Clinician Scientist Dr. Juveria Zaheer is not unique among her fellow psychiatrists in, at times, feeling a sense of personal responsibility for the life and death of her patients. In fact, when a patient dies by suicide, some psychiatrists report becoming paralyzed by guilt and self-doubt that can negatively impact both themselves and their patients.
Those are the main findings of a unique study, "I was Close to Helping him but Couldn't Quite get There”: Psychiatrists’ Experiences of a Patient’s Death by Suicide, recently published in the Canadian Journal of Psychiatry.
“We know that losing a patient to suicide is a common experience for many psychiatrists, but our knowledge of the impact of that is limited,” said study co-author Dr. Zainab Furqan, Clinician-Researcher at the University Health Network. “What we do know is that this event has a major impact on psychiatrists, with many calling it the most significant event of their careers.”
What the anonymous qualitative survey of 18 psychiatrists found was that they can feel a unique burden of responsibility for their patients’ outcomes.
“We see it in the terminology we use,” says Dr. Furqan. “In hospitals we call the attending physician the ‘most responsible physician’. This was an important theme of the study. What does it mean to be responsible for a person’s care, and when a suicide happens, are you responsible for that outcome? It’s a question that the psychiatrists in this study really grappled with. I think feelings of self-doubt and second-guessing are universal in medicine, but there is something unique about suicide where it is hard to grapple with the sense as to whether it is a choice rather than part of the illness, so these questions start to come up in a unique way.”
The study found that while up to 80 per cent of psychiatrists will have a patient die by suicide at some point in their career, many said they had never received any kind of training in medical school or in professional practice about how to process the loss of a patient to suicide, including how to speak to grieving families. A majority of respondents also indicated being wracked by guilt and self-doubt in a way that compromised their ability to assess a patient’s risk of suicide. Many also expressed fears that they would be judged by their peers or supervisors for the death of a patient.
“I would divide my recommendations into three categories: pre-emptive training before the event, actions taken immediately after the event itself, and best practices after an event,” says Dr. Furqan. “During residency, we should teach future psychiatrists about the common reactions clinicians have after a patient suicide. What are some practical strategies for supporting team members or the patient’s family after a patient suicide? And it is also important to have nuanced conversations about the ability to predict suicide. Some psychiatrists graduate with a belief that they can accurately predict suicide and therefore stop an outcome from happening. The reality of the matter is that our profession is not at that place right now- we simply do not have that ability. So having these complex discussions that can even get philosophical in nature during training could be really helpful and potentially alleviate some of the guilt and self-doubt that psychiatrists experience when this outcome happens. During and after the event, the most positive form of support can come from professional colleagues or mentors they have a trusted relationship with. That can be highly therapeutic. It is also important for the institutions they work for to review the event using neutral language and a non-judgmental tone.”
For lead author Dr. Juveria Zaheer, a CAMH Emergency Department psychiatrist who has published many studies on suicide, this study was uniquely personal:
“The piece around change in practice really resonates with me. I remember, as someone who works in an emergency department, treating people with humanity and dignity is the most important thing. But then you hear this voice in the back of your head: ‘Am I missing something? Did I do something wrong? Should I be more cautious?’ Ultimately, you are sitting in a room alone with a patient and you have to figure it out together. One of the reasons we proceeded with this study was just to feel less alone and to learn from each other.”