Each health care professional reacts and copes differently to stress, especially when their patients don’t do well clinically. Everyone must find a method to manage their emotions when stressful events occur, whether in one’s personal life or professional life. I have spent many years helping my colleagues cope after experiencing poor outcomes in patient care. Each time a devastating unanticipated patient outcome occurs, I am still significantly impacted both mentally and physically. I will share with you the practices I have found that bring some sanity into my life as a practicing critical care/palliative care anesthesiologist who consistently cares for patients at the edge/end of life.

In my opinion, one’s practice environment can be instrumental in helping to ease the burden on a colleague who has experienced an unanticipated poor patient care outcome. First, early relief from clinical duty can give one the opportunity to focus on/process the patient care events that just occurred. Second, I appreciate when other members of my group check in to see how I am doing and if there is anything they can do for me. Third, I appreciate when the quality process is expedited to allow me to learn if there was anything I could have done differently. When this quality review process is extended over weeks to months, I have found that time frame less helpful and more burdensome in my own efforts to manage my reaction to the unanticipated outcome. The first point of early relief can be problematic given that many of us are experiencing significant staffing shortages, but if possible, it is very important and helpful. As for the second and third points, I offer support to my colleagues and trainees after each poor outcome. The quality committee for my practice group tries to expedite quality reviews and provide feedback to our anesthesia colleagues.

The medical literature does not offer much direction when it comes to dealing with a health care practitioner’s reaction to a patient’s death. What is available seems to revolve around: acknowledging your emotions, using reflective practices, focusing on self-care, and seeking professional development (asamonitor.pub/3TDrEo6; asamonitor.pub/3ZA6bA7; Innov Clin Neurosci 2012;9:22-6). Acknowledging your emotions is one thing – managing them is another. If you are one who can intellectualize everything that happens to you, then stoic philosophy might work well for your continued well-being. I have enjoyed the insights of contemporary author Ryan Holiday and his many books (along with his daily podcast “The Daily Stoic”) on stoicism. For further reading, one should seek out the works of early stoics like Epictetus, Marcus Aurelius, and Seneca (make sure to find a contemporary translation). For others who do not intellectualize events as a means of coping, managing one’s emotions after the death of a patient can be a bigger struggle. When I have a bad patient care outcome, my emotional and physical reactions take longer to manage. When reading books on resilience, anger management, self-control, discipline, emotional intelligence, palliative medicine, and understanding destructive emotions, two common themes predominate as methods of coping with and reducing stress: practice in mindfulness and practice in self-compassion.

I choose meditation as my form of mindfulness, reflection, and awareness in managing my emotions. In the beginning, I was not a meditator. I had more important things to do with my time than sit and breathe. During the COVID pandemic, I needed an outlet for what anesthesiologists and critical care physicians were experiencing. I read books on meditation but found that I needed more guidance. I tried online mediation classes, but I learned that I needed to do things on my own time rather than on a class schedule. I tried many meditation apps but finally settled on one called Calm (many others prefer Headspace). Calm requires a subscription, but it has a 30-day mindfulness meditation program. I had to listen to and practice some of the lessons 10 or more times to grasp the concepts. Over these years since the pandemic, I have settled into a stable mindfulness meditative practice, and I recognize how it has impacted me. I’m calmer, less reactive, less angry, more mindful, less prone to road rage, and more content. But I have to be honest that it has taken years to achieve this state. Mindfulness meditation helps me cope after poor patient care outcomes. As time went on and my continued needs for mindfulness meditation were not being met with the Calm app, I explored other avenues. I settled on the work of Jon Kabat-Zinn. His books and teachings have aided my continued growth in mindfulness meditation. Mindfulness meditation practice is how I decompress and reflect on the events of each day. I think of the following: If I could do this day all over again, how would I do it differently? When patient care outcomes were unanticipated and poor, I do the same reflective meditative mindfulness practice, and I continue to encourage professional colleagues to consider this same practice.

Self-compassion was more difficult for me. Historically, I have been very critical of myself when I have fallen short of my (and others’) expectations. That self-critical nature of not living up to high standards did not make it easy for me to cope with bad health outcomes in my practice. One of the foundational elements of self-compassion can be found in the following question: Why don’t you treat yourself as you would your best friend or loved one? Why would we not treat ourselves in the same way we would treat a loved one? I again went into the literature to explore this aspect of managing emotions. I decided to focus on the “Mindful Self-Compassion Workbook” by Kristin Neff, PhD, and Christopher Germer, PhD. This book offered a nice step-by-step method on how to treat myself in a more compassionate manner. I’m now more forgiving and understanding of my emotions, and I am far less critical of myself than in the past (but I am still working on this).

Self-care is tricky and denotes different things to each person. For my physical health, I had to change habits. But to successfully change one’s health, you must measure it. I changed my sleep, my nutrition, how I exercised, how I used any free time, and with whom I would spend my free time. I have read several books on making my sleep quality as good as I can make it. I chose books whose authors had either PhD or physician credentials (just my choice). I now track my sleep using a fitness tracker. I’ve found that one alcoholic drink will reduce the quality of my sleep significantly, so I now drink alcohol only when socializing and limit drinking to weekends. I target seven hours of sleep a night, and this alone has improved my mood more than any other change in my physical health. I’m at a gym with a trainer several times a week and took up swimming. I now cook, prepare my own meals to avoid fast food and hospital food, and focus on the healthiest options I can find. I don’t get sick as often. I put more effort into hobbies and focus on nurturing relationships and friendships that matter. I now have fewer acquaintances and a very gratifying handful of valued friends. This is my version of self-care. Yours may be different.

From the professional development standpoint, I have been managing patients at the edge/end of life for many years. While providing a patient a dignified and comfortable death, I learned that every patient, every patient’s family member, and every professional colleague experiences death and dying differently. My interests in bioethics and disclosure have only further helped me manage very difficult and dynamic conversations with patients, their families, and my health care colleagues. I recommend that all physicians gain additional training on how to disclose adverse and unanticipated outcomes to patients and their families.

Each of us is unique in our experiences and emotions. Each of us must find a way to cope with stress. The things I have considered for my own emotional management have been slowly working, but it has taken years to achieve. Some of these things might work for you if you are struggling. We are all (including myself) a continuous work in progress, but if you don’t try to work on yourself, nothing will change!