Debriefing the Day After a NICU Death Educates and Heals

By Will Boggs MD

February 11, 2020

NEW YORK (Reuters Health) - "Rounding" on a neonatal intensive-care unit (NICU) patient the day after death helps not only to educate but also to heal staff members, according to two teams that do it routinely.

"Routine, short debriefings can help the whole team deal with the emotionally laden work we do in critical care," Dr. Wynne Ellen Morrison of Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, in Philadelphia, told Reuters Health by email.

Dr. Morrison and Dr. Vanessa Madrigal of Children's National Health Systems, in Washington, D.C., and their ICU teams routinely debrief a patient death at the beginning of patient-care rounds the following day, they write in a Perspectives piece in Pediatrics.

These discussions serve to educate the full team on how medical decisions were made, how death is declared, when organ donation is possible or appropriate, and how to talk with families facing the end of their child's life.

The occasion also serves as a ritual that allows team members to remember the patient and pause to reflect on the human implications of the end of any life and share a lasting memory of the family or child.

It also gives healthcare providers an opportunity to recognize their own emotions and to model coping skills for trainees so that they can provide more skillful, compassionate support to future patients and families in similar circumstances.

Dr. Morrison and Dr. Madrigal believe that debriefing the next day offers advantages over immediate debriefing or debriefings that occur days or weeks later, including the ability to involve many team members who cared for the patient leading up to the death, providing distance from the chaos that often surrounds the hours after death but enough closeness that emotions and questions are still fresh, and taking advantage of the relative calm and active focus that accompany effective rounding.

"The main driver behind being able to keep these types of rounds or debriefings as a 'routine' part of our day is whether the team members find them valuable," Dr. Morrison said. "If a physician in training has prior experience with the discussions and found it helpful in the past, that physician will help us remember to have the discussion the next time a patient dies."

"It also definitely helps to truly make it routine - having some discussion, even if it seems to be a fairly straightforward event to the more senior team members, often unearths previously unrecognized teaching points or areas of distress," she said.

"The biggest challenge is always time," Dr. Morrison said. "When there are pressing clinical issues for active patients, the team can feel pressured to get to them. But taking a few minutes is a great long-term investment in the team's learning and health, and well worth it. The time factor is one reason we have tried to start rounds with these discussions - avoiding the problem of everyone being distracted, tired, and pulled in different directions at the end of rounds."

"Don't forget to be multidisciplinary whenever able!" she added. "Caring for patients in the ICU takes contributions from so many different team members, and patient outcomes can impact them all."

Megan C. Quinn, a PhD and registered nurse at Cardon Children's Medical Center, Banner Health Network Neonatal Intensive Care Unit, in Mesa, Arizona, who has researched various aspects of NICU care, told Reuters Health by email, "There is a lot of lip service paid to debriefing after a code or a patient's death, but my experiences both as a bedside NICU RN and a neonatal palliative care researcher are that this kind of debriefing is rare."

"A primary method of coping after a patient's death is talking to colleagues, sharing stories of what happened, sharing fears and emotions, and creating a personal narrative of the person's life and death," she said. "Debriefing as described in the article allows for colleagues to come together and create a shared narrative, giving additional details or perspectives to build an overall picture and providing space for all team members to feel their emotional experience validated by others who shared the experience."

"Debriefing rounds are an excellent practice providing an opportunity to mindfully reflect on a life lost, build team cohesion, and potentially mitigate moral distress among staff who often wonder if they did everything they could," said Dr. Quinn, who was not involved in the new article. "But they will not happen by accident - intentional training for and consistent implementation of bereavement rounding is essential to ensure the practice becomes a tradition in the unit culture."

"Physicians must partner with nursing and ancillary staff members similarly passionate about this kind of practice to ensure team members in all roles feel empowered to develop and have ownership over the practice," she said. "This is a way to bring humanity back to medicine that we should not ignore."

SOURCE: Pediatrics, online February 6, 2020.