Physicians and nurses are feeling enormous grief in relation to the loss of patients right now. I’ve long been interested in grief as it shows up in us and how those feelings reflect what our patients and our work mean to us (read more HERE). Now I’d like to explore what we can do to heal that grief. Many use a moment of silenc to allow the medical team to process a patient death. I believe we could do so much more for ourselves, though. For today, let’s ask, how can physicians and nurses use ritual to process their grief, especially in the midst of a pandemic?

The Background

Extensive research confirms that physicians grieve patient deaths and other losses. As Sansone and Sansone wrote, “…this experience is fairly ubiquitous among clinicians.” For most of us, however, things have changed in the face of the COVID-19 pandemic. The losses are unrelenting, and the healthcare team often finds little or no time for recovery. 

Dr. Lakshman Swamy touched on this issue recently when he tweeted, “One of the worse decisions I've ever made is to leave an unsuccessful resuscitation and go immediately back to rounds.” Although that image makes me hurt, I’m sure it’s absolutely common right now.

Do we have other alternatives?

In his extraordinary brief book, Man’s Search for Meaning (which I highly recommend, by the way), physician Victor Frankl wrote, “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” 

In the situation Swamy describes, the pain of the failed resuscitation and the pressures of the ICU in a pandemic may make one feel like the “space” Frankl describes has been obliterated. The stimuli are so overbearing that Frankl’s idea of finding a “space” may seem irrelevant to the current situation. 

However, Frankl wrote Man’s Search for Meaning after 3 years of imprisonment in German concentration camps, where the stimuli were absolutely overbearing. He asked himself why some who lived those events survived and retained their humanity better than others. And in that context, he discovered the space he describes “between stimulus and response.” 

Can WE reclaim that “space” for the sake of our mental and spiritual well-being, “our growth and our freedom?” Perhaps ritual can help.

What is the Nature and Purpose of Ritual?

The term ritual -- at least in the way I’m using it here -- refers to the use of a routinized pattern to evoke a particular thought- or feeling-state. Rituals exist in religious settings and secular, at the scrub stations outside the OR and final exams. Humans use rituals to mark diverse rites of passage -- marriage, birth, death, entry into adulthood, or as we recently saw in the US, the transition of power. In each case, the ritual opens the space to step outside of the flow of things, however briefly, to acknowledge and incorporate the fact that something has changed.

Around the world, humans acknowledge death in widely varied ways. In a wonderful article in The Atlantic, “In Grief, Try Personal Rituals,” Emily Esfahani Smith explores some very interesting research on grief. She reminds us that death often creates feelings of disorder for the survivors, and writes ‘Rituals, which are deliberately-controlled gestures, trigger a very specific feeling in mourners—the feeling of being in control of their lives. After people did a ritual or wrote about doing one, they were more likely to report thinking that “things were in check” and less likely to feel “helpless,” “powerless,” and “out of control.”’ 

The mourner-subjects engaged in all sorts of rituals, many with no historic or religious connotation. The simple fact of engaging in a chosen behavior repeatedly had power to heal, to restore a feeling of continuity after things got “out of control.”  Could this knowledge benefit us? I think it could.

Let’s explore 3 steps to creating rituals for grieving the loss of patients.

3 Steps to Creating Rituals for Grieving Our Patients

1) Involve the Senses

Meaningful rituals often engage the senses in varied ways. As you create your personal ritual, consider engaging several senses in ways meaningful to you.

• Vision - Spiritual traditions around the world use light and imagery to evoke safety and our sense of  mystery. As individuals, we can do the same. Lighting a candle, contemplating nature (even through a window), or an image of a dove of peace are easy ideas. It’s up to you.

• Hearing - For many, music is crucial to healing in times of grief. Select a piece you love and go back to it each time for maximal effect. Do you need brevity? Have no fear. Bach’s “Prelude in C Major” comes at 2+ minutes and Barber’s “Adagio for Strings” at about 8. 

A brief poem (here is one), read aloud or even silently, will awaken the language centers in your brain. If you will engage in this ritual with colleagues, don’t forget to select a text carefully. It’s essential to create no barrier to connection for those of diverse beliefs or no particular belief at all.

• Touch - Mindful handwashing can mark a new beginning as can the act of doffing and donning a white coat or touching a stone or other object you find meaningful. At home, the comfort of a shawl, the sprinkling of sand, a pause for drawing or journaling, contact with a familiar yoga mat, a hot bath -- all may contribute to your personal ritual.

• Smell - Consider the fact that the olfactory nerve runs close to the memory center in the most ancient part of our brains, and the capacity of aromas to reinforce ritual’s power will make more sense. Scented candles, incense, or a drop of essential oil are all easy. For some, carrying a tiny bottle of the preferred aromatic oil in our pocket could provide an easy addition to a brief ritual. Over time, the brain will associate that scent with entering into a restorative state.

• Taste - For many, drinking a glass of water or a cup of tea enhances serenity.

• Movement - Think about posture and movement. Walking (including a flight of stairs at work), a preferred stretch or yoga pose, hands at prayer or in your lap, any can bring you into a reflective state.  

  
  
  

2) Evoke Connection

“Rituals afford us a sense of belonging,” writes Dr. Abigail Brenner in Psychology Today. ‘When we engage in the ritual process,’ she notes, ‘we are, in essence, connected to "original time." Rituals awaken that which is eternal within us and show us how our individual lives are part of a much grander design.’ 

Craft your ritual to evoke a sense of connection to something larger than yourself. You may perform your ritual with others. Or perhaps you turn your attention to God or to the mystery of life. Or contemplate the beauty of being one of the enormous stream of people over generations who have cared for others in illness and injury. Whatever connects you will be stabilizing.

3) Commit to Repetition

Above all else, create something you can do repeatedly. The research makes it clear that the power of ritual to heal grief is in the repetition, so keep it simple. Even three little steps jotted on a 3x5 card so you can do them in a hall, a lounge, or a bathroom will serve.

Some folks create a long form and a short form. As an example, you might read a poem or prayer followed by a hot bath by candlelight at home. At work, you might silently recite a favorite line from that poem then wash hands while asking the Universe to renew you, in order to evoke the feelings the long form gives you at home. The possibilities are endless!

Whatever it is, the key to a ritual that helps you heal when grieving patients is to choose something that holds meaning for you and do it intentionally over and over and over again.