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Death, Dying & the Medical Student


Death, Dying & the Medical Student Towards good practice via awareness & self-care Frank McDonald Consultation and Liaison Psychologist The Townsville Hospital – PowerPoint PPT presentation

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Title: Death, Dying & the Medical Student

Death, Dying the Medical Student
  • Towards good practice via awareness self-care
  • Frank McDonald
  • Consultation and Liaison Psychologist
  • The Townsville Hospital
  • 2006
  • Download this linked materials at

  • Background to this presentation
  • Nature of the problem
  • What can we achieve today?
  • Stressors associated with working with death and
  • Which medical students more likely which less
    likely to cope constructively with their grief
    loss experiences?
  • Loss, grief bereavement coping skills - sharing
    some ideas

  • One of the more difficult aspects of medicine
    allied professions can be witnessing the dying
    process for both uninitiated students
    experienced practitioners
  • Few curricula literature reports address how
    you are to behave, manage emotion confront
    cope with your own distress grief when pts die
  • But what if only a few of your guides mentors
    (e.g. snr residents consultants) talk about
    death dying, or teach much about thanatology
    (the study of grief surrounding death), why
    should you bother?

  • Lets hear from 1st to 4th year medical students
    who seem to be in tune with a genuine, practical
    need whose requests for change can hopefully
    influence those at the top, combined with the
    voices of community needs and experienced
    practitioners (e.g. Cairns Yates 2003) (we
    feel) inadequately prepared to communicate with
    terminally ill patients, as well as being poorly
    equipped emotionally to deal with matters of
    death and dying. This is important to us on a
    personal level as we face dying patients almost
    daily on the wards. (Am. Med. Students
    Assoc. website 2006)

  • Understand your own personal feelings about death
    Most people have a vague belief of death or what
    happens after death. For isnt it the uncertainty
    of it all that scares us most? We are so used to
    dealing with concrete physical deformities that
    we can test and probe and examine, so when we are
    faced with the ambiguity of death we suddenly
    feel helpless. So we skirt around the issue and
    leave the room in a moment of awkwardness when
    the news is broken to the patients family It
    helps to think about these things (our coping
    strategies). The more we know ourselves, the more
    evident it will be to our patients. Jemima
    Tagal, third year medical student, University of
    Cardiff (Student BMJ 2006)

  • Quite rightly, medical students receive training
    on how to break bad news to patients and
    families, but medical students who experience the
    death of a patient or a distressing case get
    little support students may receive a small
    amount of counselling to help them deal with bad
    news or bereavement. A confidential counselling
    service available 24 hours specifically for the
    medical profession, so they may deal with death
    in an appropriate way (both at a personal and
    professional level) would surely be appropriate.
    It is vital that the "medical culture that
    defines death as failure" ends.Simon Clausen,
    fourth year medical student University of Leeds
    (Student BMJ, 2003)

  • Students who have witnessed death thru personal
    experience of family, friends, or volunteer or
    other work report a range of experiences . . .
    from the traumatic . . .

  • . . . to lack of emotion . . .
  • (Too much of this can suggest denial problems
    or other, eventually costly, defences. Meier et
    al. JAMA 2001, found unexamined physician emotion
    may interfere with pt care lead to physical
    distress, disengagement, burnout/cynicism, poor
    judgment. Medicos dont have good record with
    emotional self-care.)

. . .Others who have yet to experience their
first pt death anticipate a gamut of affects
concerns sadness, confronting mortality,
frustration, guilt, self-doubt, blame,
helplessness, a sense of failure, and most
frequently quoted of all - FEAR . . .
  • . . . some, wisely, are concerned about becoming
    too inured to death that this excessive
    detachment would numb their sensibilities
    necessary for good medical practice . . .

  • . . . Individual constructions of death can
    depend on the context whether they had a good
    relationship with the pt. who is dying at
    what age.
  • Many fear the unexpected death, as well as
    the death of a child or young adult . . .

  • . . . but upon reflecting upon the death of any
    hypothetical first patient, anxiety about death
    re-emerges as a major theme . . .

  • One student sums up the need for self-care,
    for medical education to get involved with the
    need for coping strategies, when confronting the
    dying pt.

Quotes extracted from C.M.Williams et al., 2005,
J. Palliative Medicine (Highlights mine)
Nature of the problem
  • Before discussing some self-care/coping skills,
    some exercises to begin establishing these, it
    can help to understand the nature of the problem
    of working with dying pts.

Nature of the problem
  • 1. In Medicine generally physical psychological
    demands high. Working with death dying is work
    of a special nature. Places additional unusual
    demands on coping skills
  • making breaking bonds repeatedly
  • need to grieve deal with effects
  • pressure to develop realistic expectations (e.g.
    balancing self-care with care of dying pt.)
  • coping with conflicting demands (pts, families,
    social, workplace, personal needs)
  • dealing with ethical issues (when does preserving
    life become prolonging death?)
  • limited time to interact with colleagues (e.g. to

The most stressful jobs
  • Teacher high school, inner city, higher primary
  • Police officer
  • Miner
  • Air traffic controller
  • Junior hospital doctor
  • Stockbroker
  • Journalist
  • Customer-service/Complaints Dept worker
  • Waitress
  • Secretary/receptionist
  • Machine-paced worker
  • Bus driver
  • Nurse
  • Solicitor
  • Professional groups with responsibility for life
  • International airflight crew
  • Unskilled semi-skilled worker
  • Common thread/s?

Nature of the problem
  • 2. Easy to miss signs symptoms of bereavement
    overload (term refers to effects of serial
    losses originally applied to experiences of the
  • can be very insidious
  • old emotional reactions can be triggered w/o you
  • expectations of what you can do to support can be

Nature of the problem
  • 3. You risk costs of excessive stress if you
  • Ignore usual stress grief reactions
  • Dont take sufficient time-out / try to do too
  • Lack organisational social support
  • End up hurting yourself reducing your ability
    to help others

What can we achieve today?
  • Examine discuss how medical staff recognise
    cope with the stress of their grief, as distinct
    from that of those they care for
  • Help prevent bereavement overload
  • Legitimise the experience of grief-related stress
    in your work your emotional needs

What can we achieve today?
  • Heighten awareness of how losses, in the course
    of your work, can affect you
  • Discuss some ideas for better management of
    stress of grief
  • Raise awareness of early experiences and their
    influence on our reactions
  • Discuss how we can draw on our experiences with
    adversity to help ourselves and others at times
    of death
  • Being prepared for stress or demand is one of the
    best ways to mx it. Reflecting on the death of a
    hypothetical pt

Stressors of care-givers grief
  • 98 of 6,000 surveyed who work with the dying say
    they experience significant difficulties
    (Kavanaugh, 1974)
  • 3 types of stress identified
  • Forces to look at own mortality losses
  • Multiple bereavements without closurefailure to
    grieve bereavement overload
  • Unrealistic expectations about helping dying
    person alearned helplessness

Stressors of care-givers grief
  • More on bereavement overload - some causes of
    failure to grieve
  • Social negation of loss of patient - often not
    defined as appropriate loss to be grieved
  • Cut off from collegiate support
  • Strong one role bound up with doctoring (
    other jobs like army personnel, nurse, minister
  • Easy to over-identify with others in crisis of
    loss because its a universal experience - can
    avoid reawakening old losses if suppress grief
  • Overwhelmed by multiple loss

Who copes?
  • Those who understand grief bereavement theory.
    See How to tell if grief is progressing
    normally (Exercises to follow deepen this
  • Complete bereavement tasks (those who work
    through grief)
  • Use available support
  • Can choose from a range of constructive coping
    (Saunders Valente, 1994)

Who doesnt cope?
  • Environmental and personal factors predicting
    general distress in interns residents(Daly and
    Willcock, 2002)

Preventing bereavement overload
  • Description of personal coping strategies tip
    sheet for bereaved care-givers

Some resources hyperlinked
  • Supplements section of eMJA on medical student
    stress MJA 2002 177 (1 Suppl) S1-S32
  • While written for individuals going thru a
    relationship break-up, this book - mostly in dot
    point form - gives generalisable insights into,
    hope for working thru, grief How to Survive
    the Loss of a Love
  • Text only from the illustrated book for
    childrens questions about death The Fall of
    Freddie the Leaf

Some resources hyperlinked
  • Buddha and The Mustard Seed - parable about
    universality of death, sorrow suffering,
    tragedy loss. May help someone who is stuck
    in movement towards acceptance.
  • Harpers (1977) 5 Stage Model helps reflect on
    where you are in your emotional progress of
    personal and professional maturation towards
    being helpful to pts facing death, mindfulness
    of your own needs

Exercises - hyperlinked
  • Exercise 1. - Worden's "History of Loss
  • To be discussed in a dyad or triad. This
    raises awareness of how early experiences with
    loss at least and (perhaps in some students'
    cases) death leaves us with messages, feelings,
    fears and attitudes that influence our response
    to the dying and the bereaved. Awareness raised
    by this exercise prevents becoming controlled by
    these reactions.
  • Exercise 2. - Your psychological, social and
    physical responses to the three most difficult
    situations in your life. 
  • A handout structures this exercise. It
    illustrates that we all have some experience with
    grief that we can draw on to assist us in dealing
    with others' and our own reactions to the dying
  • Share with a classmate who actively
    listens/paraphrases and responds.
  • Exercise 3. - Reflect on how you might respond to
    the death of a hypothetical patient. (Handout to
    help generate pt profiles prompts for ways in
    which you may respond). Discuss in small groups
    of 2 or 3. Written reflection exercises improve

Glasbergen on the dual scientific humanitarian
focus of Medicine