Coping with Death on the Front Lines, a Medical Perspective
Being a provider in the time of COVID-19 has inherently changed what it means to practice medicine. The level of uncertainty, quantity of suffering to be witnessed and often, an inability to “cure” has challenged providers. Perhaps the largest challenge, however, is the need to bear witness to death on a scale that compares in recent memory only to the HIV epidemic. For providers who entered healthcare to fulfill a calling to heal, this can be disconcerting. Death is in many ways, still equated with “failure,” and can be a source of moral injury and distress. This is compounded by a feeling of scrutiny, both self-scrutiny and the kind of medical dissection that occurs in venues such as “Mortality and Morbidity” conference. Providers expect and are expected to be strong enough to bear witness to death and suffering while being able to help others. This trauma is unique in that we are all processing it together, while still expected to tend to the emotions of others. It is a hopeful sign that many healthcare training programs now include death and dying in their curriculums, yet very few programs offer meaningful tools for coping with suffering and death in a healthy way. Providers are expected to withstand the pain, rather than be changed by it. And this leaves a gap to be filled on an individual, case-by-case basis.
The COVID-19 crisis has stressed an already fragile healthcare system and in many ways the challenges have added to the burden on providers. The contagious nature of the disease has left providers fearing for their own safety, insufficient resources have compromised their ability to serve the massive number of patients in an idealized manner. In locations experiencing a surge of patients, the high number of deaths in a short period of time, along with the isolation that comes with visitor restrictions has meant large numbers of patients dying with only the provider at the bedside. Witnessing grief as a clinician is different than bearing witness as a surrogate for family and has impacted the wellbeing of providers, with an acute stress evolving into a post-traumatic effect that has not yet been evaluated. So much of the medical care is necessarily collaborative, dependent on family and visitor to uplift patients, orient to the familiar, prevent delirium, and provide historical context, that caring for patients without their loved ones at the bedside is necessarily fraught in a way that affects doctors and nurses used to relying on them to improve their experience of care. Add to this cognitive load, the fear of bringing disease home to loved ones, fear of becoming critically ill and the stress of having to take care of their own colleagues and it’s easy to see how the fulcrum tips towards despair.
From a public health perspective, inequitable access to care and systemic racism compounds the emotional toll, as providers witness segments of the population dying at much higher rates than the rest of the population. Being informed about and even being part of solutions for these issues can help providers reconnect to purpose. Debriefing through involvement in existing programs that are available to discuss these timely issues is also essential for healing (including Virtual Schwartz Rounds, Balint groups, and Narrative Medicine groups). Ensuring that decisions about allocation of resources are made in an ethical, non-biased and scientifically sound manner is critical, and Clinical Ethicists, Palliative Care Providers, and members of the community are needed to draft guidelines ensuring that these decisions are not improvised at the bedside by individual clinicians. This kind of advance-care planning at scale is essential to avoid the moral distress that is caused by having to allocate scarce resources. Having training in end-of-life conversations and access to technology to facilitate connection with families at the end-of-life for patients is also protective of the practitioner.
Teams will find few resources available for scaling this level of adversity. The same providers in need of support may find themselves being the source of support for others. It may be helpful to develop a meaningful ritual to honor each death. Drawing on resources available, one might enlist chaplains to offer a means of honoring deceased patients. These gestures can be quite simple, sharing a memory of a patient, a meaningful interaction, or writing names of patients down and releasing them in a way that brings closure. Teams may write the names on paper with a colorful ink; then place each piece of paper in a jar of water, witnessing as the color of the water is changed by each person’s name, mirroring how we are each changed by the patients who die.
While creating supportive programs and initiatives is important, the role of leadership cannot be overstated. System-wide, coordinated leadership and effective management on the ground, that ensures adequate resources and staffing creates a feeling of psychological safety. Cultures that have psychological safety are more likely to speak up if these are lacking, and more likely to be supported. Given the current absence of national leadership, absence of a coherent policy and a defunded public health infrastructure, local highly-functional, visible leadership has become a necessity. On the management level, also critical are adequate breaks, staffing, free food, rotating hours and time off so there are always people who are "fresh." This support is offered to fend off acute stress disorders and anxiety that ultimately can escalate during a crisis.
Transparent communication is also essential for trust building within teams. Even difficult news is important to deliver with sincerity and an understanding that providers can often co-create solutions with leadership. Granular communication during crisis is key: this can include the number of cases in the entire hospital as well as in the ICU, the number of deaths, the number and percentage of employees testing positive compared with state average and the number of discharges. Having hospital leadership get daily messages and photos about small acts of kindness and compassion offered by staff and by members of the community can also be key. Support for employees that are living apart from their families is another way to mitigate the stress on frontline staff. This can be financial support, donated housing or coordination of hotel rooms for teams can be supportive.
Feeling supported by the community is key to provider wellness as well. Campaigns such as "We stay at work to help you - You stay at home to help us," provides a link to the community and allows teams to know their work is valued. Some systems project messages from the community onto hospital screens or print artwork from children and place them on patient doors. Feeling witnessed is as important for providers as it is for patients.