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Medical staff, parents and a loss event

gOh, you are a labor and delivery nurse?... that must be so much fun! Is the usual enthusiastic comment when people find out whet kind of nursing I do. What a great job that would be. The reality is that nursing at a level 3, tertiary care canter is a mixture of emergency nursing, operating room nursing, an intensive care unit, some basic maternity nursing, and a large portion of teaching. What the best education in the world cannot prepare one for a perinatal loss a stillborn infant or a premature delivery where all efforts fail to save the neonatefs little life. I have been enabled through education, and empowered by experience, to manage the clinical aspects of caring for a family facing a perinatal loss, but what do I do with my sense of grief? No one ever told me that as a nurse I would grieve so deeply, and sometimes so often, with families that until recently were strangers to me.h (Michael R. Berman, 2001).

Medical staff and bereavement parents

Anger is expected parent's reaction and normal way of cope with the tragic event, what should not be taking personally by medical staff.
The critical is to choose the way of communication with the parents right after the situation was discovered out. Medical staffs obligate to be ready keep open and supportive talk any time when the parents need. The discussion should go to the way gWe are sorry what happened to your pregnancyh and be emotionally honest. In case if the parents begin to blame on the doctor the best way is just let them to express they feeling even via a complicated communication.

When the parents are on the active stage of grief  - the anger, doctor should not try to do any activity such as an effort to explain what happened. That will aggravate the situation, so all important information about of the event will be mess. The best way at that time is to keep silent with listening of the parents. This approach is the most suitable to shrink the gap and achieve of mutual understanding between the medical staffs and the parents in grief.
Important: do not do active against to parents in their active stage of grief!

This is naturally that the parents believe what the medical staff do not care about what happened with them. The parents in grief are looking for a guilty person and mostly this is the doctor or midwife, eventually. It is necessary to express that the doctor and the midwife are also very sorry what happened, that they are also expected the good outcome and feel disappointed because the situation could not be corrected by the medical care.
Do not say gIt cannot happenh should say gIt could not be avoidedh.

Honest sorrow and open talking able to establish trustable contact between doctor and the parents, then they will calm down and get ready to listen of the professional explanation about the accident. This is the time to let the parents know as much as possible details of what happened. The parents will repeat the same Q gWhy?h for many times and the doctor needs to explain again and again.
Never say gYou heard everything alreadyh!

If the parents keep silence, the medicals have to be in the same stage (active or passive phase should  be sinchronized) .A nonverbal communication like the keeping silence together is very important stage what  helps the parents to pass grief and do not live with a permanent hatred toward the medical staff, include a keeping a various aggressive actions against to them.
The synchronization of the phases of grief is crucial in the professional care on the bereavement parents.

The theory of culture care diversity and universality was developed by Leininger (1997), and she emphasized that nurses should expand their thinking from a unicultural perspective to one that was multicultural, holistic, and comparative. Hence, because of the increasing need to work with families of divergent cultures, it is important for nurses to be families with the traditions and beliefs of others as well as what loss means to different individuals (Speck, 1978; Gibson, 1998). One of the culturally aspect communication practices recommended for nurses when caring for bereaved family who are from Asia is speaking to the bereaved parent through a gkey personh (Engler at al. 2004): such as a respected or older person in the bereaved family.
In Asian countries, people treat death as a taboo subject, and attitudes toward bereavement are strongly influenced by the principles of Confucianism and Buddhism which teach the importance, especially amongst men, of not crying or expressing negative emotion outside the family. Asian people very often present emotional problems as somatic complaints (Wu, Tseng, 1985). As result of these cultural values or traits, it may not be easy for bereaved parents to express their needs not for nurses or midwifes to provide adequate help in the bereavement process. (Chan M. F., Arthur D. G., (2009)). Because of the increasing need to work with families of divergent cultures, it is important for nurses to be familiar with the traditions and beliefs of other as well as the meaning of loss to each person. (Chan M. F., Lou F.-l., Cao F. l., Liu L., Wu L. H. (2008)

Traditionally in Japan if some of unexpected situation occurred, doctor had have discuss with a father first of all. The information about baby loss in case of perinatal or neonatal death was kept off mother for several days during she was staying in the hospital. In fact, most of mothers were appreciated this approach. They usually wanted and tried to forget about the unfortunate pregnancy as it never happened with them, so and they relatives were followed the same way.
At present time the attitude changed: we talk to the mother and the father directly and first of all. Then, we make effort to explain what happened for other relatives if they would like to ask about details.

Usually the parents try to be calm, gkeep faceh and mostly the mother stays in numbness, but the father and parents of the mother or her parents-in-law sometimes can lets their emotions to spill out. In contrary, non-Japanese patients do not try to suppress their natural feelings in the triadic situation. It could be taken as the type of situation what make doctorfs work more emotionally hard. From the other hand, quick parentfs response could shrink a gcold gaph between the medical staff and the parents in grief off.

To help nurses and midwifes care for parent whose baby has died and cope with their own feeling it is recommended special education be provided. For medical staffs who work at hospitals what able to provide medical care for international patients an education courses about different religions and religious practices and referral opportunities should be considered. (Chan M. F., Arthur D. G., (2009)).

A Story

gc She was 28 years old, and pregnant of discordant twins.

In 32 weeks of gestation we diagnosed that the small twin as IUGR (intra-uterine growth restriction), but the other twin fine.

After I explained twins status to the parents, I showed the decision to end this pregnancy by Cesarean for rescuing the small twin in34 weeks. Because it was only 32 weeks, we had decided to prolong 2 more weeks for fetal maturation. Also I was obligated to have a business trip for 1 week (during 33rd weeks of her pregnancy), so it was an additional reason to delay the Cesarean. 

Unfortunately, early morning on just 33 weeks of gestation, I got the phone call from hospital with bad news: the small twin had suddenly died. It happened exactly one day before my business tripcI was really shocked.
I apologized for the fact that I could not predict with the mother, father and other relative:  My
business trip seemed to them the main reason to delay the Cesarean and, logically, the main reason of one twinfs death. They believed if the Cesarean was done in 32 weeks both of twins baby could have been saved.  

I was worried if I could make the right decision at that time. I evaluated survived twinfs health and I proposed we could wait till 34 weeks from medical point. If it was possible to wait, I did not want to detach the dead baby soon from mother.  butc she was having the dead baby inside and I was obligated to be of city by business. Though, over this discussion we took the risk to wait until 34th weeks for be sure about safe of the alive fetus better.

Furthermore, she stopped to talk.

From that time on, the hospital staff has been keeping to exam regularly the heart beating of only survived twin, then happened unfortunate accident; one of doctor who was not familiar with the situation make an effort to exam the second fetusfs heart beating. It has unpredictable effect; she felt revive and start to communicate. She realize that she is caring on still two her babies inside even on of them is not alive any more.

In contrary to the mother, this accident had made the father very mad. From this moment they went by the different roads.
One week later I was back to the hospital. Surprisingly, spontaneous delivery has begun the day. I felt as if both baby would have waited for me to come back. First came out the healthy baby-boy who had been immediately place in an infant incubator to pediatrician sector. He was fine.

Then it was the time to come out of the dead baby. In the delivery room, there were mother in labor, nurse and me only. It was proper company of people who wanted to meet this baby and share own sad feeling. The mother had enough time with dead baby to hold, to cry and to say goodbye.

The father was keeping his anger and avoided spending time with dead baby. By this reason we had a lot of time to communicate with the bereavement mother.

This kind and supportive treat helped to the mother passed relatively smooth the anger stage of her grief via mostly asking a questions and taking about the event.

But the father escaped to talk in a normal way with us, did not visit the hospital during the mother was staying there and, did not emotionally support her. They lost communication way, so about two year after got divorce. c" (By Dr. Takeuchi Masato).

Medical staff copes with the event

The death of a patient is a profound event for most of physicians. Unfortunately, although medical training in medical school has increased, students, and practicing physicians often still report feeling unprepared for bereavement issues in patient care. Approximately 15% of pregnancies end in early losses (before 20 weeks gestation). In the US, 1.3% of pregnancies end in either stillbirth or infant death. This means that on average, the typical obstetrician delivering 140 neonates a year could encounter nearly two dozed women with a miscarriage and one to two with stillbirth or infant death. (Golg K. J., Kuzina A. L., Hayward R. D., (2008)
Caring for patients with stillbirth took a large emotional toll on obstetrician personally. Furthermore, 34% of asked obstetricians reported blaming themselves or feeling guilty about a perinatal death in which no causes was identified, and 43% admitted worrying about ?disciplinary or legal action in a perinatal death with no identified causes. About 8% of asked obstetricians even considered giving up obstetric practice because of the emotional difficulty of caring for patients with a stillbirth. (Golg K. J., Kuzina A. L., Hayward R. D., (2008)
Physicians who had adequate training to cope with fetal and infant death were significantly less likely to report having felt guilty for a death without know cause and less likely to worry about disciplinary or legal action where cause of death was unknown. (Golg K. J., Kuzina A. L., Hayward R. D., (2008)

The two most common coping method are 1) talking informally with colleagues (87% of respondents) and 2) talking about the death with friends or family (56%). Only 9% of physicians uses of any substances (alcohol, tobacco and so on). (Golg K. J., Kuzina A. L., Hayward R. D., (2008)). Only 77% of obstetricians felt somewhat or very prepared to counsel patients about palliative care or end-of life issues, compared with about 89% in internal medicine. With stillbirth, families and physicians may experience complex emotions from simultaneous birth and death. In addition, because the cause of death is often not identified, physicians may blame themselves even for unpreventable losses. Stillbirth is number two reason for lawsuit against obstetricians in the US, preceded only by allegations for births with adverse neurologic outcomes. (Golg K. J., Kuzina A. L., Hayward R. D., (2008)

What do a medical staffs fear in these situations?

Firs of all, we are afraid to be criticized by a people around us: bereavement patients and our colleagues as well.
Fear to face with angry parents leads us rapidly give them a speech about what happened with big amount of unnecessary medical terms and keeping a gcold faceh of doctor. In fact, it is definitely not good way to provide the grief care, because increases a gap in mutual understanding between medicals and patients. In such situation very naturally that the mother can realize that it was her guilty, she did something wrong if the doctor expresses the situation so aggressively. But the doctor keeps this communication way by reason of unconsciously self-protection only.

Another common feeling is medical staff mentally cannot accept the fact of the babyfs death, because it was not detected any obstetrical pathology during antenatal checks up: gI did everything right, there was no single reason to kill the baby!h.
Mostly doctors worry to be criticized by their colleagues. There are many cases that innocent professionals lose own confidence. Even we perfectly know that we did everything exactly as it should be done in the situation, we are afraid to be criticized. Then we try to make sure ourselves:gOf course, I have done my work righth.

Some nurses reported feeling uncomfortable with various aspects of bereavement care: gWhat make me uncomfortable was not knowing what to say at a time like this and how I could be the best resource for this family being that I hade never had this type of assignment in my nursing career?h gI feel uncomfortable with the parent especially if they have just found out that they have a fetal loss as it is an emotional time for themh gI always dread the job but only because I have a hard time maintaining my distance with people who are suffering  I want to cry with themh. Comfort level with parinatal bereavement care is important because increased comfort will support better care: gIf you are not comfortable with a situation, if does show with the patient and they do not receives all they need from their nurse during this difficult timeh. (Roehrs C., Masterson A., Alles R., Witt C., and Rutt Ph., (2008)).

Japanese Ob/Gyns and midwifes attitudes and believes.

We can be in panic.

Panic because such thing should not have happened. Sometimes, right after the babyfs death is detected, we cannot say anything in front of the patients. It can happen sometimes. It is important to know that this reaction is not inappropriate; it is normal humanfs reaction on unexpected situation.

If doctor cannot say any word in the situation, better do not try to give a professional speech: talk, when you will be ready, gDo not harm!h by wrong way of communication with your patients.

Though, the word of gobstetricsh means gstand byh in Latin language. Usually we have no chance to change the fact, but can support, encourage and help for natural process.
Obviously, to keep the professional approach is not so easy, it required a special training and own desire to commit this work not only from medical, but also from social point of view. There are two most famous way: education and debriefings.

Medicals need to avoid such common way of cope as a creation of gthe physiological shieldh. That seems help to be a good professional with easy overcoming of unnecessary sensitivity and tears. In reality such approach makes more problems then seem could be. Absence of understanding the parentfs feeling, loss of humane care on the bereavement parents, desire to protect only own feelings; finally turn the parents to be an enemy of medical staffs. The best way is to learn the situation from the parentfs point of view as well.

Undoubtedly, the best professional approach implicates appropriate balance between
the due medical care and unconcealed human attitude.

 North Concept, INC    
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