting attitude, the joy & purpose she felt surviving for her kids, and her trust & willingness with me in the process made her a welcome sight to see on my schedule. We ended up having visits nearly every week as the end approached, with several trips to see her on the inpatient side when hospitalized. We both had a driving motivation to explore every possible treatment, and we even adapted an intricate phase I intrathecal treatment protocol just for her—something I’ve never done before or since. I desperately wanted to give her back the years I felt the universe owed her for her strength and resilience as a single mom working terrible night shift hours for her kids, to enjoy the golden years so close on the horizon, and selfishly maybe even share some of those years ahead, to realize the dream together. Of course, logically, I knew sheer will and good karma isn’t enough to reverse biology, but that didn’t make the fall any easier. I knew I had given her everything I had to give as an oncologist – maybe even more than most in my shoes would have – so the pain wasn’t a professional failure, it was just personal. And today I just… miss seeing her. 

“Loss due to professional’s identification with the pain of family members” 

Dr. Danai Papadatou: Sometimes we don’t grieve the loss of the patient, but we identify with the grief of the family. I remember for example, one of the nurses that was saying that, no, I don’t grieve for the child, I’ve come to terms with his death. But I grieve for the pain of the parents, because I identify with them. They’ve lost a daughter the age of my daughter, and I grieve as if I was a parent who lost a daughter. So some identify – this is a different kind of grieving.

Dr. Jafar Al-Mondhiry: I think most of us have seen how serious illness expands beyond the individual patient to eventually engulf the lives of their family members. One of the hardest parts of my job specializing in melanoma is how often it affects young adults—people who often share the role as both a child to aging parents and as a parent to young children, sometimes supporting both. It can be like watching a support beam fall, with the house crumbling around it, even as those other family members try to rally to support their loved one. Others, unfortunately, just have to live in that rubble.

A young woman I cared for with widely metastatic mucosal melanoma had two kids at home, right around the age of my own, both under seven—too young to understand the gravity of the situation but definitely old enough to feel it and see it. Each visit we watched one treatment after treatment predictably fail us, and each time I talked to her, I found myself thinking about what life was like in her house—mom laying in bed too sick or in pain to hold her son or daughter, kids lost in a spiral of illness they couldn’t predict or change. 

I tried, and practically begged her to begin talking to them about what was happening, pushing child-life services and pushing her not to lose this opportunity. And when the mounting number of brain metastases finally closed the window on that opportunity, I felt haunted for months by the sadness I imagined in those kids I had never met—reflections of my own fears and worries for what my own kids might feel in my absence. In a weird way, I wish that some day I could meet them in their more mature years and tell them the other side of their mother’s story, and maybe they could tell me theirs. Maybe it’s wishful thinking to believe these shared pieces of grief could meet and complete one another… and maybe just desperation on my part to wash away the angst of always imagining, but never truly knowing their pain.

“Loss of one’s unmet goals and expectations and one’s professional self-image and role”

Dr. Danai Papadatou: Another one is loss that is due to the non-realization of our professional goals and expectations. This may be due to the failure to ensure a good death. And we grieve the fact that we have not been able to provide the best care in order to ensure a good death. But sometimes we may grieve not the death of a patient, but the failure to prevent death or to make sense of the death. So there is the loss, not of the patient, but of a goal that is associated with my self-image and my role as a physician, or as a professional.

Dr. Jafar Al-Mondhiry: Phew, this one hits close to home. I think like many young attendings, I see my professional success in the health outcomes I can help my patients achieve. Of course, working in oncology has disabused me of the reality that not everyone can have a good outcome in the gristly business of cancer care, but it doesn’t stop me from wondering – every time a patient gets hospitalized with a treatment complication or ends spiraling downward from their disease – did I make the right choices for them? Did I manage things as proactively as I should have? Or maybe, in a darker moment, I have to ask myself:  would they have been better off with a different doctor? 

I can remember one patient with metastatic cutaneous squamous cell carcinoma that progressed really quickly after first-line immunotherapy. I was forced to make a lot of quick adjustments to beef up our treatment regimen, this time adding multiple forms of chemotherapy. I knew the patient wanted to be aggressive, and I thought he was still in pretty good shape to tolerate the step up. Within a couple weeks after the first cycle, he ended up hospitalized with neutropenic sepsis, and each day got worse. One infection turned into another, and even seeing him in the hospital I thought “no, this will turn around, we’ll just tinker with some doses and keep going.” 

Well, he ended up on a vent, and one day after another past in the ICU with minimal improvement. When the end was finally in front of us – with multisystem organ failure and a relentless cancer still surrounding everything- I realized all my enthusiasm had robbed us of the opportunity to have better prepared for that moment. We rushed into something that couldn’t be undone, and for weeks afterwards I couldn’t stop thinking about it—I should have known better, I should have slowed down, I should have brought his family into this sooner. Would we have made a different choice with better foresight? Could he have been given back several months of hospice care instead of this brisk, violent end? 

Listeners of At the Bedside have probably become familiar with many of our palliative care themes over the years, with episodes on Code Status discussion, the pitfalls of Hope, and the concept of Futility in clinical care. I have spent countless hours thinking about these concepts, reading and teaching and talking breathlessly about the value of Advance Care Planning, of open, honest, compassionate communication for patients with serious illness — but when it mattered, I had nothing to show for all that effort. I took something from him I could never give back, and while I believe I learned something valuable in the experience, someone else had to pay for my carelessness.

“Loss related to one’s personal system of beliefs and assumptions about life”

Dr. Margot Hedlin: As Jafar has just described, many types of grief center on a specific person.  But Dr. Papadatou also outlined how clinicians may struggle with conceptual loss.

Dr. Danai Papadatou: Another type of loss is related to our personal system of beliefs and assumptions about life. Some deaths, often under extreme conditions, evoke losses that challenge our world of assumptions. Our world of assumptions help us to make sense of who we are, of how we perceive the world, and how we perceive life. Now, these deaths invalidate our worldview, and we struggle to attribute meaning to them. Some of these deaths challenge our views on life, on death, on humanity. And what we are grieving is not that this person died, but that we’ve lost our view of the world and of life as we believed in before.

Dr. Margot Hedlin:  My medical training acculturated me to a particular form of scientific rationality. When I was in medical school in North Carolina, my patients were largely suffering from diseases I could attribute to dietary patterns and smoking. In my residency training at Bellevue, a public hospital in New York City, many of my patients came in with complications of poverty and mental illness, and it wasn’t hard to blame our broken social safety net. But after residency, I took a job as a nocturnist at a cancer hospital, and my understanding of cause and effect started to melt. I cared for countless young patients whose cancers – widely metastatic, resistant to all attempts at treatment – came out of nowhere. I remember sitting with a mother one night as she held vigil for her son, who lay dying of gastric cancer. “Why did this happen?” she asked, watching his chest rise with each labored breath. But with each answer I tried to provide – genetic mutations, environmental exposures, horrendous luck – the mother shook her head. “I still can’t understand it,” she told me. I know now that there are no good answers for this question, but there is one response I wish I’d given: “I don’t know, and I’m so sorry.” I know that a healthy lifestyle helps lead to a long life, but I’ve lost a lot of confidence in its protective power. I’ve struggled for years now with an intrusive thought: death comes for everyone – often, when we least expect it.

“Past unresolved losses or anticipated future losses”

Dr. Danai Papadatou: The other one is past unresolved losses. And this is quite common, that we have experienced earlier in our life, that surface without us being always aware. So we don’t grieve the patient, but we grieve our grandmother or our parent, or perhaps it’s also grief of the losses that we anticipate to encounter. So we identify with somebody who is losing his or her mother, and we are grieving the loss of our mother. That is not happening, but is in anticipation. 

Dr. Margot Hedlin: When I started my training at Bellevue, I had a close friend who was struggling with mental illness and substance use. At first I hadn’t thought of it as “struggling” – his stories made the world come to life. But as the summer cooled and the leaves began to fall, his demeanor changed, and with it, the drugs he took to match his mood. At first I saw his mania as exuberance and his depression as philosophical. But as intern year stretched on, it became harder to ignore the parallels between my friend and the patients I was so desperate to help: The man who fell out of the tree he climbed intoxicated on ecstasy and acid, who would never walk again. The man in his thirties pacing the halls, trying to leave, but whose Wernicke’s encephalopathy made the corridors a maze too complex to escape. The woman who stood on her bed, bacteremic and febrile, and screamed at me in Russian and English that she was fine, she was fine, she was fine. It’s sobering to work with people whose  lives have been marked by mania and addiction. They, too, had great stories 10 years ago. I grieved my friend before he was lost, seeing the end of his path when he was still at the beginning. I’ll spare you the saga of the year I spent trying to save him from the parts of himself he loved most. It was a battle I never could have won.

“The death of the self”

Dr. Danai Papadatou: The very last one that I would like to mention, and it’s interesting because that was mentioned most often by professionals who were sick themselves: the loss of their own life. I mean, being confronted with their own mortality every time a child was dying or was dead, they saw themselves. And with the adult population, it’s even more so. We think if we identify our condition with the condition of another adult that is similar to us, then we see in them our own mortality. And this may trigger intense emotions.

Dr. Margot Hedlin: I’m incredibly lucky to be healthy, but the five years I spent working nights at a cancer hospital left their mark. One night when I was about 8 months pregnant, I walked into the room of a young woman who was dying of respiratory failure. As I watched the muscles on her neck strain with each hard-won breath, I knew we had hours at most to decide if we were intubating or calling her family in to say goodbye. Her bed was strewn with cards and markers, and she barely paused her writing as I introduced myself. I asked what she was working on, and she looked up at me, her eyes lingering for a moment on my pregnant belly. “Birthday letters for my son,” she said. “I need to finish them before I die.”

I wonder sometimes if we’re meant to see this much death. For 5 years I watched people die of cancer, people who were kind and vibrant and healthy just last year, people that looked like me, like my friends, like my family members. And I didn’t make space for my grief, didn’t make time to process and find meaning and acceptance, and so it calcified into something I’m still hesitant to explore. It is an honor to walk alongside patients as they are dying, but for us to do this long-term, to remain as present and compassionate as our patients deserve us to be, we need to make space for our emotions. We need to make space to cope.

Coping

Dr. Tamar Schiff: So as Margot just said, grief – in all its forms – is a natural reaction to death. But to continue in our professions, and in our lives, it’s important to be able to cope with that grief. And coping is a process. 

Dr. Danai Papadatou: Normal and adaptive grief involves several emotional, cognitive, behavioral, spiritual, and physical responses that are very healthy, although painful. And we professionals experience a grief that involves an ongoing fluctuation between focusing on the loss and experiencing all these grief responses, and avoiding, moving away from loss and focusing on the tasks that need to be done on the duties that we have to carry out.

Dr. Tamar Schiff: Dr. Papadatou has written about how clinicians cope by fluctuating between leaning into the emotions of sorrow, grief, and loss and then pulling away from these experiences and feelings. This often lets clinicians protect themselves from being overwhelmed by grief, while continuing to meet the demands of their work. 

The “leaning in” can take different forms: speaking about loss with colleagues, journaling about the experience, attending the funeral, finding other ways to reflect. The “pulling away” involves distancing behaviors and a compartmentalizing of the difficult feelings, which can include avoiding people who bring up these feelings or immersing ourselves in the care of other patients.

Dr. Danai Papadatou: So, the ongoing fluctuation between the focusing and avoiding grief, which is healthy and adaptive. And at the same time, it help us, this fluctuation process, to attribute meaning to the losses of our patients. 

So sometimes the meaning is not why did he die? Because we, we expect the person to die. Other times the meaning we need to struggle to make sense of is how? Because the conditions were not the very best. Have we been helpful? What else could we have done in order to ensure a good death, an acceptable death, an appropriate death, a death that has not meaning for us, but meaning for the patient and for the family according to their beliefs and according to their priorities.

Dr. Tamar Schiff: So through this process, we can make meaning of the loss, but the balance in these fluctuations is delicate, and problems can arise when clinicians focus too much on the loss or, conversely, go too far on repressing their emotions.

This can have a big impact on how we relate to patients and colleagues. First, Dr. Papadatou described one of these extremes:

Dr. Danai Papadatou: Grief complications occur when there is no fluctuation between experiencing and avoiding grief. Under those conditions we are totally overwhelmed. And for a prolonged time, we experience a grieving process to the point that we are unable to manage our daily responsibilities and tasks. Or we become totally detached and systematically we suppress all our grief responses. We don’t acknowledge any of them. We don’t acknowledge our vulnerability in the face of death. And as a result, we are deprived of much needed support. So we go to the other extreme, and we stop investing relationship with patients. We keep our distances, we become impersonal, and sometimes we even project a false image that we are super powerful, we know well our staff, what needs to be done, or we display an image of chronic niceness. That means we are with everybody sweet, with everybody. We tell them, you know, I’ll take care of you, et cetera, which is a false self. But it is a way of not allowing anything to emerge and projecting an image of being powerful, in control, when inside, deep inside, we are extremely vulnerable.

Dr. Tamar Schiff: And then there’s the other far end of the spectrum.

Dr. Danai Papadatou: On the other hand, when we suppress and avoid our grief, we may resort in harming others through the expression of anger, blame that is directed toward colleagues. We distance ourselves from our patients, we become impersonal. This is a harming behavior towards the people who seek our services. And all this is done in order, again, to protect ourselves and to remain immune, in our fantasy, from suffering.

Dr. Tamar Schiff: When clinicians struggle to cope with grief, it can also impact our personal lives. Relationships with our own family members may be negatively affected, we may want to withdraw from social activities, we can become increasingly cynical or hopeless about our professional roles. 

Dr. Danai Papadatou: One thing to keep in mind also is that when grief complications occur, we do harm ourselves, in the sense, by suppressing our feelings, and sometimes by drinking a lot, resorting to alcohol, to drugs, sometimes spending money impulsively, eating a lot, gaining a lot of weight. These are ways of suppressing a natural vulnerability that we all have in the face of death.

Dr. Tamar Schiff: Importantly, coping isn’t something we do just as individuals – our process of grieving and coping is also heavily impacted by the culture of the teams we work with.

Dr. Danai Papadatou: Every team has a set of rules that are not always spoken, openly acknowledged about how professionals should deal with their own suffering. And by suffering, I mean especially in the case of loss of patients. Okay? So some teams are very open to acknowledge the grief that colleagues experience, and they develop patterns to support each other. They may have a time to share the experience, exchange feelings and perceptions and all of that. But there are teams that have very rigid rules that the feeling should not be obvious, grief should not be displayed, or if it’s displayed is at your home, beyond the clinic. And they may go even to extremes to become aggressive to any professional who may be open with feelings.

Other teams are much more open. They create a safe space. They may have rules, don’t show any feelings, but at the same time, they may take care of their own members. So each team has more or less functional ways of coping with the suffering of the members.

Dr. Tamar Schiff: And all of this of course occurs within a greater healthcare organization with its own culture. And some organizations don’t foster a healthy grieving process.

Dr. Danai Papadatou: The system may be a cause for suffering of professionals. If it’s very hierarchical, it’s very competitive, it’s very disease-oriented, it doesn’t leave much space for exploring the impact of how its members, how its employees are affected.

Dr. Tamar Schiff:  But some environments do have mechanisms or resources that help clinicians cope with grief in a healthy way.  

Danai Papadatou: Death reviews is an approach that allows everybody on the team to discuss the patient, the family, and how death took place, what went well, what didn’t go, but also the feelings of those involved in the care of the family of a child who died.

Dr. Tamar Schiff: Support along the way is crucial. Some people seek this support by talking to friends, colleagues, or family members. Individual therapy can also be helpful. And some institutions offer sessions with therapists whose practice is dedicated to supporting clinicians through the unique challenges that we face. Other interventions that have been studied to support clinicians through grief include debriefing sessions, group creative arts initiatives, memorial services, and sympathy cards for families. Ultimately, different people respond differently to grief and to the interventions available for coping. It’s worth exploring the resources that your institution offers, and trying a range of methods to see what could be helpful to you.

Conclusion

Dr. Margot Hedlin: I wanted to wrap up by talking about how grief shapes us. When we had this interview I was struggling with a personal loss, and I just wanted to skip ahead to the part where I felt normal again. So I asked Dr Papadatou how we could transcend our losses. 

Dr. Danai Papadatou: I don’t know if losses are transcended. They are integrated into our life story, especially when we attribute meaning to them, and we find a place within ourselves to integrate them.

Dr. Margot Hedlin: There’s a phrase I heard when I was mourning: our grief doesn’t shrink, we just grow around it. But “growth” isn’t a value-neutral term. Do we grow around our grief the way a hypertrophic scar grows over a wound? Or do we flower? 

Dr. Danai Papadatou: We need to be aware that we have a lot to learn from dying patients and their families that will shape us to become better professionals if we stay vulnerable enough – not overly vulnerable, not overly controlling of our emotions, but open enough, vulnerable enough in order to deal with our grief, to acknowledge our limits, but also our possibilities. To know when we have to step back and when we need to move forward, and come closer to them using always empathy and compassion.

Dr. Margot Hedlin: It’s a delicate balance to walk when we care for dying patients. We want to be close enough to guide patients and their loved ones through some of the hardest decisions of their lives, but not so close that we fall into despair with them when things don’t pan out the way they’d hoped. We want to be confident enough to navigate the uncertainties that inevitably arise, but not so confident that we base our self-worth on goals we may not be able to achieve. We want to find meaning in our experiences with death, without taking it so seriously that it crowds out the joys of our lives outside of medicine. It’s a tightrope that I’m still learning to walk. And it’s one we shouldn’t feel obligated to walk alone. Clinician grief is an occupational hazard; our organizations have a duty to provide the time, space, and resources for us to heal.

Dr. Danai Papadatou: And self-care and mutual support is critical in this field. And taking care of ourselves involves, on one hand, sometimes to disconnect, go to other things, leave behind our patients, the hospital, our colleagues, you know, make a break away from them, but that’s not enough. Self-care should always involve sometimes also to reflect on what we experience, how we give meaning to the work we do, what we need more in order to flourish in this field and be more competent and more giving, and more empathic towards the people we care.

Dr. Margot Hedlin: Grief is so painful, but we grieve because our patients matter to us, and our work matters to us, and I would rather have pain than detachment. The poet Mary Oliver puts it best: “Someone I loved once gave me a box full of darkness. It took me years to understand that this, too, was a gift.”

Dr. Jafar Al-Mondhiry: Thanks for tuning in!  We know these topics can stir up more questions than answers, and we look forward to hearing more about your experiences with clinician grief. Please continue the conversation with us online at our Facebook page, on twitter or “X”, or email us directly. Find show notes and contact information for us on our website:  coreimpodcast.com

If you enjoyed listening to our show, and you’re not busy processing the many layers of grief in clinical practice, please give us a review on iTunes or whichever podcast app you use; it helps other people find us.  We work really hard on these podcasts, so we’d love to hear from you.  Let us know what we are doing right and how we can improve.  And as always, opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions. 

Finally, special thanks to all our collaborators on these episode, our wonderful audio editor Claire Yvon Abatayo, ChatGPT for the AI-generated graphic, moral and executive support from Shreya Trivedi, and most importantly, thanks to you, our listeners!

References

• Papadatou, D. (2000). A Proposed Model of Health Professionals’ Grieving Process. OMEGA – Journal of Death and Dying, 41(1), 59-77. 
• Chen C, Chow AYM, Tang S. Professional caregivers’ bereavement after patients’ deaths: A scoping review of quantitative studies. Death Stud. 2019;43(8):500-508.
• Childers J, Arnold B. The Inner Lives of Doctors: Physician Emotion in the Care of the Seriously Ill. Am J Bioeth. 2019;19(12):29-34.
• Meier DE, Back AL, Morrison RS. The inner life of physicians and care of the seriously ill. JAMA. 2001;286(23):3007-3014.
• Shanafelt T, Adjei A, Meyskens FL. When your favorite patient relapses: physician grief and well-being in the practice of oncology. J Clin Oncol. 2003;21(13):2616-2619.
• Yazdan R, Corey K, Messer SJ, et al. Hospital-Based Interventions to Address Provider Grief: A Narrative Review. J Pain Symptom Manage. 2023;66(1):e85-e107.