Support after patient death in the intensive care unit: Why ‘I’ is an important letter in grief

Care of the dying and deceased patient and his or her family is an integral part of nursing in critical care that deserves our respect and attention. Most nurses will encounter an average of two patient deaths each week in their unit,1 and they face many unique challenges in providing quality end-of-life care.2 Contextual issues, such as the pace and complexity of intensive care, the severity of patient illness, unpredictable dying trajectories, and nurses' frequent exposure to death that may be sudden in nature, all give rise to concerns about the emotional burden of caring and the importance of support after death. Grief is a concept that has been studied extensively and has meaning for the community of critical care, both families and staff. In this editorial, we discuss grief support in the context of nursing but recognize that many of the considerations are relevant to the interprofessional team. At the time of writing, we are mindful of the COVID-19 pandemic and the morally distressing situations experienced in intensive care units (ICUs) worldwide. We are also sensitively aware that some readers may be experiencing grief in the workplace, and we pay tribute to all departed colleagues and offer our condolences to you. Consistent with the theme of this editorial, it has been acknowledged that frontline workers will need support in dealing with their grief.3 Grief is a natural response to loss4 and is most often discussed in the context of loss through death. As nurses, we are not immune to the impacts of death, and grief comes through the connection that happens when we care.5 We know that many critical care nurses invest in the relationship with patients and families to the extent that prioritizing care can be a source of conflict when providing end-of-life care.2 It is not unusual to hear critical care nurses speak of “my patient” or to be involved in a patient's care from the very early moments of admission and throughout the ICU stay. Loss may therefore be deeply felt when a patient dies; “our routine, our role, our bond has gone.”5 However, each caring relationship is invested in a unique way, resulting in varied degrees and forms of grief expressions.6 Care providers may also grieve different losses, and it is important to understand the subjective nature of their loss.6 Therefore, in just the same way as we advocate patient- and family-centred care, helping nurses to work through their loss and reactions to patient death requires a personalized approach. I often experience situations involving death while working in the intensive care unit, and the more I experience patients' deaths, the more I become numb to death and my feelings become exhausted. I would like to have a system that manages the emotional suffering of the ICU nurse.13 Compassion fatigue is a term that describes the physical, emotional, social, and spiritual exhaustion that can result from caring relationships with patients and families.11 It is an observable threat to critical care nurses who are vulnerable to cumulative loss. Repeated exposure to dying and death could lead to emotional disengagement, and this may ultimately affect the quality of end-of-life care.14 Grief can also be insidious, and death can sometimes touch us in surprising ways.15 The surprise, of course, may be positive, possibly rewarding, or perhaps not so good. A recent integrative review of the literature identified the potential for grief complications for individual nurses who experienced patient death in hospital settings.16 These findings further highlight the importance of workplace support for critical care nurses after the death of a patient in their care. Clear signposting to sources of grief support can facilitate informed choice and communicate an organization's commitment to workforce mental health. Throughout the literature, we are reminded of the individualized nature of grief and the importance of avoiding a “one-size-fits-all” grief support plan.17 This also means recognizing that some nurses will work through their grief naturally and have an ability to help themselves, whereas others may actively seek support or require access to what is available. Evidence suggests possible effective support strategies, and these are helpfully outlined in the recently published Intensive Care Medicine's guide to care at the end of life.1 In addition, we identified complementary interventions that may help with grief resolution and closure. The continual high demand for intensive care leaves little space and time to adjust after a patient death.9, 10 A period of silence known as the “The Pause” in honour of a deceased patient offers a moment for team reflection and closure in preparation for the next patient or care situation.18 ICU staff have reported positive benefits of this practice, including decreased feelings of disappointment, failure, grief, and distress.19 Costa and Moss20 also suggest that storytelling and narratives, either orally or in writing, could be a powerful way for critical care teams to process their emotions. Experiential accounts can be meaningful for health care organizations too, enabling the employer to tailor interventions to perceived grief support needs. Other interventions are funeral and memorial service attendance and the sending of sympathy cards to families.12 With regard to the latter, a multicentre trial reported a potential negative outcome of a condolence letter sent to relatives of patients who died in ICU.21 These findings invite us to consider the reciprocal outcomes of support interventions for grieving staff and families, both in practice and research. Care after death is an integral part of good end-of-life care. On reading this statement, thoughts about the final acts of personal patient care may be foremost, or consideration might be given to immediate and ensuing family support and care. Perhaps what comes to mind the least is the importance of self-care after death. In reality, patient and family needs are likely to take priority, and finding time for self can be challenging in a busy modern-day ICU. However, nurses have an ethical obligation not only to care for others but also to care for themselves.22 This means engaging in self-care practices for your own well-being; notwithstanding the employers' duty of care to influence and improve the well-being of its workforce. Cotter23 suggests that mindfulness helps us become more aware of how we treat ourselves and to observe our experiences and reactions in a more balanced and non-judgemental way. This arguably has significance in an environment like the ICU, where the mission of care is to save lives, and as such, death may be viewed as failure and defeat.24 Feelings of failure are among the symptoms of compassion fatigue in nurses.25 In such cases, Kompanje26 stresses the importance of focusing on the values of professional performance, working from the perspective of humanity towards patients, families, and colleagues, and the willingness for critical self-reflection. This is where participation in clinical supervision, peer support groups, and debriefing sessions come in to play. Some nurses, however, may feel it is self-helpful to deny or conceal their grief. This might be in an effort to be strong for others27 or because of professional stigma.28 The way nurses express their grief and their personal coping strategies may also be different depending on their cultural background.29 A recent study exploring Muslim critical care nurses' experiences of end-of-life care uncovered the presence of “disenfranchised grief,”30 a concept that can be present in groups and societies where there are clear norms about who is seen as being eligible to grieve.31 We sometimes need to remind ourselves (and others) that it is okay for nurses to grieve, and it is okay not to be okay. Self-compassion is a foundation for compassionate care.32 Remember to show yourself the same kindness, respect, patience, and understanding that you give to those who receive your nursing care.