Editor's Note: The online version of this article contains the survey instrument used in this study.

Introduction

The death of a patient can be emotionally and psychologically stressful for clinicians, particularly trainees.1–5 One national survey showed that 40% of residents were not prepared to manage their emotions about patient death.6 Emotional and psychological stress are linked to burnout and poor mental health in trainees and may lead to decreased quality of patient care.4,7,8

There is currently little information in the literature about ways to help trainees cope with the emotional impact of patient death. Much of this small body of literature addresses pediatric medicine.1,9–11 Internal medicine literature includes mostly descriptions of the trainees' experiences and attitudes toward patient death,2,3,5,6,12 but few articles address their emotional reactions. We describe an annual memorial service to help internal medicine residents cope with patient death and reduce related stress by promoting humanism and reflective practice.

Methods

At Johns Hopkins Bayview Medical Center, we created a memorial service to pay respects to patients who had died under the care of our internal medicine residents and provide a venue for reflection, discussion, growth, and healing. The memorial service lasted an hour and took place in the same location and time as the noon teaching conferences. All internal medicine residents, medical students on the internal medicine rotation, and internal medicine faculty were invited via e-mail. The residents were also asked if they would like to share reflections about their own patients' deaths during the service. The director of pastoral care was invited to speak at the service. We did not formally invite nursing and other members of multidisciplinary care teams in order to promote an intimate atmosphere for the residents, although the residents could invite others.

The room was decorated with flowers and candles. We projected a list of patients who had died in the past year on the internal medicine wards but made sure to not list any protected health information. The service started with an introduction and the reading of a poem by the chief residents and personal reflection about a patient's death by the residency director. The audience was then invited to share reflections about their own patients' deaths. Some volunteered unprepared reflections while others read prepared comments or poems or performed musical dedications. A few minutes were reserved for silent reflection, after which participants had an opportunity to come to the front of the room to dedicate a flower to the patients. The director of pastoral care offered concluding words of support. Because of the intimate nature of the service and our aim to provide a safe environment for sharing, we did not take attendance during the service.

After the first event in December 2010, anecdotal reports offered information on the service's benefits for the residents, and we repeated the memorial service in 2011. Following this service, we administered an anonymous 10-question survey, developed empirically by the residency directors and chief residents, to evaluate impact. The survey was sent via e-mail to all internal medicine residents and to attendings and students who had attended the memorial service in 2011. The survey assessed attitudes and self-reported behaviors regarding reflection on patient death and whether the memorial service was helpful in facilitating such reflection (provided as online supplemental material). Results are described using only descriptive statistics given the small sample size.

The memorial service was not a research initiative but rather a program to improve the well-being of our residents. We deemed that Institutional Review Board approval was not required for its implementation or evaluation as a quality improvement effort.

Results

The memorial service occurred in place of a noon conference and did not interrupt other clinical or educational activities. The time the chief residents spent preparing for the service was comparable to that required to plan a regular conference. No special training was involved for the residency directors or the chief residents to lead the service. The financial cost was limited to the cost of flowers and candles used during the service.

Each service in 2010 and 2011 had approximately 20 to 25 attendees, consisting of residents, medical students, and internal medicine faculty, which was similar to the attendance at noon teaching conferences. However, we did not track exact attendance in keeping with the intimate nature of the event.

Twenty-two people who had participated in a memorial service in 2010 or 2011 responded to the survey. They included 3 of the 7 medical students, 5 of the 28 first-year residents, 5 of the 15 second-year residents, 5 of the 15 third-year residents, and 4 faculty members.

Of the 22 respondents, 21 (95%) thought that reflecting on patient death was important. Although 64% (14 of 22) of the respondents thought that enough time was spent during residency for reflection on patient death, only a minority of the respondents answered “often” or “always” when asked how often they have a chance to reflect on patient death during various rotations (36% [8 of 22] during wards, 9% [2 of 22] during intensive care unit, and 27% [6 of 22] during outpatient setting). Of the 22 respondents, 21 (95%) thought that the memorial service was helpful in providing an opportunity for reflection and bringing closure. The following are comments on the value of reflection and the memorial service:

“Reflection provides a catharsis of emotions, an opportunity to realize that we are all not alone in our feelings of sorrow and pain, and a chance to reflect on improving care for future patients.”

“[The memorial service] gives us a chance to acknowledge and reflect on all of our patients who have passed away. Being able to memorialize them brings a sense of closure.”

Discussion

We describe a memorial service in an internal medicine residency as a novel and feasible forum that provides a structured, supportive environment for reflection and coping with the emotional impact of patient death. A survey of residents, medical students, and medicine faculty showed that the service was well-received; most of the survey respondents considered reflection on patient death to be important and thought that the memorial service helped facilitate such reflection.

The literature offers scarce resources to help trainees cope with patient death; most of the resources focus more on the clinical aspect of caring for dying patients,9,11,13 and very few address the emotions surrounding patient death.14,15 Our project extends this limited body of literature. The format of a memorial service also allows role modeling among the different levels of trainees and faculty.

Limitations of our project include the small sample size in one institution with no control group. Our survey tool has not been validated, and we do not have exact response rates. These limit the interpretation and generalizability of our results. The long-term impact of the memorial service on trainees' well-being and professional development is also unknown. Future research should include further development and refinement of the survey, tracking of attendance in a nonintrusive manner that maintains the intimate nature of the service, improved recruitment strategies to increase response rates, and more detailed assessment of the trainees' specific needs on coping with patient death to ensure that future memorial services can better address these needs.

Conclusion

An annual memorial service offers a supportive forum to help trainees cope with the intensely emotional experiences of patient death and is a place for closure and integration. It can be easily adopted by other residency programs to facilitate dealing with grief and improve trainee well-being.