Pausing to Reflect and Debrief: Emotional Processing in the Face of Death

By Jennifer Ku, PharmD, BCPS

As pharmacists, we are called upon to ensure the delivery of high quality, compassionate, patient-centered care. To do so, empathy is paramount. However, many pharmacy learners struggle with balancing empathy for patients and families with their own emotional needs in emotionally challenging situations, like those regarding death and dying.

So how prepared are student pharmacists for this challenge? As Dr. H Andrew Wilsey pointed out in his Pulses post, pharmacy learners are not well prepared for coping with death and dying in the clinical setting.1 This is all in spite of the growing emphasis on clinician empathy towards patients and patients’ loved ones before and after a patient’s death.

Clinicians often rely on emotional distancing or suppression to protect themselves from being seen as unprofessional or from burnout. However, these strategies can have the opposite effect: amplification of negative emotions, burnout, and lower quality of patient care.2 So how can preceptors help pharmacy learners feel safe displaying empathy in the face of death? Here are some strategies that I have learned as a member of an interdisciplinary palliative care team:

Create an Emotionally Safe Environment

First, create an environment where learners can be emotionally vulnerable without judgement. This is critical to allow learners to feel safe sharing and expressing their emotions. One way to foster a safe environment is by modeling appropriate approaches to processing, such as being emotionally vulnerable with team members and patients. This includes openly expressing emotions such as anger, grief, and fear. Discussing the challenges of coping with emotions also helps. Additionally, it may be important to verbally affirm to learners that emotional responses such as crying in the face of death and family grief is both expected and acceptable (i.e. not considered unprofessional).3

Make Contingency Plans

When possible, be selective with which emotionally unsettling events to expose learners to, depending on their readiness to cope with such situations and personal experiences dealing with serious illness. For example, family meetings from which learners are unable to excuse themselves if feeling emotionally overwhelmed could make learners feel emotionally unsafe. Also discuss before any emotionally unsettling encounters how learners may excuse themselves if feeling overwhelmed. Similarly, a learner may need additional support or may not be ready to care for a patient who is dying from an illness that hits too close to home (e.g. learner suffered a personal loss from a similar illness). Discuss early on and regularly throughout the rotation with learners on which situations may be emotionally challenging and most helpful for the learner to experience.

Debrief on Emotional Aspects of the Experience

Ensure timely and consistent debriefing after emotionally unsettling events. Different models of debriefing after a patient’s death exist, but most agree that necessary elements include:

  • Model grief and emotional response after a patient’s death: Learners need to realize they are not alone in their grief (even experienced practitioners feel it!).3
  • Focus on the emotional aspects of the death and dying process: Debriefs that include the discussion and exploration of grief and the emotions experienced by learners gives them opportunities to express their own grief and receive emotional support from mentors and team members. Learners that receive this type of debriefing also report feeling better prepared to cope with a patient’s death in the future.3
  • Discuss strategies and resources for coping with grief: Some resources to consider are Employee Health & Wellness (or the student equivalent) and hospital Chaplaincy or Spiritual Services.3

Use Empathetic Communication Skills

Lastly, provide emotional support by using empathy when responding to a learner’s emotional responses. Some tools used by palliative care clinicians to articulate empathy to learners that I have found to be effective as a preceptor include:

  • The NURSE mnemonic: Naming, Understanding, Respecting, Supporting, and Exploring a person’s emotions.4
  • “I wish” statements that acknowledge both a person’s words and the limitations of the situation. Examples include “I wish the situation were different” or “I wish we were able to do more” in response to a learner’s frustration about a patient’s circumstances.4
  • Active listening without interruption.
  • Nonverbal expressions of empathy such as meaningful eye contact, open body language, and concerned facial expressions or tones of voice.

Beyond an Emotionally Safe Space

Research has shown that preceptor role-modeling is the most important influence in learning empathy.5 Helping learners develop healthy coping strategies for emotionally unsettling experiences is important, but are not enough to help learners utilize empathy in situations involving death and dying. Thus, we, as preceptors, need to remember to be empathetic and present with dying patients and grieving loved ones in order to model empathy in the face of death for our learners.

Acknowledgements: Many thanks to Dr. James Ray and Dr. Kashelle Lockman for sharing their experiences in teaching palliative care learners healthy emotional coping skills.

References:

  1. Wilsey HA. Pulses Website. An important lesson: dealing with death. https://cptlpulses.com/2019/02/19/dealingwithdeath. Published February 12, 2019. Accessed March 25, 2019.
  2. Granek L, Ben-david M, Nakash O, et al. Oncologists’ negative attitudes towards expressing emotion over patient death and burnout. Support Care Cancer. 2017;25(5):1607-1614.
  3. Eng J, Schulman E, Jhanwar SM, Shah MK. Patient Death Debriefing Sessions to Support Residents’ Emotional Reactions to Patient Deaths. J Grad Med Educ. 2015;7(3):430-6.
  4. VitalTalk. Responding to Emotion: Respecting. VitalkTalk Website. https://www.vitaltalk.org/guides/responding-to-emotion-respecting. Updated 2018. Accessed March 28, 2019.
  5. Tavakol S, Dennick R, Tavakol M. Medical students’ understanding of empathy: a phenomenological study. Med Educ. 2012;46(3):306-16.

Jennifer Ku is a PGY2 Pain and Palliative Care Resident at the University of Iowa College of Pharmacy. Educational scholarship interests include interprofessional education, development of emotional coping skills, and gamification of classroom learning. In her free time, Jennifer enjoys breaking out of escape rooms and exploring local restaurants.


Pulses is a scholarly blog supported by Currents in Pharmacy Teaching and Learning

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