Andrew Cooper is a Family Therapist and a Professor of Social Work at the Tavistock and Portman NHS Foundation Trust. Andrew talks about one of the most difficult things that any of us face in the current situation, the impact of living and working with death, a particular challenge with COVID-19 even for very experienced NHS and social care staff. He brings some thoughts together about what can make our contact with death in this context so hard, and has some suggestions and practical examples of what can work well in trying to look after ourselves and each other when facing the emotional labour of caring for those at the end of their life.
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Hello, my name is Andrew Cooper and I work at the Tavistock and Portman as a Family Therapist and I’m Professor of social work. I’m going to speak about some of the challenges of working with death and with dying people, and some possible ways of helping ourselves with this very demanding task.
In this crisis many more NHS and social care staff find themselves caring for dying patients or are in the situation with unprecedented regularity and intensity. Increasingly, because of isolation procedures, nurses and doctors are alone with people at the moment of their deaths. Families and loved ones are excluded – on the outside looking in. You may be acutely aware of their grief and anguish. Staff are fearful for themselves and for their own families. Professionalism and a sense of duty spurs people on, while the instinct of self-preservation pulls strongly in the opposite direction.
You may want to move towards the dangerous situation and simultaneously flee from it. This conflict can cause huge anxiety, to act on all the other anxieties. Most of you will have suffered the loss of someone close to you at least once in your life. A family member or friend may be very ill right now whether from Covid-19 or another illness. Working in close contact with dying people stirs up these memories even if the pressures of the job mean you hardly have time to think about them – if a patient dies, but you have to move on to the next emergency. Your feelings for the dying person in front of you can become mixed up with your own grief and anxiety about loved ones. This is normal, but immensely stressful. It can feel somehow selfish to be preoccupied with your own losses and fears when you’re supposed to be caring for others. It isn’t selfish, it’s ordinary.
I myself had an uncle I never met because as a young man he was killed in the Second World War, but my mother told me stories about him, while his brother; my father, never spoke of him. Somewhere the grief about his loss passed into me and is still alive. Many of us carry these ghosts inside us and they can come to life in the face of our work with dying people. Will all tend to carry around an idea of what a good death might be like. Whatever that is, your experiences at present will be far removed from this image or ideal. That’s hard to bear in itself and in these pressurised circumstances, when a patient dies you may be left with painful questions: did I do enough? Make the right decisions? Give them enough at the very end of life? Sometimes these thoughts collect in a very difficult way: did I in effect kill this patient? We may know such thoughts are not rational but they can still be very real in our minds.
My colleague Jo Stubley made another podcast in the series about trauma. Most of what she says is completely relevant to you if you’re working with dying people, or people you’re afraid might die. The same situation affects different people differently. You may hardly have had time to get to know many patients, or they are sedated, but something about a particular person can still trigger powerful memories and feelings, and unexpected grief wells up in you when you are working under these exceptional conditions day after day. If you don’t find some release for these feelings they accumulate into what Jo Stubley calls cumulative trauma.
So, what can you do to look after yourself and your colleagues? Letting yourself feel and think when you’re having to work so relentlessly can feel risky. You may worry you’ll fall apart and not be able to function, so you might want to pick your time and place to let yourself slow down and allow some feelings to surface. Most people will find it a relief and feel a bit stronger afterwards.
in some acute assessment wards where patients often die, but the throughput of work is relentless, a team working with the patient who dies do something called ‘the pause’: they stop and take two minutes together to remember this was someone’s daughter, mother, son, partner, friend. But also to remember how hard they themselves worked to try to save the patient. You might try this but if not, you can find a trusted colleague and take some time with them to share your feelings from the shift: fear and anxiety, distress, grief, guilt, anger.
Closeness to death and dying frightens us and makes us want to weep. It’s the most normal reaction in the world but as the saying goes, we need a shoulder to cry on. If you can trust someone else to receive your distress and also offer them some time and understanding, this can be hugely helpful. An honest recognition of what you’re facing together is a bond and to get through this terribly difficult time, strong bonds with colleagues are vital. We are assailed by images of the crisis in the media. I remember one: an exhausted hospital worker sitting on the pavement, head in his hands, being comforted by standing colleague who has her hand on his shoulder. But lastly if these approaches don’t work here or there is just no time, and you feel the pain and distress rising up in you, then a few moments of steady deep breathing will probably settle you, calm your mind and body.
There is no magic solution for the stress of what people are doing when working so close to death and dying. whatever ways you find help yourself, it’s so important to remember that everyone is finding it just as difficult, although each in their own way to some extent. In all this there are moments of hope and success. Some patients recover and can be discharged. You feel you did as good a job as possible in breaking the bad news to a patient’s family. Colleagues thanks you for your support and understanding. It is important to hold onto these moments because they can be wiped out by the overwhelming demands of the art of our task. Everyone in the caring system may be touched by some or all of what I’ve spoken about: porters, cleaners, administrators, managers. Remember one another, everyone has their part to play and is vital to the overall effort. Reaching out to others when you sense distress and being open to others when they offer you something are the best route to getting through and being able to carry on doing your best for the patients and their families.