During medical school and internship, we meet with death in all forms and shapes. Death, as a dying or deceased body, as mourning relatives and where our actions as physicians ends. Transitioning into psychiatric practice, we mainly talk about death as the suicidal desire for the release death offers or the anxiety that the certainty of death evokes. It is uncommon to encounter death in psychiatry. When it happens, such as through an in-ward suicide, it is considered a medical error and can unsettle even the most seasoned psychiatrist. It was first when I began my current work as a consultation-liaison psychiatrist in a department with a medical ICU I met with death again.
I must admit it is somewhat embarrassing, but I did not feel entirely professionally equipped to meet with death in the ICU setting. In the first situation I met, death had only been a close encounter. I was tasked with advising a young patient who survived an avalanche. The rescue team had to dig almost six feet down to evacuate the patient and the patient recalled being certain to die. There was no psychopathology for me to assess as a psychiatrist; the patient was simply "shocked". While examining possible interventions to reduce the likelihood of the patient developing PTSD, I came across the debriefing controversy, which left me even more uncertain about what to suggest. Luckily, my manager had arranged for a mentor, my predecessor, Professor Emeritus Øivind Ekeberg, to assist me. Anyone new to this field should have the benefit of someone like him. He offered me guidance that included a crash course in psychological first aid. Some months later, a newspaper covered the rescue mission, featuring an interview with the patient, who had taken our advice to seek help if nightmares continued, and told she had been able to return to her studies the same autumn.
During my first autumn in the position, within a brief timeframe, we got admitted four patients who had attempted suicide by hanging. None of them survived. They were young individuals, some of whom had children. Since the position had been unfilled for a few years, my intensivist colleagues and the nurses were relieved to have a professional who could manage the relatives' reactions. After all, psychiatrists are supposed to understand and adjust human behaviour, aren’t they? With each patient, the family dynamics turned increasingly dysfunctional. The family of the last patient exhibited various coping strategies, even resorting to intoxication on the premises. I felt overwhelmed and inadequate, scared of making a mistake. In my mind, I had twisted “handle the reactions of the relatives” to mean that I should make the relatives calm and content… I could not recall from my training in psychiatry, a treatment regimen suitable. That autumn I learned a lot: My skilled intensivist colleagues navigated the relatives through the uncertain phase until all diagnostic procedures were finished and death became inevitable. They even managed to install some sense of purpose if the patient became a donor candidate. I observed nurses offering drinks and blankets, ensuring the patients' children felt secure in the ICU. I participated in counselling sessions with the hospital chaplain and the relatives: “the sorrow you experience is equal to the love that once existed.” I realized that the pain and sorrow caused by death could not be addressed with regimented treatments like those taught in medical school or psychiatric training.
During the first spring of the COVID-19 pandemic, regardless of how snugly the mask was fitted, my goggles always fogged up. Was I safe? A patient, not yet fifty years, with spouse and young children, had been on a ventilator for five weeks. We had no treatment options left; the patient was dying. I helped arrange visits for the spouse and children in the ICU so they could be there when we ceased intensive care treatment. The patient passed away peacefully and instantly with the family by its side. Witnessing the spouses’ grief, entangled with the frustration of the personal protective equipment during their final farewell, was heartbreaking. The younger child wondered, “Will we get a new parent now?” Once more, I felt somewhat helpless, but I understood the source of that feeling and believed I maintained professionalism.
Death can occur unexpectedly, even in an ICU environment where it is a frequent occurrence. A patient of ours leapt out the window just moments after being moved to another department on a high floor. The patient had been healthy prior to admission just a few days earlier. Although no definite diagnosis was made, there were signs suggesting a pathological issue affecting the brain. The subsequent autopsy revealed a malignancy with a grim outlook. The patient's closest relative wished to view the site. I was reluctant, as the first time I saw a scene involving a patient jump, the patient had already been taken to the ER, and all I could see was a pool of blood. This time, there were no apparent injuries, and the body appeared at peace. To this day, I still think about this patient whenever I pass that location. The evening was hectic. Involvement came from at least three different departments, emergency services, and the police. Understandably, the relative was upset and wanted to leave the hospital promptly to join family in their local community. I was fortunate enough to be able to notify a seasoned colleague who went to the grieving family's home and found them in good care. Alongside the on-call hospital chaplain, we organized a debrief at the end of the shift to ensure everyone left with a sense of calm.
During this first autumn, my weariness from striving to relieve the pain of someone losing a loved one must have been apparent. A senior intensivist colleague remarked, “You don’t always have to absorb it all; maintaining professionalism is enough”. I thought to myself that is easy for the intensivist - they can adjust the ventilator and the anaesthetics and update the family on the patient's condition - which is good care. The psychiatrist's role involves discussing emotions, pain, and sorrow... I had made at least two incorrect assumptions.
First, I had neglected what I needed to remind myself many times during my psychiatric training, a lesson taught early in medical school by a general practitioner: “Never let the patient leave their monkeys in your office.” In this context: By utilizing psychoeducation and psychological first aid I could assist the relatives in dealing with their pain and sorrow, without "absorbing it all". In addition, I read a small book I found at the nurses' station, "To be where you are" by two Danish hospital chaplains (1). It helped me understand that when conversing with grieving relatives, just being present as a compassionate human being was important – and often enough.
Second, an essential aspect of being a health care professional is “doing,” which is closely linked to preventing death and alleviating suffering. When death is inevitable, the sensation of having nothing more to offer can easily creep in. While the intensivist could still adjust the ventilator, as a psychiatrist, I felt somewhat lost until I understood the importance of being an eager provider of drinks and biscuits for both family and colleagues. I realized I could do something!
I must confess that when I learned the steps and phrases to use, I executed them without much empathy several times. Suppressing my own empathy is an easy way to cope during stressful periods, but it is not a viable long-term solution. In our ICU, patients anticipated to stay for several days receive a diary chronicling their experience. Its primary purpose is to prevent trauma and PTSD, while also reminding us that we are caring for a fellow human being. Close relatives of deceased patients are invited to a meeting in the department after some months. The more tragic the death, the more gratitude is expressed by the bereaved in these meetings. I believe these practices help us integrate our human and professional selves.
Working as a team of intensivists, nurses, social workers, priests, and psychiatrists is essential for maintaining our humanity and professionalism. We can learn from and support each other, sometimes with something as simple as asking, 'Have you had lunch yet?' We can even laugh amid the pain and sorrow. I smiled late in the autumn of my first year when I noticed a poster at the nursing station saying, “either it will be okay, or it will be over.” More laughter and smiles might occur at the kitchen counter at home. For me, a crucial coping mechanism is sharing my work experiences - without disclosing any sensitive information - with my husband, who is not a physician. He manages to find humour even in the saddest stories.
As I write this, there is ongoing war in Europe and a terrible conflict in the Middle East. I almost feel ashamed to discuss my meetings with death and our ability to "endure" as professionals meeting with death in the ICU, as if it is an impressive feature. Nonetheless, the topic intrigued me, and when I ventured into research a few years ago, this became my focus. The research project I am involved in examined the work experiences and psychological responses of nurses and physicians in ICUs during the COVID-19 pandemic. We discovered a robust group with minimal psychological distress, who prioritized collegial support over other resilience-building methods (2). Less professional experience correlated with a higher rate of burnout (3), which mirrors my own professional journey.
My intention is not to criticise my psychiatric training because I was not prepared to meet with death as a consultation-liaison psychiatrist. In fact, the intention is double: It is an expression of gratitude to my colleagues and manager for their trust! When I applied for my position I shared my concerns with my manager, who reassured me by saying that as long as I had basic manners and skills taught me by my parents and my Medical school, I could learn what I didn’t know! It is also a promotion of consultation-liaison psychiatry. In Norway it is limited to the largest hospitals and comprises of only a small section of general psychiatric education. Practicing as a consultation-liaison psychiatrist makes you utilizes all your fundamental psychiatrist skills and offers continuous learning. It is never being boring and I highly recommend it! In the ICU, when death presents itself in numerous forms you have the opportunity to assist during the most vulnerable moments in people's lives. Perhaps cynically, these meetings with death occasionally remind me to value the time I have and strive to use it wisely (at times). □
References
Falk B, Smith AM. Å være der du er: oppmerksomhet, grenser og kontakt i den hjelpende samtale. 2. utg. Bergen: Fagbokforl; 2016.
Hovland, I. S., Skogstad, L., Stafseth, S., Hem, E., Diep, L. M., Ræder, J., Ekeberg, Ø., & Lie, I. (2023). Prevalence of psychological distress in nurses, physicians and leaders working in intensive care units during the COVID-19 pandemic: a national one-year follow-up study. BMJ open, 13(12), e075190. https://doi.org/10.1136/bmjopen-2023-075190
Hovland, I. S., Skogstad, L., Diep, L. M., Ekeberg, Ø., Ræder, J., Stafseth, S. K., Hem, E., Rø, K. I., & Lie, I. (2024). Burnout among intensive care nurses, physicians and leaders during the COVID-19 pandemic: A national longitudinal study. Acta anaesthesiologica Scandinavica, 10.1111/aas.14504. Advance online publication.