Mary Higgins: Where dartboards and dominos meet after an adverse event

IMG_0701Occasionally, when talking to women who have experienced an adverse outcome, I come across someone who takes me completely by surprise with their kindness and generosity.

These are people who entered pregnancy expecting only one outcome, and exited with a completely different one—their dreams in shreds. And yet these amazing people can ask how a staff member is, wondering if they are okay after everything.

The reason this generosity and kindness completely floors me every time it occurs is that there really isn’t any reason this woman needs to think about others, because frankly this should be about her.

One way to think about how the person most directly affected by illness or loss should always be prioritised is through the “ring theory.” This theory was first described in relation to those with cancer, but it can apply to anyone affected by an adverse outcome.

Consider the affected person in the centre of a ring—I think of it like the bull’s-eye of a dartboard. Surrounding her (or him) are the people closest to them—so in the case of bereaved parents, it would be their family and close friends. Surrounding that second ring is a third group of people—those closest to the second group, such as extended relations, friends of the family, acquaintances at work—and these rings continue out as far as is required.

The beauty of this concept is how it advocates the rule “comfort in, complain out.” So the person(s) in the centre should only receive comfort, and can complain to and confide in whoever they want to. The second group should only give comfort to the first, and complain to those within their group or to an outside group. So, for example, the grandmother shouldn’t lament to the mother that she is finding it very hard to deal with her baby’s death, but instead give the mother as much time and comfort as that woman needs.

The concept of the “domino effect” is well known within medicine: after an adverse event the first victims are the patient and their families, but staff (the second victims) and organisations (the third victims) can also be harmed. Where dartboards and dominos join is that the second victim is always that: second to the first, with unidirectional comfort.

It doesn’t mean that we cannot acknowledge that we too are affected, but that we always keep the patient’s feelings and experience as the focal point. Consider the difference between: “Staff members here are very upset” and “The staff are so very upset that this happened to you.” See the difference?

If women (or family members) in their generosity try to make the comfort bidirectional this is incredibly kind and wonderful, but it doesn’t have to happen. Instead, what can happen is that the ring theory can occur for dominos: the second victims comfort the first and the first can open up to the seconds, then the second victims balance this by commenting to their peers, and so on. If we are in the business of caring, we need to care for each other. After all, some day we will all be in the bull’s-eye.

Mary Higgins is an obstetrician at the National Maternity Hospital, University College Dublin.

Competing interests: None declared.