Losing a patient is an experience that all surgeons are likely to face at some point in their careers. The circumstances surrounding these deaths differ—one patient’s life might have been in the process of ending for years due to a terminal illness, while another might suffer complications during what should be a routine procedure. These events can be devastating for everyone involved, and with that in mind, several Fellows of the American College of Surgeons (ACS) are sharing strategies they’ve learned that ease the difficulty of patient loss, as well as advice they would offer to people considering careers in surgery.
Telling the truth
Geoffrey P. Dunn, MD, FACS, general surgeon, department of surgery, and medical director, palliative care consultation service, University of Pittsburgh Medical Center (UPMC) Hamot, Erie, PA, said he has seen a change in the way that death is perceived in the surgical world. Dr. Dunn said that when he started his career 30 years ago, surgeons were not inclined to see death as a natural occurrence. The main question was, “Is my treatment of the patient working?” Recently, however, Dr. Dunn has noticed the focus shift from the single event of the death to improving the surgeon’s ability to anticipate it and to enhance the patient’s comfort level during this time. Dr. Dunn is the Editor-in-Chief of Surgical Palliative Care: A Resident’s Guide, published by the ACS, and in the introduction, he and one of the book’s Associate Editors write that over the last decade, palliative care has become recognized as an essential component of patient care.
When he began practicing at UPMC, Dr. Dunn learned how important it is to be completely honest with patients’ families because, many times, he knew the families and would often cross paths with them outside of the hospital. And as the son, grandson, and great-grandson of surgeons who practiced at the same institution, Dr. Dunn said he felt a great sense of responsibility to his patients and their loved ones. Recently, he treated a 102-year-old man on whom his grandfather also had operated.
Having that connection can be helpful, Dr. Dunn said, but it can also make it more painful if something happens to the patient. Even in those circumstances, though, staying in touch with the patient’s family has helped him to cope. One of the first losses Dr. Dunn experienced was with a patient on whom his father had operated years before. After the funeral, the family invited him to dinner, where he heard them talk about the man’s life. He and the family kept in touch for years.
Dr. Dunn said he also became an early believer in the value of a condolence letter, which serves as a tribute to the patient and a source of comfort to the survivors. In those letters, he makes sure to recall qualities of the patient and offers a way to keep in touch.
“Death is not a final, defining point for the individual or the relationship that occurred around it,” Dr. Dunn said.
Developing a relationship with a patient’s family also helped Danielle Saunders Walsh, MD, FACS, get through the loss of a patient. Dr. Walsh, a pediatric surgeon who has been practicing for approximately 10 years, is an associate professor at Brody School of Medicine, East Carolina University, Greenville, NC.
Dr. Walsh said the death of every child affects her, regardless of how well she knows the family. “Children bring a different perspective in dealing with death. In general, we view them as innocent. We see it as a loss of an opportunity for someone to experience a full life,” she said.
One of her first experiences with loss occurred with a teenage patient who had a birth defect that had become increasingly problematic as the girl matured. No other physician whom Dr. Walsh consulted was able to help. The girl died suddenly while Dr. Walsh was performing a procedure.
Dr. Walsh said that losing this patient was extremely difficult, and she contemplated whether a career in surgery was right for her. “If this is so painful, why am I doing it?” she wondered. But at the funeral, the girl’s mother could tell she was hurting. “She said, ‘I hope you don’t give up,’” which reassured Dr. Walsh that she should continue in her chosen career.
Dr. Walsh said that in her experience, many conversations with patients and families would be easier if Americans could view death as a natural part of life—no matter how brief or lengthy that life may be. But we are not quite there yet as a society, she said, because people tend to think there is always more, medically, that can be done.
Patricia J. Numann, MD, FACS, FRCSEd(Hon), FRCSGlasg(Hon), is an ACS Past-President and Lloyd S. Rogers Professor of Surgery Emeritus, Upstate Medical University, Syracuse, NY, and State University of New York Distinguished Teaching Professor Emeritus. Dr. Numann said she has noticed that accepting the death of patients seems to be harder now than when she started her career as a surgeon. When she was a medical student in the 1960s at the State University of New York Upstate Medical University, there were no intensive care units, according to Dr. Numann. “A lot more people died. We didn’t have these extraordinary, heroic things that we could do for people.”
Dr. Numann said she was always reasonably comfortable talking about death. As a child, she would walk around Woodlawn Cemetery in the Bronx, NY, with her aunt, and they would look at the flowers on the graves. When she was a third-year medical student, Dr. Numann left school to help take care of her mother, who had pancreatic cancer and wanted to spend her remaining time at home. Dr. Numann’s mother died shortly after she returned to school. Her mother was, in a way, the first patient she lost.
From that experience, Dr. Numann began to see that some patients do tend to cling to life, waiting for certain events—babies to be born, graduations—before they pass away. It can be important to the process that they have something to look forward to, she said, and she always made it a habit to visit dying patients at home when she could. Many families want to know that their loved ones are not alone when they are close to death. Dr. Numann said family members have asked her to sit with patients if they are not emotionally strong enough to do so.
Dr. Numann said she would always try to go to the family’s calling hours after the death of a patient in order to cope. Doing that shows families that “you did truly do your best, and you did truly care about the person,” she said. Dr. Numann added that many people don’t realize how much surgeons miss some of the patients they have treated. “[Some patients] become like part of your extended family,” she said, because, as part of a trusted relationship, they would get to know what was going on in each others’ lives.
Being involved with patients’ families also helped Frederick L. Greene, MD, FACS, medical director of cancer data services, Levine Cancer Institute and former chairman, department of surgery, Carolinas Medical Center, Charlotte, NC. Dr. Greene is also the host of The Recovery Room, a podcast featured on the ACS website that deals with medical topics.
Imparting difficult information was a big part of Dr. Greene’s job as a cancer surgeon, and he found the best approach was to communicate any bad news as early as possible.
“I think it’s important that you don’t wait until an event is over. For me, if I was going to operate on a high-risk patient, a lot [of learning to report bad news] has to do with communication with the family up front,” Dr. Greene said.
He cautioned to never impart difficult information in a public arena, like a hospital hallway. Instead, he suggested taking the family into a private area, such as a conference room, and making sure they sit down. Once the information has been presented, Dr. Greene said it is important to let the family be alone. The surgeon can also offer to contact another physician for a second or third opinion. Dr. Greene added that this can be difficult for some surgeons who want to believe that they can take care of their patients better than anyone else, but “you have to be the one opening the door for that conversation,” he said.
If a death occurs, the surgeon should ask how he or she can help the family with the grieving process. Dr. Greene said he has gone into the homes of families to explain autopsy results if such a conversation is necessary to determine how the patient died, or to discuss genetic risks for survivors.
Heena P. Santry, MD, FACS, assistant professor, University of Massachusetts Medical School, Worcester, MA, rarely has the opportunity to form lasting relationships with patients or their families. As a trauma and critical care surgeon, Dr. Santry said she is usually delivering bad news within hours of meeting the patient and oftentimes within minutes of meeting the family. In her four years of practice, Dr. Santry said she has developed a gut instinct concerning how to deal with the situations she encounters when she walks into the family waiting room.
Sometimes, Dr. Santry explained, she will give families a brief overview of what happened to the patient before giving them the news. Other times, people are so hysterical or nervous that she knows she needs to tell them right away, adjusting her word choices, body language, and intonation to the emotion of the situation.
There is not much time to train surgeons in their interpersonal communication skills, Dr. Santry said, and she has relied on mentors in developing her own style. It can be difficult to teach, so the best way for trainees to learn is to watch surgeons deliver difficult news over and over again, Dr. Santry said.
“The key is to develop a style that allows you to perceive the needs of the family you’re talking to while conveying the appropriate amount of empathy,” she noted.
Returning to the OR
Dr. Greene said that weekly morbidity and mortality conferences, which enable surgeons to come together and discuss surgical outcomes, have been helpful for him. Dr. Greene said the conferences, which were started by Ernest Amory Codman, MD, FACS, a founder of the College, are educational and provide a supportive atmosphere for surgeons at all stages in their careers. Even after analyzing outcomes, however, surgeons must remember that negative patient outcomes are still, unfortunately, a reality.
“Many people can’t cope with that,” he said. “I have seen surgeons who become devastated, and that’s why burnout occurs.”
For Dr. Dunn, it’s important to get in touch with peers and not become psychologically isolated after losing a patient. When that happens, he said, you tend to lose perspective. “You’ve got to have a place to put all the negative energy that can occur because of losses. Share your thoughts with someone you trust,” he said.
If another patient is waiting to be cared for, however, the doctors agreed that there is no time to express their sadness. Dr. Walsh said that learning to silo her emotions has been helpful to her after a patient dies, particularly if she must tend to another patient right away. “You have to put those emotions away in order to go take care of the next person who needs your help,” she said. To deal with those emotions outside of the operating room, Dr. Walsh said she turns to people she cares about who can provide the words and guidance necessary to help ease the pain.
Dr. Santry said there have been times when she has cried with the families of patients after a loss. But surgeons need to have a laser-like focus, she said. They have to be so fully engaged with the next patient that they simply have to shut down lingering feelings, if only temporarily.
Tyler G. Hughes, MD, FACS, ACS Governor and Chair, ACS Advisory Council for Rural Surgery, general surgeon, McPherson Hospital, KS, agreed that sharing the experience with someone else is helpful. For him, that means talking to another physician or someone other than his wife or friends.
“You have to find some objective way to see if you contributed, and be honest with yourself about it,” Dr. Hughes said. He added that it can be difficult to do that in McPherson, where the population is 13,000, and many people know each other.
Dr. Hughes cautioned against returning to surgery too quickly after a loss. The event might cloud your judgment, he said, and you don’t realize that you’re not listening to your current patient because your head is still back in the operating room with the last one. Surgeons of his generation were trained to be “bulletproof,” he said, but he’s learned that it’s not a sign of weakness to ask for help. It can also be comforting to know that every surgeon has most likely gone through the same thing.
“Never be too proud of your work,” Dr. Hughes said. “The easiest case can go south, and [you should] expect it to do so, because that’s going to happen one day. Know that every surgeon has been right there.”
No matter the circumstances that lead to the death of a patient, the surgeons agreed it’s always difficult for all involved. Some surgeons said it was important to keep in contact with the patient’s family because interaction with the family helped to show how much these physicians cared about the patient, while another surgeon found the reassurance she needed to continue practicing surgery from these personal exchanges. Many surgeons said it was important to talk to someone they trust after a loss, whether it be a family member or fellow physicians who help them see these situations objectively. No matter how sad they may feel, however, it’s essential for surgeons to be able to put their full focus on the next patient.