August 24, 2017

This physician told his team to 'move on' after a death in the ED. Here's why he regrets it.

Daily Briefing

    Editor's note: This popular story from the Daily Briefing's archives was republished on Feb. 10, 2020.

    The competing demands of the ED mean that the idea of "moving on" after a patient death is "embedded into emergency medicine practice," but this attitude has drawbacks and isn't the "right or healthy" way to process such an event, Jay Baruch, an associate professor of emergency medicine at Brown University's Warren Alpert Medical School, writes for STAT News.

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    Reflecting on the recent death of a young patient, Kevin, who was involved in a drunk driving accident, Baruch writes that while there was "so much to process and make sense of, ... we [did not] talk about it." Instead, the staff sought "safe harbor in our respective duties and rituals," documented the details of the case, cleaned the body, notified the organ bank, changed clothes, prepared for Kevin's family to arrive, and, as Baruch puts it, simply "move[d] on."

    He explains, "Moving on is embedded into emergency medicine practice." The necessity of "simultaneously caring for a large number of patients, juggling the sick, the not so sick, and the needy" means "there's always too much to do and too little time," he writes. "Focusing on any one activity for long means that other patients wait. We move on because desperation and efficiency demand that we do so."

    How 'moving on' affects ED staff

    But that approach is a mistake, Baruch argues. He cites research showing that ED providers suffer from high rates of depression and burnout, and that when physicians are having problems, patient care can suffer. "When my emotional reserve drops, it means I have a limited supply of what my patients deserve—compassion, patience, and comfort with stories that unwind without direction," Baruch writes.

    According to Baruch, burnout in medicine has been linked to multiple contributors, including a lack of control over one's workplace environment, the demands of EHR documentation, and, for ED providers in particular, the "constant exposure to patients suffering from extreme physical and emotional trauma." He continues, "Add to this list the 'it's what we do' mental trap."

    A different way to process loss

    "The impulse to keep moving is natural and invested with purpose and pride," Baruch writes. "But what Kevin's untimely death taught me is that it comes with a cost." According to Baruch, the painful experiences helped him realize "that the nobility of the 'it's what we do' attitude often serves as easy cover for those crushing experiences that deserve to be recognized, not blindly endured."

    Baruch shares how he told his colleagues that he "screwed up" with his approach toward Kevin's death. "I should have brought the team together for a few minutes after we pronounced Kevin dead," he said, citing what trauma centers call "the pause"—a moment or two "of silence after an unsuccessful resuscitation that honors the life that is now gone."

    And perhaps it should be even more than a pause, according to Baruch. "Maybe it should have been a complete stop," he writes, "Such a gesture would not only honor Kevin and the other lives altered by this tragedy, but remind us all that such deaths are not normal, and we shouldn't pretend otherwise" (Baruch, STAT News, 8/2).

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