"Birth and death are subject to the Command of the Lord's Will; through His Will we come and go" (Ang 472)
Healthcare professionals from nurses and doctors to allied healthcare professionals (such as physiotherapy, occupational therapy, respiratory therapists, etc.) all deal with death in their jobs. Although this post focuses on healthcare providers, I think many of the points addressed also equally apply to first responders such as police, paramedics, and firefighters. It has been well studied that healthcare professional grieve the deaths of their patients and that facing deaths can have negative outcomes on their health including burnout and more serious consequences for their health, jobs, and other domains of life. We will discuss the things that make grief different as a healthcare professional, coping strategies, and a Sikhi perspective.
There are several factors that make grief as a healthcare professional different from the general population. These include facing repetitive deaths/traumas, being reminded of one’s own family members, bringing up previous unresolved experiences with loss, responsibility over the person’s life, personal vulnerability factors, and stigma around expressing emotions. In terms of responsibility for life, this is especially true for physicians because their role is essentially perceived as saving someone’s life and this expectation exists not only in medical training but also from the families. Death often brings up feelings of failure or blame, loss of confidence, etc. This is addressed well through Sikhi and we will talk about it below. Personal vulnerability factors means things like having a heavy workload, time pressure, and long hours. Having been awake for almost 30 hours straight repetitively every couple of days, I understand how this significantly impacts our ability to deal with situations how we would normally. The mind simply doesn’t function the same without sleep. Lastly, I think that the stigma around expressing emotions is definitely a big factor as it is seen as unprofessional or a weakness, and medical culture trains healthcare providers not to express emotion. Ultimately this causes a bottling up of natural feelings instead of dealing with them.
Some of the coping strategies recorded by those who regularly work with the dying like palliative care workers and pediatric oncology nurses include starting with basics like caring for the body (massage, exercise, sleep, eating), mind (meditation, journaling, talking to colleagues/mentors, counselling, time with family, hobbies), and soul (spiritual connection, prayer, music). Personally I have found the support from colleagues- fellow residents and nurses to be one of the most helpful and impactful strategies, especially when it is the middle of the night and you don't have your usual supports around. Other strategies mentioned in the articles were sending cards to the family, attending the funeral, rituals (like praying while washing hands), and sharing memories via memory boards. Many articles mentioned the important of making meaning in order to let go including: the idea "we did everything we could", that it was the end of suffering, comforting the family, and connecting to faith. On a more systems level approach, strategies include: mandatory debriefs after deaths and adverse outcomes, limiting/altering work hours or workload, automatic sick leave, creating a work culture where it is acceptable to express emotion, mentors that practice healthy coping, meditation/tranquility room, and formal education about grief, death and palliative care. These require institutional policies which in my experience, usually are not in place, but if implemented would help to address some of the vulnerability factors we identified above. There was a balance described by Dr. Papadatou, who talked about how healthcare providers have to go into “action mode” in a life and death scenario as the emotions must be put aside in order to effectively do the job and carry out the actions. Then there is also a time for “presence mode” in which the healthcare providers have to reconnect to those emotions to be able to sit with the family and connect to the patient and the experience. These go back and forth and are quite different than the grieving process experienced in the general public.
Now let’s move on to what Sikhi teaches us as healthcare providers and healers. Our Guru Jis taught us to have utmost compassion for others. Guru Arjan Dev Ji build a place to help people with Leprosy at Taran Taran, Guru Har Rai Ji made a medicinal hospital which helped to cure Dara Shekoh (son of Emperor Jahangir), Guru Har Krishan Sahib Ji healed those with smallpox and Guru Amar Das Ji took special care of the elderly. The Guru Jis provided food via langar and water wells to preserve the health of the people. Bhai Kanhaiya Ji gave water and medicine to all regardless of which side they were fighting for. In the presence of poverty, illness and death the Sikhs in our history expressed an endless supply of compassion that we can learn from. Our Guru Jis not only healed the body, they healed people’s suffering by changing their thinking and joining them to God. I talked to a Veer Ji recently on this topic and he shared his spiritual knowledge with me that as a healthcare provider, one of the unique things that we can do for someone as they are dying is to put your dhyan (focus, attention) into doing simran for that person. We do not have to do it out loud, but we can do it in our minds. This is a unique thing that we will be able to do do for our patients, and depending on our own spiritual avastha (state) that can change the outcome of the course of that death (not whether they die, but rather whether they are reincarnated with human life again or become jeevan mukht, etc. after that death).
Let me share this sakhi about Guru Nanak Dev Ji that teaches us about healing. Guru Nanak Dev Ji was so focused on meditation on God, he would not eat for some days, or speak to anyone. His parents became concerned and called the village doctor, Hardial. He came to feel Guru Ji’s pulse, explaining that he would need this to diagnose the problem (they diagnosed people based on their pulse back then), and Guru Ji pulled his arm away. Guru Ji said "The physician hath been called to prescribe a remedy; he holds my arm to feel my pulse. The simple physician does not know the pain really is in my heart and mind. Physician, go away, take not my curse with you. I am imbued with my Lord; To whom would you administer medicine? Where there is pain, the physician stands by with a store of medicine. My body groans because my soul is crying. Physician give none of your medicines, Physician, go home; few know my malady. The Creator Himself, who has given me this pain, will remove it when it pleases Him to do so.” On Ang 1279 of the Sri Guru Granth Sahib Ji, this is described:
“The physician was called in; he touched my arm and felt my pulse. The foolish physician did not know that the pain was in my mind. Second Mehl: O physician, you are competent physician, if you first diagnose the disease. Prescribe such a remedy by which all sorts of illnesses may be cured. Administer that medicine, which will cure the disease, and allow peace to come and dwell in the body. Only when you are rid of your own disease, O Nanak, will you be known as a physician.”
Then the doctor asked Guru Ji to describe his symptoms. Guru Ji then said,
“First, there is pang of separation [from the Beloved]; then there is pain of hunger. Again, there is anguish of tyranny and death; then there is affliction of bodily ailments. O ignorant physician, give me no medicine. O ignorant physician, give me no medicine. If there is pain in the heart, there will be continued suffering in the body. Such medicine as you have, brother, cannot remove this pain. Pause. When one indulges in sensual pleasures by forgetting the Lord, then one's body contracts many ailments. The blind mortal receives his punishment. Prescribe no medicine, O ignorant physician! As sandalwood is useful when it spreads its perfume: So man is useful as long as he has breath in his body. When the breath departs, the body crumbles away and becomes useless. No one takes medicine after that. One's body becomes like gold and one's soul is made pure, when one possesses the essence of the divine Name. Thus all pains and diseases shall be dispelled; and one will be saved, Nanak, by the True Name.” (Ang 1256)
The doctor left explaining to his parents that Guru Ji does not need any medicine and is here to heal humankind! In this sakhi, Guru Ji explains that although the physician thought he was coming to cure Guru Ji, Guru Ji taught the physician that not all is physical and can be cured by physical medicine. There are types of suffering and things beyond the control of modern medicine. The pains of the heart and the mind’s journey to God, the soul’s merging with God are only cured by God, through Naam. On Ang 618, Guru Ji tells us “My physician is the Guru, the Lord of the Universe, He places the medicine of the Naam into my mouth, and cuts away the Noose of death.”
I personally have faced death after death both inside and outside work, and one day I came to the Gurdwara Sahib upset after a long call shift. Gyani Ji, said to me that this line in Gurbani is written for me: “Kabeer, the physician says that he alone is good and all medicine is under his control. But these things belong to the Lord, He takes them away whenever he wishes.” (Ang 1368). This is further elaborated in the Punjabi translation that the doctor thinks they are knowledgeable because they know how to save lives by curing the body, but the soul is a gift given by God and whenever God wishes, it is taken back. That is out of the physician’s hands. Guru Ji very clearly tells us here that because the body is simply a vessel for the soul, and the soul’s time to return to God is written, that this is under God’s Hukam.
Similarly, surgeon Dr Atul Gawande describes that the process of dying has not always been our “responsibility” as a medical professional because people used to die in their homes. He states, “Modern scientific capability has profoundly altered the course of human life. People live longer and better than at any other time in history. But scientific advances have turned the processes of aging and dying into medical experiences, matters to be managed by health care professionals… As recently as 1945, most deaths occurred in the home. By the 1980s, just 17 percent did… Across not just the United States but also the entire industrialized world, the experience of advanced aging and death has shifted to hospitals and nursing homes…This experiment of making mortality a medical experience is just decades old.” This helps to explain that people are in fact coming in with more complex issues, with more advanced disease, and in the process of dying at which point normally previously they would have been home, but the process has simply now been moved to hospitals where healthcare professionals are now part of that process.
The sewa of caring for those who are sick obviously has a powerful role in our religion and was demonstrated by our Guru Jis, however it is important for us to understand our limitations and let go of what is not in our hands. We need to create a boundary where we are not attached to the outcome as suggested by the anonymous physician from “Hearts in Healthcare.” The perception that death is our failure is wrong because as Dr Atul Gawande writes, “death, of course, is not a failure.” Just like I described in part 1 of this post, it is important for us to be prepared and remember that dying of this is written by God and the soul continues to travel its journey. I think the concepts we have can be difficult to grasp if we just use our manmat (own thinking). They require us to connect deeply to God through Gurbani, because clearly Guru Ji has given us guidance as healthcare professionals on how to do our job without getting burned out and continually delivering it with love and compassion.
References
https://ideas.ted.com/death-and-the-missing-piece-of-medical-school/ Dr. Atul Gawande's piece
Papadatou, D. (2000). A Proposed Model of Health Professionals' Grieving Process. OMEGA - Journal of Death and Dying, 41(1), pp.59-77.
Houck, D. (2014). Helping Nurses Cope With Grief and Compassion Fatigue. Clinical Journal of Oncology Nursing, 18(4), pp.454-458.
Rosenstein, A. (2017). “Addressing Physician Stress and Burnout: Impact, Implications, and What We Need to Do”. Journal of Psychology & Clinical Psychiatry, 7(4).
Jones, S. (2005). A self-care plan for hospice workers. American Journal of Hospice and Palliative Medicine, 22(2), pp.125-128.
Zheng, R., Lee, S. and Bloomer, M. (2017). How nurses cope with patient death: A systematic review and qualitative meta-synthesis. Journal of Clinical Nursing, 27(1-2), pp.e39-e49.
Heiner, J. and Trabulsy, M. (2011). Coping With the Death of a Patient in the Emergency Department. Annals of Emergency Medicine, 58(3), pp.295-298.
https://www.vitas.com/partners/making-the-rounds/2017/february/01/how-to-cope-when-your-patient-dies
