Where Do Psychiatrists Go when a Patient Dies?

A nurse showed me the newspaper just as I was walking in. I saw the smiling face of the young man I had taken care of since he was a teenager. Several times after hurting himself or threatening suicide he had been admitted to the Connecticut hospital where I work as a child and adolescent psychiatrist.

I wished I had seen that smile during our interactions. It looked genuine. But this was an obituary.

I was devastated. I didn’t know what to do with how I felt, and too ashamed to let people know. Suicide assessments were a fundamental part of my psychiatric training, but what to do when suicide occurs was not. This is true for many psychiatry training programs across the country. The emphasis lies on suicide prevention but there is not enough focus on preparing psychiatry trainees for the loss of a patient due to suicide or how to deal with the aftermath.

This young man’s death was particularly painful because he was not a complete stranger. His last hospitalization, a couple of months before his death had been the first time I didn’t care for him. Just before that hospitalization, the lovely lady who altered my clothes mentioned that her grandson had been hospitalized several times.  She knew I was a psychiatrist and started telling me about the arduous journey her family had faced because of her grandson’s mental health struggles. Then she mentioned his name.

In my field, which depends on the absolute confidence of patients, it’s difficult to treat someone and have a separate relationship with a close relative. I felt I couldn’t pretend I didn’t know the grandson. I had known her for over ten years, and we had shared many personal conversations. But I knew, too, that I had to protect the patient’s confidentiality, to stay silent about his fears, his hopes and his unrealized dreams. Faced with this ethical quandary, I excused myself from caring for the young man the next time he was hospitalized.

Now he had killed himself. Only months later did I acknowledge to myself that the dresses hanging unaltered in my closet reflected my sense of how I had failed that grandmother—and my lack of courage to face her again.

I was haunted by a conversation I had with her grandson during the last hospitalization I had cared for him. He told me he felt hopeful about life while in the hospital but the outside world was unpredictable. Somewhere in my irrational mind I believed I had let him down – I failed to make the world predictable. If that is what it took to make sure he was alive today, I should have found a way to do it.

The internal hospital reviews that followed were analytical and disconnected from the deep emotional impact felt by the physicians and staff members. As a doctor, I feel compelled to maintain and project reasoned compassion, to accept the loss of a patient as simply another aspect of my job. And yet as a fellow human being, the suicide of a patient had left me bereft.

Dr. Heather Paxton, a close colleague who practices at a prominent Connecticut psychiatric hospital where I worked, puts it this way: “You don’t realize the fallout till much later, how it weighs on you. Patient deaths due to suicide are upsetting, but some can be really traumatizing.”

Of the suicides Paxton has dealt with in her own practice, one case, involving a young patient who committed suicide shortly after being discharged from the hospital, was particularly difficult. She found herself having recurring nightmares and uninvited memories. She recognized these as signs of transient post-traumatic stress.

Paxton considered herself lucky. Colleagues understood what she was going through, and members of the hospital’s crisis response team invited the nurses and clinicians who had worked with the patient to meet and talk about what had happened.

“They created a space and acknowledged that patient suicide is stressful,” she told me. “It is a difficult experience even for people who take care of other people.”

I had run into Paxton as I was walking away from the inpatient unit after seeing the obituary. “I’m so sorry, I heard about your patient,” she told me, touching my arm. “I know what it’s like.” 

That was all she said. But those few words meant a lot. I wasn’t alone.

Patient suicide has been described as an occupational hazard in psychiatry. In 2009, Bengi Melton and colleagues from Baylor College of Medicine reported in Academic Psychiatry that just shy of one in five psychiatry chief residents felt prepared to face the aftereffects of a patient suicide. As Paxton explained to me, the aftermath is made more difficult when psychiatrists have no training on what to expect.

That gap in training is perhaps more glaring today as psychiatrists find themselves on the front line of a growing mental health crisis. According to the Centers for Disease Control, suicide is now the second leading cause of death in individuals between the ages of 10 and 34. Even more alarming is the 28 percent increase in suicide rates in the US between 1999 and 2016.

Some medical centers, however, are stepping in to create support teams for their clinicians.

One example is Boston’s Children’s Hospital. In 2003, Children’s decided to create a team to intervene whenever there is a difficult patient-related situation that affects any of the hospital’s clinicians. Lauren Coyne, a social worker and nurse practitioner in the hospital’s Office of Clinician Support (OCS), has played a key role in the program.

Suicides are different from other patient deaths, Coyne noted. In chronic illnesses, physicians and families can usually prepare for the patient’s death. Not so with suicide, in which the suddenness of the loss can shake the foundations of any clinician, whether early-career or deeply experienced. Coyne, whose office sees up to 300 new cases a year, said responses start with profound sadness but often include a haunting concern that things could have been done differently or better to save the patient.

“People have a little bit of denial about the risk of the population or you couldn’t come to work every day,” Coyne said. “If you thought about the chances of getting into a car accident all the time, you wouldn’t be able to get into your car. But if you get into a car accident, even a minor one, it breaks down that denial. It’s the same thing when there is a patient suicide.”

Coyne has discovered that even mental health clinicians, whose profession depends in part on getting patients to trust in the relationship and confide, have trouble opening up. This creates a barrier in confronting their own emotions. However, this barrier often drops once psychiatrists connect with colleagues at OCS. These are peers who live and breathe the same air as them. OCS is known as ‘the safe place to talk,’ where trust and confidentiality are fiercely guarded priorities.

It’s important that grief and loss have a place in the life of a psychiatrist, just like any other physician. We deal with terminal illness as well. Still, I wish someone had prepared me during my training years for patient death. Suicide is preventable in many cases, but not all, and when we take care of very sick patients this can happen; it is not a failure. 

Institutions need to ensure that the deep emotional impact felt by psychiatrists is acknowledged and appropriate support is provided. Formal audits and hospital debriefings often do not address the sense of loss or grief, but instead focus on analytically reviewing the decisions made by the clinical team. The care of a psychiatric patient does not occur in isolation within a physician’s office. There are multiple systems involved that determine the direction of care. The burden of responsibility should not be placed on a few. This loss has to be owned by everyone, who come together to support one another. Only then can the cloud of shame and guilt be lifted.

I do wonder if I would have acted differently for my staff and myself, if a team similar to Coyne’s had approached us. Knowing that there were people who understood and did not blame. Perhaps I would have looked at the picture in the obituary a second time. And I would hope that I would have gathered the courage to tell that grandmother just how sorry I was.