{"id":50597,"date":"2021-07-06T16:37:19","date_gmt":"2021-07-06T15:37:19","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=50597"},"modified":"2021-07-28T15:00:48","modified_gmt":"2021-07-28T14:00:48","slug":"loss-of-a-fellow-doctor-due-to-covid-19-a-case-of-disenfranchised-grief","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2021\/07\/06\/loss-of-a-fellow-doctor-due-to-covid-19-a-case-of-disenfranchised-grief\/","title":{"rendered":"Loss of a fellow doctor due to covid-19: a case of disenfranchised grief?"},"content":{"rendered":"

The grieving doctor has to be given space and time to grieve, both of which are difficult in our current healthcare environment, observe Sai Krishna Tikka, Deyashini Lahiri, and Vikas Bhatia<\/p>\n

Among doctors, our satisfaction in helping others and the camaraderie we have with our colleagues are crucial to the care we provide. These two elements allow us to get through difficult times, but the covid-19 pandemic threatens to dismantle these two forms of support.<\/span><\/p>\n

The covid-19 pandemic has overwhelmed many countries\u2019 healthcare systems, with India particularly hard hit this spring. It poses numerous moral challenges to doctors experiencing the deaths of patients. They have to navigate breaking the news of a patient\u2019s death to family and friends while behind a layer of personal protective equipment or speaking remotely,1<\/sup> as well as dealing with the loss of their patients themselves, which is often termed \u201cphysician grief.\u201d2<\/sup>\u00a0<\/span><\/p>\n

Doctors lost patients, but they also lost colleagues too. By late June it had been reported that the second wave of the covid-19 pandemic in India had already claimed the lives of about <\/span>798 doctors<\/span>,3<\/sup> taking the total number of doctors who had died in India due to covid-19 to more than 1500. These deaths don\u2019t just represent a personal loss, they also cause a ripple effect of grief among the doctors and colleagues who worked alongside the individuals. During the prevailing second wave of the covid-19 pandemic in India, where the primary focus has been on \u201cbringing down the curve,\u201d<\/span> there has barely been the space to notice, let alone acknowledge, a doctor\u2019s grief for a fellow doctor\u2019s death. Before the pandemic there had been reports framing physician grief as \u201c<\/span>disenfranchised grief”4<\/sup> but we\u2019d argue that this term now fits doctors\u2019 experiences more than ever.\u00a0<\/span><\/p>\n

Disenfranchised grief is defined as \u201cgrief that people experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported.\u201d5<\/sup> The three main reasons offered for such disenfranchisement fit with how society may often view<\/span> a doctor grieving for a fellow doctor\u2019s death. Firstly, grief can be disenfranchised if it centers around an unrecognized relationship. We\u2019d argue that society doesn\u2019t universally recognize the camaraderie between doctors as a relationship that is close and special. Secondly, disenfranchised grief features a death that is a socially undervalued loss. During a pandemic where almost four million lives have been lost, society may count the death of a doctor as just another number. Ongoing narratives during the pandemic about healthcare workers as \u201cheroes on the frontline\u201d may also instil the idea that these deaths are to be expected in their role, with healthcare workers cast as \u201csoldiers\u201d in the \u201cbattle\u201d against the virus. Lastly, disenfranchised grief arises when society views a person as an incapable griever. In this instance, society may think that doctors, who are more exposed than most to death and who may have witnessed several deaths in a day during these past months, will be less likely to grieve.\u00a0 <\/span><\/p>\n

Given that the characteristics of grief are generally universal, doctors experiencing grief for their fellow doctors will go through the same stages of crisis as any other person. However, two aspects that are specific to our context\u2014the covid-19 pandemic and the disenfranchisement\u2014are likely to complicate their grief. <\/span><\/p>\n

It\u2019s already been predicted that various factors related to the covid-19 pandemic\u2014the nature of the illness, characteristics of its spread, how it\u2019s overwhelmed healthcare systems, social distancing rules, restrictions on people\u2019s access to day to day facilities, lack of usual mourning rituals, and several other traumatic characteristics\u2014will potentially contribute to complicated or prolonged grief, in general.6 7<\/sup> It has also been suggested that many symptoms that are currently not included in the diagnostic criteria of grief disorders such as \u201csevere forms of traumatic distress, guilt, somatization, regret, anger, and unspecific symptoms\u201d might further complicate it.7<\/sup> <\/span>Secondly, disenfranchisement is a unique situation that might lead doctors to evade the normal mourning process, internalize grief, and thereby eliminate the supportive influence of external societal sources. The internalized nature of disenfranchised grief paradoxically causes grieving emotions to intensify and complicate.5<\/sup><\/span><\/p>\n

There are no certainties around how long a person will grieve for,8<\/sup> and there are no formulas or algorithms that can help us reduce the time it takes to heal from a loss.9<\/sup> The grieving doctor has to be given space and time to grieve, both of which are difficult in our current healthcare environment. However, all efforts should be made by hospitals and healthcare institutions to identify those who are grieving, and to provide selective support to them. <\/span><\/p>\n

Whenever there is loss in the workplace, many non-health corporate organizations arrange prompt individual and collective grief counselling sessions. These are rare in a healthcare setting. However, certain recommendations for clinician wellness during the covid-19 pandemic10<\/sup> should still be implemented across healthcare facilities. Individual as well as collective online grief counselling sessions by mental health professionals should be made mandatory. These sessions must include information on basic symptoms of grief that will help people identify themselves as being in grief or other grieving doctors, the universal stages of grief, and various supportive and self-care measures.6<\/sup>\u00a0<\/span><\/p>\n

Additionally, given the distinct disenfranchised nature of doctors\u2019 grief for a fellow doctor, some specific recommendations11<\/sup> may be useful while providing collective grief counselling:\u00a0<\/span><\/p>\n

    \n
  1. Resisting the urge to control or condemn the doctor’s grief responses.<\/span><\/li>\n
  2. Acknowledging the importance of the fellow doctor\u2019s loss.<\/span><\/li>\n
  3. Affirming the value of the doctor’s effort towards patient care during the covid-19 pandemic.<\/span><\/li>\n
  4. Encouraging a memorial service in the name of the lost doctor to allow other staff to mourn and recognize their sense of loss.<\/span><\/li>\n
  5. Encouraging staff to create a memory board of lost doctors\/healthcare workers to confirm the reality of their experience.<\/span><\/li>\n<\/ol>\n

    Doctors\u2019 ability to provide patient care in the way they would wish and to enjoy the camaraderie of their colleagues are both affected by their disenfranchised grief for the loss of a fellow doctor. We need to notice, acknowledge, destigmatize, and heal these losses. <\/span><\/p>\n

    Sai Krishna Tikka, <\/b>associate professor, Department of Psychiatry, All India Institute of Medical Sciences, Bibinagar, Hyderabad Metropolitan Region, Telangana, India.<\/span><\/em><\/p>\n

    Deyashini Lahiri, <\/b>consultant clinical psychologist, Hyderabad, Telangana, India.<\/span><\/em><\/p>\n

    Vikas Bhatia, <\/b>executive director, All India Institute of Medical Sciences, Bibinagar, Hyderabad Metropolitan Region, Telangana, India.<\/span><\/em><\/p>\n

    Competing interests:<\/b> none declared.<\/span><\/p>\n

    References<\/b><\/p>\n

    1)<\/span> Tikka SK, Garg S, Dubey M. How to Effectively Break Bad News: The COVID-19 Etiquettes. Indian J Psychol Med<\/em> 2020; <\/span>42: 491\u20133. doi:10.1177\/0253717620948208.\u00a0<\/span><\/p>\n

    2) Sansone RA, Sansone LA. Physician grief with patient death. Innov Clin Neurosci<\/em> 2012; <\/span>9: 22\u20136.<\/span><\/p>\n

    3) The Times of India. 798 doctors died during second wave of Covid-19 across country; maximum lost their lives in Delhi: IMA. 30 June 2021. Available at: https:\/\/timesofindia.indiatimes.com\/india\/798-doctors-died-during-second-wave-of-covid-19-across-country-maximum-lost-their-lives-in-delhi-ima\/articleshow\/83974877.cms\u00a0<\/a><\/span><\/p>\n

    4)<\/span> Lathrop D. Disenfranchised Grief and Physician Burnout. Ann Fam Med<\/em> 2017;<\/span>15: 375-378. doi:10.1370\/afm.2074.<\/span><\/p>\n

    5)<\/span> Doka KJ. Disenfranchised Grief: New Directions, Challenges, and Strategies for Practice. Champaign, Ill, USA: Research Press; 2002.<\/span><\/p>\n

    6)<\/span> Varshney P, Prasad G, Chandra PS, Desai G. Grief in the COVID-19 times: Are we looking at complicated grief in the future? Indian J Psychol Med<\/em> 2021; <\/span>43: 70\u20133. doi:10.1177\/0253717620985424<\/span><\/p>\n

    7)<\/span> Kokou-Kpolou CK, Fern\u00e1ndez-Alc\u00e1ntara M, C\u00e9nat JM. Prolonged grief related to COVID-19 deaths: Do we have to fear a steep rise in traumatic and disenfranchised griefs? Psychol Trauma<\/em> 2020; <\/span>12: S94\u20135. doi:10.1037\/tra0000798.<\/span><\/p>\n

    8)<\/span> Cohen ME, Chandra S. The Time to Grieve: A Difficult Question in Medical Training. Acad Med<\/em> 2017; <\/span>92: 580\u20131. doi:10.1097\/ACM.0000000000001649.\u00a0<\/span><\/p>\n

    9)<\/span> Riesel JN. Formulas for grief. Lancet<\/em> 2019; <\/span>393: 2582\u20133. doi: 10.1016\/S0140-6736(19)31421-7.\u00a0<\/span><\/p>\n

    10)<\/span> Bansal P, Bingemann TA, Greenhawt M, et al. Clinician Wellness During the COVID-19 Pandemic: Extraordinary Times and Unusual Challenges for the Allergist\/Immunologist. J Allergy Clin Immunol Pract<\/em> 2020; <\/span>8: 1781\u201390. doi:10.1016\/j.jaip.2020.04.001.\u00a0<\/span><\/p>\n

    11) Aloi JA. A theoretical study of the hidden wounds of war: disenfranchised grief and the impact on nursing practice. ISRN Nurs<\/em> 2011; <\/span>2011: 954081. doi:10.5402\/2011\/954081.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

    The grieving doctor has to be given space and time to grieve, both of which are difficult in our current healthcare environment, observe Sai Krishna Tikka, Deyashini Lahiri, and Vikas […]<\/p>\n

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