April 30, 2020

Losing Patients to COVID-19 and Managing Grief

What the research says on coping with patient death

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During this difficult time of the COVID-19 pandemic, it is important to recognize the range of challenges faced by healthcare providers – from providing care to critically ill patients to dealing with an increase in patient deaths. A recent study conducted in China during the COVID-19 pandemic found that healthcare workers reported symptoms of depression (50%), anxiety (45%) and insomnia (34%), with nurses and those providing direct care to COVID-19 patients having an increased risk for more severe psychological distress (Lai, Ma & Wang, 2020). Exposure to the loss of patients can amplify these symptoms.

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Beth Gardini Dixon, PsyD, a clinical psychologist in the Psychosocial Oncology Program at Cleveland Clinic’s Cancer Institute, works with nursing colleagues who frequently encounter death and dying in their clinical work. She shared that surveys of nurses who experience patient death reveal a broad range of emotional reactions, including sadness, frustration, a sense of grief and feelings of helplessness. For some, their experience contributes to a diminished sense of confidence in dealing with loss.

Several factors influence the ability to recover from loss, such as your professional developmental stage and personal circumstances. Nurses with more clinical experience tend to have a greater acceptance of death. In some situations, a caregiver’s personal circumstances, such as dealing with family stressors or providing care outside of work, may affect the ability to bounce back. Certainly, the current pandemic has introduced new, unexpected challenges that can impact coping and well-being.

One of the greatest risks to healthcare providers is professional burnout, which stems from repeated exposure to others’ pain and suffering, along with the constant demand to move on to the next patient or caregiving task. Signs of burnout include emotional exhaustion, feelings of depersonalization or detachment, and decreased capacity to be productive. Additional symptoms may involve intrusive thoughts about work, irritability, anxiety, and pessimism about the future or the value of one’s efforts.

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Dr. Dixon says she sees some overlapping clinical features between caring for patients with certain advanced cancers and patients with COVID-19. Unpredictable disease course and limited ability to prolong life for some patients generates existential questions that can lead to uncertainty and angst. The rapid onset and decline of patients with COVID-19, and communicating with their family members who cannot be present, creates uniquely challenging emotional encounters.

As nurses and all providers continue to care for COVID-19 patients, developing and practicing effective coping skills is essential to managing the stressors of these unprecedented times. A recent review of the literature on coping with death among nurses identified the following key themes as helpful (Zheng, Lee, & Blumer, 2017):

  1. Set boundaries: Set physical and emotional boundaries that promote healthy separation from your work and the ability to maintain work-life balance.
  2. Take time for reflection: Think about your role in caring for the patient. Also make a conscious effort to recognize your contributions and think about how they align with your personal values.
  3. Acknowledge and express emotions: It is important to be able to express sadness, anger or other emotions triggered by the loss. Many nurses report crying in response to patient deaths as a normal reaction to grief.
  4. Think about your beliefs on death: Your beliefs can help with processing death. They may be spiritual beliefs and/or acknowledging that death is an inevitable part of life, even with ideal medical care.
  5. Draw on your life and work experiences: Use your previous life and work experiences to deal with patient death and to inform perceptions and attitudes about it. Many nurses report that increased exposure over time reduced their anxiety about this aspect of their role.
  6. Keep daily routines and activities: Regular exercise, engaging in hobbies, getting good nutrition and sleep, relaxing and restoring your energy are critically important. Engage in the things you enjoy and find meaningful.
  7. Talk and be heard: Share experiences with colleagues and even with family members of the patient as appropriate. It’s important to acknowledge your thoughts and feelings and to share them with people you trust, whether teammates or other supports. Identify resources, including mentors or other staff.
  8. Take part in spiritual practices if it helps you: Talking to and leaning on chaplains and spiritual care providers can offer comfort and ease death anxiety.
  9. Learn from educational programs: Utilize institutional resources to participate in educational offerings on bereavement care and grief counseling.
  10. Debrief: Create opportunities to process your reactions with colleagues. Routinely sharing your experiences and receiving and giving advice can assist with adjustments to loss.

Dr. Dixon says one of the most important things you can do is reach out for help when you need it. Allow yourself to accept your own human limitations. Caring for yourself is essential to maintaining your ability to care effectively for others.

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