Dr. Brown, thank you so much for sharing that with us. So I'm a nurse scientist, a health services researcher. I'm finishing up my second year as a national clinician scholars program research fellow at the University of Michigan. I've been asked to talk a little bit about caregiver grief and trauma from patient death. And for this talk, I'm actually going to be referring to us as the critical care clinician as the patient caregiver. A little bit about me, my clinical background, it spans 25 years in critical care as a nurse, in palliative care as a nurse practitioner, and in critical illness survivorship. But I spent many of my younger years at the bedside as a critical care nurse. So my disclosures, and then the objectives of my talk here. But I'm going to share two stories first. These pictures are shared with permission. The first one is actually me in the middle in Belize with some of my wonderful nurse friends. And this is a time, you know, I'm a new nurse. I'm a new critical care nurse. And I was taking care of a 19-year-old boy. He wasn't, I guess he's an adult, he's a man, but he was a boy. And he was over Christmas break. It was December 30, 2000. This is how detailed I remember this. And he had come home from Virginia Tech. He had a full scholarship in engineering and was an unrestrained passenger in a car accident. And he was my patient. And I did everything that I could for him. And I stood in the room. I held his hand. I counted down at midnight with him. And a few hours after that, he passed. And his family came in. His younger brother was 12, 13 years old. And I'm standing there. I'm watching this interaction, watching the family be with this boy that just passed. And I look at the nurse's station. And they're toasting with non-alcoholic champagne. It's New Year's. And I was so overwhelmed. I was unsupported. I actually, thank goodness, I was my only patient that night. I left. I went home. And fortunately, I still had a job. But I just, I couldn't handle that grief. I had no resources. I had no support. It was what you signed up for back then. The other picture is my son, Jake. He recently graduated from nursing school. That's my dog, Charlie. She doesn't mind I'm using that picture either. And Jake just graduated from nursing school in 2020, December of 2020, almost 20 years later, which is crazy. And went right to work in the COVID ICU. He was still living with us at the time, and day after day. And I tell this story, and I know so many of you can connect with this, the death day after day after day in the ICU early on. And every day, a little bit more distressed, a little bit more distressed. He would come home. And the final straw was he came home. He's in tears. He's sitting with my husband and I. And he's telling us the story about a man that he was taking care of that night, the husband in bed 12 of the COVID ICU, who they did just a traumatic resuscitation that the patient eventually died. And about four hours later, his wife, who was in the next bed, also arrested and died, leaving four kids. And my son's like, I can't do this anymore. And he's actually quit nursing. He's in sales. And I don't know if he'll ever go back because of that. So when we think of the nature of death in the ICU, these are the four types of death we're seeing as clinicians in the ICU. So it's arguably unique, the experience of our patients dying in the ICU. This first, the rapid unexpected death, they're unexpectedly deteriorating. It's a surprise, the rapid expected death. But the death's following a clear line with the patient's condition. The chronic unexpected death, people typically have a protracted illness leading to the ICU admission. And then the chronic expected death, where we recognize the patient's dying and they will likely die in the ICU. So when you think of how we deal with grief in these certain situations, that rapid unexpected, it's really hard to be able to give good end of life care or give a good death. It's challenging. We're typically running a code in the room. The patients often lack decision making capacity. So we don't really know what their wishes were. And as we know, families tend to not be the best surrogate decision makers. That moment of crisis, it's hard. And these are the situations where that complicated grief is more likely to occur. With rapid expected death, we're at least recognizing that the dying process is going to happen. It does, at times, give us an opportunity for a smooth transition, good end of life care, if we know what their wishes were ahead of time. And we usually see that with a short period of illness. And because it is expected, we may or may not be able to have some anticipatory grieving. With the chronic unexpected, we know that there's a pre-existing chronic condition. There's still uncertainty to diagnosing dying in this population. And there could be some complicated grief trajectories that come from these types of deaths. And then that chronic expected death, this is what I feel like we know the most about. The patient may have expressed their wishes for their preference in treatment and care. There is clear guidance on end of life care in this population. And we have more opportunity to have some anticipatory grieving. This is our cancer patients, our COPD. We have a lot of literature on this. And my favorite patient that falls into this category, when I was working as a palliative care nurse practitioner, it was this man. He's in his 80s. He's a farmer, end stage interstitial lung disease. On all the oxygen in the hospital, high flow, 60 liters. But he knew what he wanted. We sat and we talked for an hour. And we planned his death for the next day. It had to be the next day at noon, because there was a new episode of Homicide Hunter with Joe Kenda coming on that night on Investigation Discovery. And he didn't want to miss it. And he wanted to be well-rested when his family got there, when we decided to transition to comfort-directed care. And that story feels a lot different from the first story that I told. The relationship with the patient and the family was still there. But having that chronic expected death, my grief response was very different. So we know that grief is a normal response. Sorrow, heartache, confusion, losing something or someone important. It's an emotional experience, psychological, behavioral, physical, spiritual for us. And it's also a common response after a traumatic event. And I think where we get complicated in the ICU is that we have the overlap of that traumatic experience when we're seeing those rapid unexpected deaths and grieving the death of the patient. It can become overwhelming. And obviously, with COVID-19, it's just brought another layer to this, because we are coming in, taking care of these patients. And we're not just our professional roles. We are also dealing with personal loss. And it just feels like it keeps coming and coming. And then there's even vicarious grief, where we're grieving for the family of the patient and with them. So factors that are affecting this grief that we're dealing with in the ICU as clinicians, as I mentioned, through these different types of death, that prognostication, how rapid it is, how smooth or unsmooth that transition is to comfort-related care and critical care, or even as interventions occurring during the dying process. I think a lot of us as critical care clinicians struggle with differing opinions on what that care looks like at the end of life. And we know that the patient and family dynamics are also going to affect this. And are it pre-existing mental health and well-being, what we're coming to our jobs with? And if we have that social support, do we have the family structure to support that? Do we have the family structure to support us? Do we have our social networks? So modes of coping, I like this. And this is actually Brene Brown. It was a podcast. And the first mode is, I won't feel I do. I don't need help. I help. And the second being, I won't function. I'll fall apart. I don't need, I don't help. I need help. And I think it pretty much sums up the two different types of coping that we have in the ICU. And I think that even in the story at the beginning, I initially was coping with, I don't need that. I help. I'm the one that is doing this. And after that initial death, the first traumatic death for me, I just shut down. Everything was depersonalized. And this is how I was avoiding grieving for this patient, which brings us to these potential harms that we have, right? So secondary traumatic stress. When we're being exposed to other people's traumatic experience, this can happen. Burnout, I know we've had so many really great lectures this conference about burnout. And as we know, it's the ineffective ability to cope with stress at work. And compassion fatigue, I think, we are seeing a lot of that now with that emotional exhaustion, depersonalization, and just that decreased sense of personal accomplishment. And it can manifest psychologically and physically. So some strategies to mitigate these harms and deal with the grief that we're feeling for our patients and their families. So I think, most importantly, these individual strategies, there is so much power in naming and normalizing grief. It really allows us as clinicians to make meaning of the event. And I think the second most important thing is just giving yourself permission to grieve. Like, grieving takes time, energy, and tension. We're allowed to grieve. I think a lot of us struggle with that, this comparative suffering. Like, I shouldn't be grieving this poor family. Like, I feel selfish grieving this. But the thing is, we need to be able to recognize when this gets bigger than us. I mean, and that self-awareness is so important. I mean, the compassion that we're showing ourselves should be as important as the compassion that we show our patients and families. Self-care. I mean, I know that we hear about this all the time. And I don't know how many years I'm like, oh, self-care. I'm going to eat right. I'll get some sleep. I don't do any of that. However, I recently started doing yoga. And for the first time in a 25-year career, I feel like I have a space to be able to do yoga. Be able to deal with these things. And I used to think it was just hype. I mean, I really believe that this is an important thing. And as I mentioned, as it becomes bigger than ourselves, like being able to reach out and ask for help, and ask for professional help, and look for individual counseling. Institutionally, I think the first and foremost thing is having organizational commitment to the ICU workforce mental health. I know all of you can stand behind that. But I think we also need to remember that there is not a one-size-fits-all for grief support plan. Things shouldn't be mandatory. And I think it was a nursing group out of Johns Hopkins that had published on formal bereavement debriefing sessions, which just sounds so wonderful. And it was interesting. Dr. Jackson and I were talking before the session. And in the middle of COVID, their group at Vanderbilt had started offering peer support groups for health care providers. And they're no longer doing that. And it's interesting. And it gives me pause when I think about these strategies where in these support groups, the nurses were really willing to share their feelings. But the physicians were a little bit more hesitant to do that. So I think we need to consider the types of offerings that we have for, even though we consider ourselves interprofessional teams and we're all working towards the same mission, due to our training, we may require different things. But these debriefing sessions, they can be requested for professional distress, sudden unexpected death. If there was long-term relationships with the patient. When I worked as a nurse practitioner at UPMC for the palliative care department, we actually provided these services within the ICU. Case-based rounds or death rounds. It was Dr. Terry Huff in 2005, they put out a paper that talked about introducing death rounds. And this was the idea of monthly discussions around the emotions and the issues surrounding the care of dying patients. And it was directed towards house medical staff that were rotating through the ICU. And it was found to be helpful. And then last, the pause. And I'm embarrassed to say I didn't know what this was until I started preparing the presentation. But this is the idea that we are doing just that. We're pausing and honoring a deceased patient. And it gives us a moment as the team to reflect and have closure and preparation for the next patient or situation. And work that's been done in this area has shown that ICU staff have reported positive benefits, decreased feelings of disappointment, failure, grief, and distress. So to summarize, and I think Dr. Brown also said this, each person's grief is as unique as their fingerprint. And I like this statement. But what everyone has in common is that no matter how they grieve, they share a need for their grief to be witnessed. That doesn't mean needing somebody to try to lessen it or reframe it for them. The need is for someone to be fully present in the magnitude of their loss without trying to point out a silver lining. And that's it. Thank you all so much for listening.

caregiver grief

trauma

patient death

critical care settings

grieving process