An important lesson: Dealing with death

By H Andrew Wilsey, PharmD

“Time of death… 08:43”

I surveilled the room; syringe caps and sterile wrappings littered the floor, a ransacked code cart, with its drawers ajar. My eyes drift up from the patient, to a nurse, her face set, but flush from compressions, the attending preparing to meet with a grieving family, and finally to my pharmacy student – his eyes wide, jaw slightly agape, impossibly pressed into a crevasse of the patient room.

Pharmacy curricula may not adequately expose student pharmacists to the realities of death and dying. We review the pharmacology, discuss clinical guidelines, delve into pharmacotherapeutics, foster networking and patient counseling – and yet, discussions of death and end of life care may not be sufficiently discussed or reviewed.

Experiencing death is a common occurrence in healthcare, ranging from the traumatic, abrupt loss of a patient emergently coding to the more gradual transition associated with palliative or hospice care. When students experience the death of a patient, it is crucial that preceptors recognize this may be the learner’s first encounter with patient death. Remember these processing skills are gradually developed, just the same as our student’s clinical skills. Patient death is a learning and potentially transformative experience for students, and as educators, we can work to instill, within our students and ourselves, a reflective process following a death.

Start from the ground up
Developing students’ ability to cope with death starts with a curriculum integrated with death and end-of-life care discussions. A 2012 survey of education in pharmacy schools reported only six hours were dedicated to death and dying.¹ Unlike medical school, pharmacy school accreditation standards don’t require separate courses in end-of-life care.² Anderson et al. surveyed graduating medical students about personal experience with death and exposure to death during experiential training. Students who reported prior experience with death had significantly higher confidence regarding their ability to help dying patients and their families.³ Pharmacists are at the bedside now, more than ever before, and with the development of pain and palliative care positions, it remains essential to meaningfully incorporate discussions of death in pharmacy curricula. While curricula changes may lay strong foundations, they cannot fully allow students to cope with losses during their experiential training. Here, preceptors become pivotal.

Know when to exit
In initial exposures to death or emotionally challenging cases, the most impactful action to help our new learners is to identify when to exit a situation. I experienced use of this technique as a PGY-1 resident on rotation in the emergency department. A young man was found down after an overdose. After an hour of advanced cardiac life support, efforts were withdrawn. Seeing the family approach, my preceptor, told me to leave the code cart, and suggested we take a walk. I was confused, but followed. She recognized we had served our role to the patient and made it okay for me to exit. Facilitating a new learner’s departure before family entry may be particularly helpful, as some professionals have reported family reactions more disturbing than coping with the death itself.⁴ We should have deliberate discussions with our learners to understand where they are in their development and communicate that it is okay to exit when our role is complete.

Decompress and Discuss
Support directly following the event can be helpful to start the process. Remember, this may be your student’s very first encounter with death, we need to be highly aware of their emotions.

• Discuss the events that occurred. Make it clear that often patients are in critical states and that no one action, additional drug, etc. would have changed the outcome.
• It is okay to be upset. They may not want to be embarrassed or ashamed of their feelings or burden a preceptor with their self-perceived weaknesses. There is no shame in feeling the loss of a patient.
• Identify an outlet- music, exercise, cooking, a co-worker, friend or family member. Find ways to process these emotions in an individualized manner.
• Learners may be disconcerted by how seemingly unfazed other members of the healthcare team may act and it may be valuable to mention the adaptation of coping skills and compartmentalization over years of experience.

Prepare
We need to be able to effectively put our patients first. If we recognize a challenging situation, we can focus on the controllable factors. Narrow your mind to the task at hand. Know that you can ensure your patient gets the right dose, of the right drug, at the right time.

When students are facing the death of a patient, no matter how painful, we can foster tremendous growth and learning for students. Students may begin to cultivate a lifestyle of effective coping techniques and continue to improve teaching regarding death and dying for future generations of pharmacy students.

Acknowledgements
I’d like to thank Dr. Regan Baum and Dr. Robert Kuhn for sharing some of their own coping techniques within their emergency medicine and pediatric patient populations.

References

1. Dickinson GE. End-of-life and palliative care education in U.S. pharmacy schools. Am J Hosp Palliat Med. 2013;30(6):532–535
2. ACPE (Accreditation Council for Pharmacy Education). Accreditation standards and key elements for the professional program in pharmacy leading to a doctor of pharmacy degree. Chicago, IL: ACPE; 2015. [January 25, 2015].
3. Anderson, WG, Williams JE, Bost JE, Barnard D, “Exposure to death is associated with positive attitudes and higher knowledge about end-of-life care in graduating medical students.” J Palliat Med. 2008. 11(9): 1227-1233.
4. Batley NJ, Bakhti R, Chami A, Jabbour E, Bachir R, et al.”The effect of patient death on medical students in the emergency department.” BMC Med Edu. 2017; 17(1): 110.

H Andrew Wilsey is a PGY2 Critical Care Resident at the University of Kentucky Medical Center. Educational scholarship interests include gamification of classroom learning and developing student metacognitive abilities on clinical rotations. In his free time, H Andrew enjoys spending time outdoors and trying new restaurants around town with his co-residents.

Pulses is a scholarly blog supported by a team of pharmacy education scholars.