What do you say at work when you’re not really OK? More to the point, how do you know you’re not OK when you’ve practiced showing everyone just how OK you are through all manner of hardship?
We are clinicians and researchers working in geriatrics and palliative care, trying to improve systems of care to meet the needs of seriously ill older adults. Before the pandemic, our workplaces operated on thin margins, with barely enough clinical staff to meet patients’ needs. To fund our research, we had to act like entrepreneurs, writing grants to fund salaries and benefits for ourselves and any research staff, as well as money to pay for data collection and analysis.
We are also grieving losses that transformed each workday into a minefield of triggers.
One of us (K.L.H.) lost a father to trauma from a cycling accident in 2018, a stepfather to a neurodegenerative disease five months later, an uncle to sepsis, an aunt to overlapping health issues, and a cousin and a friend and a neighbor to cancer — all while parenting a young child and writing grants to conduct and analyze interviews with former caregivers of people who died from dementia.
One of us (M.G.) unexpectedly lost a mother in early 2021, having forgone visits to see her the year before due to pandemic-related air travel restrictions. She grieves the time she didn’t get to spend with her mother and now struggles with a geriatrician’s concern for her father. Providing clinical care to people with similar stories is painful, and it’s difficult to keep a professional appearance rather than crumple into personal grief.
One of us (A.G.) found his adult son, who had died unexpectedly in his home after a viral illness led to diabetic ketoacidosis. The nature of the death meant the police did not allow the family to touch or hold him before he was taken away. The last exchange between father and son: a kiss through a body bag and “Go Devils.” His grief was complicated in many ways, not least of which was his work providing care to people with serious illness and their families.
Medicine and academia reward those who can make hardship invisible, who can be productive amid — and despite — crisis. Yet doing so takes a toll: grief that manifests longer or more intensely, grief that interferes with daily functioning, grief that may cause burnout and more.
Every grief experience is unique; no single approach or policy can suit all situations. Yet just as parental leave policies and norms are increasingly becoming substantial and customizable, similar changes are needed for bereavement leave. But for that to happen, the culture, norms, and expectations around loss and bereavement leave must be shifted.
As health care professionals whose work includes death and grief, leading the way in making such changes falls to us.
The time to engage in this conversation is now, as most people in the U.S. are experiencing collective grief and multiplicative grief, related to the many losses of the ongoing Covid-19 pandemic. The three of us are grieving patients, family members, and friends lost to Covid-19; grieving those who died from other causes during this period; and grieving the loss of personal and professional routines. Clinicians (like M.G. and A.G.) are grieving while providing medical care in difficult or crisis situations, staying up to date on medical advances, and dealing with the continued uncertainty of the pandemic.
Without acknowledging this grief and creating systemic supports for those experiencing it, institutions risk losing even more health care workers.
As clinicians and researchers, the three of us know a lot about death. Yet we were shocked by the power of grief. As academicians, we went to the literature and read about chronic grief, complicated grief, prolonged grief disorder, multiple losses, and more. None of this helped.
Each of us took different paths through the early stages of our grief. One resumed her normal work routines immediately until the shock subsided and colleagues canceled her meetings so she could take time off. One took three weeks off to help her father and continues to regularly travel to help him in between clinics to avoid canceling more sessions with patients. One made up a term for what we were feeling: gruilt. It is 80% unadulterated grief and 20% guilt. We see gruilt in ourselves and in our patients, research participants, and their families who say: “If only I had gotten him to the doctor sooner.” We three, and our grieving patients, reflect and find points in the journey where maybe, just maybe, we could have done something differently.
The magnitude of grief, and proximity to it, can be overwhelming. How can institutions, managers, and colleagues expect a team member to perform at a high level in clinical care or research when this is the first holiday season without their parent or child? Why does our culture make it seem as if grief should be over within a year, when we will carry the love for the person who has passed on for the rest of our lives? How much more productive would grievers be if we worked in a culture that agreed that grief has no timetable and acknowledgement is the only real medicine.
Like other grieving clinicians, professionals, and people from all walks of life, what we needed was systematic supports and anticipatory guidance. At our workplaces, we needed people assuming we would take time off and actively enabling it when we said that was what we needed, not just in the immediate aftermath of a death but periodically thereafter. We needed things to be as simple and burden-free as possible: no complicated forms to fill out or needing someone to do that on our behalf; automatic connection to bereavement counselors; time, date, and contact information for local grief support groups; and more. We needed assumptions from our leaders that we might need extra supports beyond a few weeks, perhaps as for as long as a year or two.
Medical centers and health care institutions should take the lead instituting policies like these. Leaders first need to acknowledge all types of grief, including grief related to patients’ deaths but not limited to that. Leaders must also acknowledge the multiplicity of losses related to Covid-19 and create associated supports. New curricula — lectures or even courses — for students and resident physicians could include discussions of dealing with patients’ death, impact of grief on health, and acknowledging and responding to colleagues who have experienced losses and are grappling with their personal losses. A clear need exists for this type of curricula: Duke Medicine is offering “Grief 101” in January 2022, a course that was filled within 10 minutes of its being offered.
Institutions can also advocate for broad policy changes. In 2020, the California Assembly introduced a bill to require companies with 25 or more employees to offer 10 days of unpaid bereavement leave. It passed the Assembly but died on the Senate floor. President Biden’s original version of the Build Back Better Act included caregiving leave and a mandatory three days of bereavement leave, yet that benefit no longer seems to exist in a later version.
Personal grieving practices are necessary but insufficient, particularly for people grieving multiplicative losses while also under high professional and/or caregiving stress. Leaders, and those supporting grievers, must be careful to not emphasize resilience at the risk of being callous or blaming the bereaved. As a resident physician told one of us (A.G.), “You know what’s wrong with resilience? It makes us feel like we did not do enough.”
The power, longevity, and impact of grief need to be acknowledged. It ironically falls to those in the unenviable club of bereavement — people who need extra support, not extra work — to advocate for policy changes that mitigate, rather than exacerbate, the challenges of grief.
Krista Lyn Harrison is an interdisciplinary social scientist studying policy and systems of care for seriously ill older adults and an associate professor of medicine and health policy at the University of California, San Francisco. Meredith Greene is a geriatrician and HIV specialist focused on improving care for older adults with HIV and an associate professor of medicine at the University of California, San Francisco. Anthony Galanos is a palliative care physician, clinical director of Duke Palliative Care, and a teacher and clinician at Duke Medical Center in Durham, N.C.