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Grief: An under-recognized reality that deserves serious attention.
The first time I met Ida, an outgoing, warm-hearted woman in her mid-80s, she shuffled into my office for a comprehensive medication review (CMR). She ambulated stooped over on a rolling walker, her husband dutifully tagging behind her with her purse and paperwork.
Ida, a pseudonym, was the kind of person who smiled as much with her eyes she did with her mouth. As soon as we locked eyes, the walker and her stoop-and Ida’s agony-melted away. We had an instant patient-provider connection.
During the CMR, Ida told me that her ambulatory challenges resulted from an adverse drug reaction that had left her bedridden and in the hospital for months. Her long road to recovery included arduous physical therapy. Although she eventually regained the ability to walk, she required assistance.
Over the next few months, I became Ida’s personal pharmacist. She called me for drug information and even requested that I serve as her advocate when her insurance company asked her to change to cheaper medications.
I was a recent graduate at the time, and earning Ida’s trust boosted my confidence as a new pharmacist.
A few months after Ida’s CMR, I saw her husband standing in line at the pharmacy.
“I wonder how Ms. Ida is doing,” I said to Dan, also a pseudonym, the other pharmacist on duty.
After a brief pause, Dan said: “She died.”
I froze. Overcome with a sudden wave of grief and shame, I left the counter and hid between the pharmacy shelves like a scolded puppy licking its wounds.
“Frieda, it wasn’t your fault,” Dan tried to console me. “Her husband thinks the world of you.”
Ida wasn’t a relative or a close friend, but neither of these factors softened the sudden blow of her passing. Toxic thoughts began to flood my brain: What could I have done differently? Was it even appropriate for me to feel sad? Is it acceptable to ask my colleagues about how they cope when they lose a patient? I felt too ashamed-and stupid-to ask.
It was truly an awkward moment in my career: questioning whether my feelings were appropriate and not knowing how to process them. I would eventually learn that the emotions I experienced that day were OK, and that they are normal.
Grief and Self-Blame
When a patient dies under the normal provision of care, healthcare workers may struggle with strong emotions including grief and self-blame, according to Brady Shuert, project manager with Christiana Care Health System’s Center for Provider Wellbeing, where he directs their peer support program, Care for the Caregiver.
For Andrea Seitzman-Siegel, PharmD, a clinician whose experience includes various hospital settings as well as telemedicine, circumstances and the type of practice setting sometimes amplifies the emotional toll on the pharmacist.
“I have attended codes with family present and when the patient dies, I have a much harder time dealing with that than if the family was not present,” says Seitzman-Siegel, a clinical advisor at Optum. “There is something about having the family there in the room that reminds me that this is not just a patient, but someone’s loved one.”
Seitzman-Siegel also says the impact of patient death intensifies when a child dies. She recounted an incident that involved a child who drowned and who was about the same age as her own son. Witnessing the medical team exhaust all options to save the child’s life, coupled with the parents’ reactions, devastated her.
“It changed the way I viewed my own child,” says Seitzman-Siegel. She signed her son up for swim lessons that week. While she took measures to help ensure the future safety of her own child, she didn’t take action to address her emotions.
“The people at the code were given the option of counseling. While I didn’t attend due to scheduling, I think it would have been helpful,” she says in retrospect.
“Pharmacists risk burnout if they bury their feelings and don’t acknowledge them,” warns Judith A. Smith, PharmD, BCOP, FCCP, an associate professor at the University of Texas Science Center at Houston Medical School.
As an oncology pharmacist who frequently works with dying patients, Smith says expecting practitioners to become desensitized is unrealistic. “It’s hard to completely detach yourself from a patient emotionally because you develop relationships with them,” she explains. “Acknowledging sad feelings after a patient dies is both normal and human.”
A Need for Teaching Coping Skills
Stories about how patient death impacts physicians are not uncommon, and they touch on grief and post-traumatic stress disorder. But articles about the impact of patient death on other healthcare professionals-such as pharmacists and nurses, many of whom tend to have more frequent and intimate patient contact-are not as common.
A study from 1987 found that 68% of pharmacy programs included some form of death education in their curricula; [Beall J, Broeseker A. Pharmacy students’ attitudes toward death and end-of-life care. Am J Pharm Educ. 2010 Aug 10;74(6):104]. However, that statistic pales in comparison to 95% and 96% of nursing and medical schools that included death training, respectively.
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Daniel Hays, PharmD, BCPS, FASHP, a clinical pharmacy specialist in emergency medicine at the University Medical Center of Southern Nevada, attributes the sparsity of dialogue surrounding the impact of patient death on pharmacists to the lack of training they receive as students.
However, he also believes the lack of death education in pharmacy training reflects the fluid climate of pharmacy practice and the industry dynamic shifting to more patient-centered care.
“As pharmacists, our roles have been evolving over the last 20 or so years to more bedside engagement,” Hays observes. “The traditional pharmacist didn’t do much bedside care.”
While current Accreditation Council for Pharmacy Education (ACPE) standards encourage patient-centered care and interdisciplinary practice, ACPE offers no explicit guidance regarding training in palliative care and the emotions surrounding patient death.
Hays says pharmacy schools should expose students to palliative care and end-of-life issues as early as possible in their curricula. Similarly, pharmacy residents can also benefit from training about death to learn coping skills for themselves and also to deal with bereaved family and friends.
Shuert recommends that practicing pharmacists take a moment to assess their emotional health following the loss of a patient. Some clinicians may find that exercising extra self-care or taking a day off can be cathartic.
“Above all, the pharmacist should reach out for support, whether from friends, coworkers, and family, or from a professional, if necessary,” Shuert says.
Hays took advantage of employer-provided counseling early on in his career-a service he has used regularly.
After taking time to work through their emotions, Shuert advises pharmacists to resume their routines and a sense of normalcy as soon as possible
Another critical element is setting healthy boundaries that allow pharmacists to grieve without becoming so emotionally invested that it limits their ability to practice. Seitzman-Siegel says pharmacists can find closure while setting boundaries so they can continue serving other patients.
For example, one of her colleagues sends sympathy cards to the patient’s family-an act that the pharmacist finds both courteous and therapeutic without being emotionally overwhelming. Saying a prayer or having sympathetic thoughts towards the patient and the family also allow pharmacists to manage their emotions in a healthy way.
In the oncology setting, Smith frequently uses humor to lighten the mood. Her team also makes a concerted effort to encourage a positive work culture by giving grieving colleagues small gifts such as pastries. Additionally, she finds keeping the goal of helping patients at front-of-mind makes the coping process less painful.
“Peer support is crucial to normalizing the experience for the affected team member, and reaffirming the individual’s competencies,” Shuert says. “This emotional support is a critical element to coping with the loss of a patient.”