David L. Berry, M.D.
Austin Perinatal Associates
In a busy medical practice, patient grief often goes unnoticed and unaddressed.
The worst possible news any pregnant patient could receive is that there is something wrong with her pregnancy. Such news is disabling to a soon-to-be new mom and sometimes equally devastating to the obstetrician. We came to obstetrics to help bring new light into the world, not to experience the crushing sadness of loss. Unexpected diseases and conditions will turn a joyful moment into life’s most difficult challenge. Helping each of these patients through the worst day of their life becomes the duty of the obstetrician and the perinatologist.
So, how do we help our patients in their greatest time of need?
The Process of Grief
A deeper understanding of the process of grief offers useful insight. Swiss psychiatrist Elisabeth Kübler-Ross published On Death and Dying in 1969 and has since become the most widely accepted model for the grieving process. Dr. Kübler-Ross postulated the five-step model of grief based upon her work with the terminally ill patients in Chicago. These well-recognized stages are: Denial, Anger, Bargaining, Depression, and Acceptance. These steps can occur in any order and may progress at any pace. Pathological grief, which we as physicians work to prevent, happens when patient progression towards acceptance is arrested.
In this regard, our duty is to aid and support our patients, not only in the physical realm of diagnosis and treatment, but also through their psychological and emotional turmoil rather than solely the physical attributes of the patient. As physicians, this helps us ensure the best care for the patient now and years to come, but also ensures optimization of the overall patient experience.
Here are a few examples of situations you may have encountered:
A) Imagine that you have a patient that you have delivered two of her previous pregnancies without any complications. She is low on your worry list, since she is 32-years old at delivery and has undergone two previous term vaginal deliveries. Her prenatal care has been uncomplicated until her 18-week CBC comes back with a WBC count of 28,000/mL. She has had no infection, fever or other illness and feels well, except for a fine skin rash. A repeat CBC shows a WBC count of 31,500/mL with 11% myeloblasts. A visit to the hematologist leads to a bone marrow biopsy and a diagnosis of acute myeloid leukemia. Now she must decide to terminate the pregnancy, keep it and delay potentially life-saving chemotherapy, or expose herself and unborn baby to that same chemotherapy, hoping for the best.
B) You have a patient who is 24-years old, a newlywed G1 who is very excited about her new pregnancy. She is 12 weeks along and comes in to your office for a routine screening nuchal translucency. Her happy day ends with the diagnosis of a 12-week fetus with a very large cystic hygroma. An urgent CVS done the next day shows Trisomy 18. She does not believe in abortion, but cannot stand the idea of losing her baby in two to three months, or even worse, delivering at term and having a neonatal demise. She asks, “Doctor, what would you do?”
Sometimes, there is no “right” answer -- just options and risks associated with each. As a physician, you are expected to communicate and evaluate these risks. But having compassion is important as well, the patient is dealing with many spoken and unspoken fears. This also allows the patient to feel empowered in the process and in control of a very personal and life-altering event.
Patients may stay in Denial. These patients must be given the facts and the opportunity to express their fears. At some point, the obstetrician, perinatologist or neonatologist will have to tell these patients that nothing more can or should be done. This situation can be the toughest of all, as the patient and physician are at a loss of power to remedy the situation.
Those in Anger may blame the obstetrician for a delayed diagnosis. Patients will invariably blame themselves, regardless of the circumstances. Sudden and unexpected outbursts are best handled through active listening and an overabundance of sympathy. Having a readily available second opinion is critical. Offer to send the patient to a specialist or sub-specialist skilled in diagnostics. Have a chaperone with you when interacting with patients stuck in Anger, as Anger clouds perception and recollection of what actually occurred.
For patients who are in the Bargaining phase of grief, saying with great empathy, “I am so sorry. I wish there were something I could do or say, but I can’t fix it.” Second opinions are frequently helpful with these patients, as is printing literature that describes the problem, especially with pictures, photos or diagrams that show the same condition in others. Remember, these patients are confused and are seeking your guidance in processing an unfortunate truth.
The Depression phase of grief can be long-standing and difficult to treat. Anger and self-blame will have deteriorated into hopelessness in the Depression phase. These patients feel lost and completely alone. They will require long-term grief counseling and possibly anti-depressant medications that should be managed with the help of a psychiatrist and psychologist or licensed counselor. Three months of Zoloft will not be adequate. Be on the lookout for signs and symptoms. A study conducted by the New York State Psychiatric Institute found that major depression is 2.5 times more prevalent in women who have miscarried.
At Austin Perinatal Associates, Dr. David Berry and his staff have extensive grief-counseling experience. Each patient requires individualized care based upon their own unique condition and their particular expression of their grief. We are always honored to meet with any of your patients caught in the grief process, helping the patient and the obstetrician through these challenging times. Should you encounter patients with unexpected emotional trauma or high levels of grief in past or current pregnancies, please know that we are here to assist you and your patients with compassionate and professional help.