From my earliest days in medicine, notifying loved ones about a patient’s unplanned or unexpected death was among my most stressful and challenging responsibilities. I recognized that my words at that critical moment might stay with people for a long time, maybe the rest of their lives. What I said could soothe and provide comfort — or fester and cause pain. I also realized that, with the right words, I just might be able to preempt the pathology of blame and guilt that can surface after the initial shock passes. In short, I quickly came to see that my responsibility to a patient does not end with his or her death. It extends to this all-important conversation with the people left behind.
So I came up with three simple steps to allow me to help those who have experienced a loss. I am always honest during these conversations, but I use my three guideposts to chart the way. I suggest that my students and residents use them as well, and I share them humbly with you here.
1. Say something positive about your patient. It is your responsibility to know your patients as people. You should have something personal to say that is dignifying, that speaks to the person’s courage, wisdom, or humanity. Make clear that this person was not just another patient, but someone with admirable qualities. You can find the best in everyone, and this is an opportunity to share that insight with the people who will appreciate it deeply. I can remember telling family members about how the person treated me kindly, showed strength in the face of immense health challenges, or revealed wisdom. Usually I have not had to think hard to recall something that not only compliments the person but also illustrates the personal connection I had with him or her. If you never formally met the patient, perhaps in the setting of a cardiac arrest when you are covering for other doctors, take a moment to find someone in the hospital who knew the person, even a detail from the chart. You can always find something that will add dignity.
2. Try to convey that the death was not painful. Of course, your responsibility is always to work hard to diminish suffering by palliating symptoms and mitigating pain. But actually mentioning that your patient did not suffer can make a huge difference to loved ones, who always worry about this issue. Ideally, this was the case and you can identify the specific steps that were taken to prevent or reduce suffering. That kind of specificity matters.
3. Most important, seek to alleviate guilt. Most people will harbor some belief that they contributed to a death. They may think that they could have pushed the patient to see a doctor sooner — or should have recognized the early signs of illness. I have heard many people say (mistakenly) that it was something they fed the patient, or some stress that they caused. Discover who is holding on to such guilt and set them free. Help them understand that it was not their fault, and give them the gift of knowing that the doctor is certain about that fact. You must be honest, but it is almost always true that these feelings of guilt are unfounded. Even if there is some possibility that the loved ones could have done things differently, this moment is not the time to discuss that. Be kind and sensitive to what they are experiencing and the concerns they have. Your responsibility to the patient does not end until you have intervened to alleviate this type of guilt. Your words have the power to heal or hurt and will often be remembered for many years. You can set a family on a path of healing as they begin a journey of grief.
These three steps always help me to finish caring for my patient after death. Not everyone will agree with this approach. You may have your own, and I’d like to hear it. Also feel free to share specific stories about discussing patients’ deaths with their loved ones. What have you learned? What do you teach other caregivers who have this responsibility?