A doctor recently asked me about an occurrence in his practice and I realized that most doctors receive no training on how grief can interfere with the doctor/patient relationship. Doctors need to understand how grief impacts on communication and what communication tools will help the patient/family move through their grief. The following is not meant to be a complete treatise on Grief but hopefully it will facilitate you, the medical educator thinking about what you need to prepare your students for. Most medical students received some awareness of the stages of grief as stated by Dr. Kübler-Ross, so we will begin there.
We know that upon first receiving bad news, patients and family members frequently enter a state of shock where they stop being able to hear or feel because their brains are functioning at a flight/fight/freeze stage. To admit to the pain is to admit to an ending. In some cases, people use alcohol or drugs to maintain the feeling of numbness which can be useful initially but doesn’t allow the person to move through the stages. Some people belief letting go of the pain means letting go of the old self/family member.
- Avoid saying:
- I know how you feel
- It’s part of God’s plan
- They are in a better place
- Some suggestions at the initial meeting:
- Offer coffee or tea to give people time to unfog
- Sit silently until the person is ready to talk
- If information needs to be conveyed at this point, bringing a third party such as a friend or as a last resort a nurse in to take notes. Remember the person is unlikely to remember details of what you say
- A cycle of emotional pain avoidance can precipitate addiction and it may be worthwhile nonjudgementally mentioning the need to be careful about alcohol and drug use during this time.
- Expect people to cling to hope.
All that ever sounded like judgments and criticism are just tragic, suicidal attempts at saying please …(meet my need) –Marshall Rosenberg
Although not a stage in Kubler-Ross, in my experience Hope goes hand in hand with denial. We are a culture that believes in miracles, popular literature is full of the power of prayer, angels and positive thinking. The patient and family will think “If it worked for a stranger it should work for me.” You will find this stage a paradox because on one hand, your medical training says X and you may feel the patient is challenging your knowledge. On the other hand, you wish there could be a miracle no matter how unlikely. Understanding that hope is a normal response and your competence isn’t really being questioned is important.
Never put your but (t) into the face of an angry person –Marshall Rosenberg
If the miracle cure didn’t happen, the patient/family is overwhelmed with feelings of rage. Abuse of alcohol and drugs traps a person in feelings of anger. At this stage, they are looking for someone to blame. God isn’t available but medical personnel and family members sometimes are. Again it’s important for the resident to realize anger needs to be spoken and this is not the time for defense. At the heart of the anger is a person in profound pain. This is the time to listen with compassion. Compassionate listening deescalates violence and allows the thinking brain to come to the surface. Once it surfaces, the patient/family is ready to engage in any problem solving that is needed.
- Avoid saying:
- You have so much to be thankful for
- You should or You will
- You have no right to be angry at me even if that is true, this statement will escalate anger.
- Some suggestions for communicating with an angry patient/family member:
- Sit quietly and listen lowering your height appears less threatening
- Say you are sorry they are angry/in pain (you aren’t admitting guilt, you are acknowledging their pain)
- Ask “Have you thought about. . .?” “What can I help you with?” once they have settled down.
Finally help students/residents to identify their own support systems.
The Angry Patient
Breaking Bad News
Collusion in doctor-patient communication about imminent death: an ethnographic study
DEATH AND DYING in Light of Affect
Disclosing Adverse Events
Helping Patients, Families, Caregivers, and Physicians, in the Grieving Process