ONE METHOD OF COPING: RESIDENT DEBRIEFING AFTER THE DEATH

OF A PATIENT
JANET R. SERWINT, MD

Objective To describe residents exposure and reactions to pediatric deaths, their debriefing experiences, and factors
associated with debriefing.
Study design Cross-sectional survey completed at the end of residency. The survey reflected experiences from the prior 18
months concerning number, type, and setting of deaths; resident reactions; whether resident debriefed and with whom after
a patients death.
Results Seventy-four residents (84%) completed the survey over 4 academic years accounting for 363 deaths; 59% were
inpatient deaths of patients with chronic diseases, 22% were inpatient, 18% were emergency department (ED) deaths of
previously healthy patients, and 1% were deaths of patients with chronic diseases who died in the ED or in their home. Mean
number of deaths experienced per resident was 4.6 (range, 0-19). Thirty-one percent of residents expressed guilt, and 74%
stated they had debriefed at least one time, but debriefings took place after only 30% of deaths. Resident debriefing was
associated with an inpatient death of a previously healthy child, OR 5.3 (95% CI: 1.31, 22.3), P = .01, whereas there was not an
association with number of previous deaths, acute outpatient or chronic inpatient deaths, or resident guilt.
Conclusions Pediatric residents were involved in a small number but varying types of death experiences. Debriefing took
place after a minority of deaths. Future research needs to investigate the potential benefits of debriefing. (J Pediatr
2004;145:229-34)

he death of a patient is one of the most powerful experiences during pediatric residency,1-4 yet the impact on the resident

T has rarely been studied.4-9 The Institute of Medicine report, When Children Die, states the importance of
acknowledging the reactions and concerns of all involved with a patients death, including the healthcare providers.8 The
American Academy of Pediatrics Statement on Palliative Care stresses the importance of support for healthcare professionals,10
whereas the Ambulatory Pediatrics Association Educational Guidelines discuss the need to share feelings with colleagues and to
understand ones personal responses and feelings when dealing with death and dying.11
Whether a resident chooses to distance from or to comfort a bereaved family impacts on the satisfaction and long-term
coping of the bereaved family.5,12-16 This choice may also modify the residents perception of the experience as either a very
stressful one with possible personal disappointment and burnout or one of the most rewarding of his/her careerbeing a true
healer to a family.5,17-21
Although many factors influence the decision to distance oneself or to remain
involved, this study will focus on three components of a multidimensional framework: (1)
From the Department of Pediatrics,
the characteristics of the patient deaths (number, type, and setting); (2) the reactions and Johns Hopkins Childrens Center,
involvement of the residents (experience of guilt, responsibility, and whether the primary Baltimore, Maryland.
informant); and (3) the potential coping strategy of debriefing. These factors were chosen Presented in part at the Pediatric
Academic Society Meeting, Seattle,
for study because they may serve as facilitators or barriers that influence the residents WA, May, 2003
experience and response to patient deaths. Submitted for publication Feb 10, 2003;
There has been little research examining these factors in pediatric residents. One last revision received Mar 22, 2004;
6 accepted Apr 19, 2004.
study, published 20 years ago, included resident recall over the prior 2 years, whereas the Reprint requests: Janet R. Serwint,
second study queried interns but only about deaths while on call.9 Pediatric residents MD, Johns Hopkins Hospital, Depart-
reactions to death have been investigated by two researchers.6,7 Although the ment of Pediatrics, Park 389, 600 N
8,10,11 Wolfe St, Baltimore, MD 21287.
process of debriefing is supported by many professional organizations, there have E-mail: Jserwint@jhmi.edu.
0022-3476/$ - see front matter
Copyright 2004 Elsevier Inc. All rights
reserved.
ED Emergency department
10.1016/j.jpeds.2004.04.055

229
been no pediatric studies that have examined debriefing or
the potential factors associated with debriefing by pediatric
residents.
The objectives of this study were to describe residents
exposure and reactions to pediatric deaths, to determine
whether residents debriefed, and to determine factors associ-
ated with debriefing. The study hypotheses were that residents
would be more likely to debrief after a death in a previously
healthy patient and when they felt guilt about a patients
death.
METHODS
This study was a cross-sectional survey of residents at
a large, academic medical center. Four cohorts who completed
residency during the academic years 1997-2000 participated.
Twenty-two residents were in the program each year, and the
anonymous survey was completed at the end of their post-
graduate level-3 year. Responses were to reflect their
experiences from the last 18 months of residency, after a death
and bereavement seminar that was given during the middle of
their postgraduate level-2 year. This day-long seminar pro-
vided opportunities for residents to practice sharing bad news
with standardized patients; didactic and interactive sessions on
autopsy, organ and tissue donation, and role of pastoral care;
and interactions with a panel of parents who had had a child
who had died.22 The impact of deaths on healthcare providers
and the importance of debriefing postmortem were empha-
sized.22 Institutional Review Board approval was obtained.
The survey was developed by the investigator as no
validated survey tool was available, and it was piloted for
comprehension the academic year before the initiation of the
study. The survey focused on three components: characteristics
of patient deaths, reactions and involvement in the death, and
whether the resident debriefed after the death. Residents were
asked the question, How many patients with whom you have
been involved in their care have died? Residents were then
asked to describe the deaths, in particular, whether the death
occurred in the inpatient, ED, or home setting, and whether
the patient had had a chronic illness or had been previously
healthy. This distinction was utilized to differentiate between
a sudden death (previously healthy patient) or a more expected
death (patient with a chronic disease), although there are no
specific definitions and this distinction may be more ambiguous
for patients with chronic diseases.8 Deaths in the ED included
patients who died while in the ED, in addition to those who
were pronounced dead on arrival.
Reactions were assessed by the questions, Are there any
deaths about which you feel guilty? If residents replied
affirmatively, they were asked to state the reasons for guilt.
The following question was added to the survey the second
year of administration: Do you feel in any way responsible for
any of the deaths?
Aspects about debriefing included the question, Have
you sought out a colleague or an attending physician for
debriefing following any death in which you were involved?
The question was phrased in this manner to emphasize aspects
230 Serwint
of peer support. The number of times and the person(s) with
whom they debriefed were also asked.
Data analysis was performed using the Statistical
Program for the Social Sciences, version 10.0 (SPSS, Inc,
Chicago, Ill). Univariate analysis was performed using v2,
Fishers exact test, and odds ratios were calculated.
RESULTS
Seventy-four of 88 residents (84%) completed the survey
over the 4 academic years of 1997-2000. Fifty-five residents
completed the question concerning their level of responsibility
because that question was added to the survey the second year
of administration. All who completed the survey had attended
the death and bereavement seminar, and equal numbers of
residents (18-19 per year) completed the survey over all 4
years. Forty-five (61%) of the residents were female, with the
following distributions by race: 56 (76%) Caucasian, 4 (5%)
African-American, 8 (11%) Asian, and 6 (8%) other.
Characteristics of Patient Deaths
The 74 residents reported a total of 363 deaths. Figure 1
demonstrates the distribution of number of deaths with which
a resident was involved (mean, 4.6; SD, 3.1; range, 0-19
deaths). Five residents (7%) stated that none of their patients
had died. Four of these residents were male and one female. In
examining the types and settings of deaths, residents had
provided complete information on 333 of the deaths. Figure 2
demonstrates that the majority were patients with chronic
illnesses who died in the inpatient units. In looking at the
percentage of residents who had a patient die by type of death,
84% of residents had been involved with a patient with
a chronic illness who died in the inpatient setting (range, 1-12
deaths per resident), 67% with a previously healthy patient
who died in the inpatient setting (range, 1-5 deaths), 55% with
a previously healthy patient who died in the ED (range, 1-4
deaths), and 3% and 1% with a patient with a chronic illness
who had died at home or in the ED, respectively.
Resident Reactions/Level of Involvement
Thirty-three residents (45%) stated that they had ever
been the primary person to inform a family of a childs death
(range, 1-6 times), whereas 46 residents (62%) had been the
primary person to run a code (not necessarily followed by
a death [range, 1-13 times]). Twenty-three residents (31%)
stated that they felt guilty about a patients death, whereas 9 of
55 (16%) stated that they felt responsible. The reasons for guilt
are listed in Table I. Some qualitative comments about their
guilt included:
 That day I considered increasing the amphotericin dose on my
patient with leukemia and after the discussion with the fellow,
we didnt. That night she coded. Autopsy revealed disseminated
fungemia.
 One patient I saw in the ER the day before he died. I wondered
if I should have done more. Did I miss something?
The Journal of Pediatrics  August 2004
Fig 1. Number of patient deaths per resident (range, 0-9 deaths).
Fig 2. Type and setting of deaths (n = 333).
 I had seen the patient for a routine newborn exam. We had
concerns about the mother but let her take the baby home. The
next week the infant was brought to the ED in full arrest,
diagnosis pending. But I believe it to be child abuse.
 I was unable to find the parents when the child was dying.
They arrived 10 minutes after the childs death.
 I felt I should have done more, or been smarter, or been luckier.
Multiple factors were compared to see if there was an
association with guilt. Feeling responsible was associated with
experiencing guilt, odds ratio of 10.5 (95% CI: 1.57, 88.9),
P = .005; and female gender approached significance, odds
ratio of 3.44 (95% CI: .97,12.9), P = .06. There was no
association with number, type, or setting of death or whether
the resident informed the family, ran a code, or chose to
debrief.
Coping Mechanism/Debriefing
Fifty-five residents (74%) debriefed after at least one
patients death, whereas 19 (26%) residents (including the 5
residents who had not experienced a death) had never
debriefed. Figure 3 shows the range of the number of deaths
after which the resident debriefed (mean, 1.5; range, 0-7
times). Of the 363 deaths mentioned, residents stated that
they had debriefed after 110 (30%) of the patient deaths. Of
those who had debriefed, 22 residents (40%) had debriefed
One Method of Coping: Resident Debrieng After the Death of a Patient
Fig 3. Number of patient deaths about which resident debriefed.
Table I. Reasons for guilt (n = 23 residents)
Reasons for guilt n (%)
Not aggressive enough treatment 6 (26)
Resident inexperience 5 (22)
Underestimated patient acuity 4 (17)
Should have been more compassionate 3 (13)
Continued too aggressive of treatment 2 (9)
Resident not present at death 2 (9)
Parent not present at death 1 (4)
with an attending physician alone, 12 (22%) with the entire
team, 11 (20%) with a housestaff colleague, 9 (16%) with
a fellow, and 3 (5%) with a nonmedical friend. Although the
question had been phrased in a way to emphasize responses of
peer support, 3 residents had written in the response of
friend. Some poignant comments about debriefing included:
 In the NICU, we had debriefing at the end of the month with
the full team (including social work) secondary to multiple
deaths. (multiple underlined 3 times.)
 Talked with intern and team about what could have been
done, how to deal with feelings that we should have done more.
 Would have liked to but didnt think these particular
attendings would have been helpful.
 I as the senior and the intern took care of the patient the entire
month. We debriefed after the patients death and it was very
helpful. We also bought a baby tree and gave it to the family to
plant on their farm in the patients memory. This was
unbelievably therapeutic and healing for me.
 Discussing the sense of it all, I guess. What is the lesson in the
death of a beautiful 2-year-old girl ravaged by disease?
Table II examines the associations between
characteristics of the deaths and resident debriefing.
Resident involvement with an inpatient death of a previously
healthy patient was associated with debriefing (odds ratio, 5.3
231
Table II. Factors associated with debrieng
Whether debriefed factors
Yes (n = 55)
Characteristics of patient deaths
Inpatient death/Previously healthy 41 (75%)
Inpatient death/Chronic illness 48 (87%)
Outpatient death/Previously healthy 32 (58%)
>4 patient deaths 28 (51%)
>9 patient deaths 4 ( 7%)
Resident reactions/Involvement
Felt guilt 20 (36%)
Informed family 26 (47%)
Resident characteristic
Female sex 37 (67%)
[95% CI: 1.31,22.3], P value .01). Sudden ED deaths in
previously healthy patients, inpatient deaths of patients with
chronic diseases, number of patient deaths, being the primary
informant, feeling guilt, or female gender were not signifi-
cantly associated with debriefing.
DISCUSSION
Our studys average of 4.6 deaths in 18 months was
significantly less than the average of 35 deaths over 2 years
of residency, described in 1984.6 This could be as a result of
the current availability of more aggressive interventions
resulting in lower national mortality rates, a difference in the
recall period of 18 versus 30 months, or it could be the result of
the exclusion of the internship year. Tanz and Charrows study
found that an average of 2.3 patient deaths occurred per intern
per year or 0.03 deaths per on-call experience.9 An important
finding was that the interns perceived workload and sleep
were altered on nights when a patient died, highlighting the
importance of providing routine help to address feelings of
grief and failure for residents who have experienced the death
of a patient.9
Residents were exposed to a variety of different types of
deaths in different settings. Families who experience the
sudden death of a loved one, especially of a younger child, may
have more long-lasting psychological distress than families
who experience a death that was more expected.8,23,24 Perhaps
different types of deaths may also elicit different grief reactions
for healthcare providers.18 The association between resident
involvement with an inpatient death of a previously healthy
patient and debriefing, which supported our first hypothesis,
suggests that this type of death may have a more powerful
impact. Yet, sudden ED deaths were not found to have
a statistically significant association with debriefing. Although
this was not specifically studied, it could be that inpatient and
outpatient deaths elicit different reactions. The inpatient team
may feel a greater sense of responsibility because they have had
more opportunities to develop a relationship with the patient
and family and to make therapeutic decisions. Inpatient
232 Serwint
No (n = 14) OR (95% CI) P value
5 (36%) 5.27 (1.31, 22.3) .01
10 (71%) 2.74 (0.54, 13.6) .22
6 (43%) 1.86 (0.49, 7.1) .47
6 (43%) 1.38 (0.37, 5.3) .81
1 (7%) 1.02 (0.09, 26.1) 1.00
3 (21%) 2.10 (0.46,10.8) .36
7 (50%) 0.90 (0.24-3.4) .91
7 (50%) 2.06 (0.54, 7.89) .37
debriefing may be easier to accomplish because more time and
opportunities are available to debrief after the death, than after
a death in a busy ED where the same team members may not
work together again.
Guilt may be an intense reaction after a childs death,18
and it was acknowledged by 31% of the residents. Reasons for
guilt ranged from those reflecting concerns of personal
competency to lack of compassion or physical absence at the
death. Our quantitative results are comparable to those of Sack
et al who found that 25% of residents experienced guilt via
qualitative comments.6 Contrast these resident responses with
those of ED attending physicians, of whom 64% reported
feelings of guilt or inadequacy after an unsuccessful re-
suscitation of a child.25 Khaneja and Milrod found that
although 61% of pediatric attending physicians and 73% of
specialty attending physicians stated that they sometimes
perceived the death of a patient as a failure, 60% of residents
stated that this was rarely or never the case.4 Perhaps residents
feel less comfortable in disclosing these feelings of guilt or
inadequacy. It is interesting that our second hypothesis, that
residents who felt guilt would be more likely to debrief, was
not supported. Although these reactions may be normal, the
impact may cause emotional vulnerability for residents because
they may often be assigned or assume blame.6
The concept of debriefing was developed in the military
for soldiers after combat.26 Although a variety of definitions
exist,26 debriefing during the previous death and bereavement
seminar referred to a formal or informal forum to talk about
ones actions and reactions after the death of a patient. Based
on the qualitative comments and the responses of the people
with whom they debriefed, it appears the residents used this
definition. While Scurry et al surveyed residents from various
primary care specialties and found that 80% of them usually
talked with others about dying patients, they did not isolate
responses confined to pediatric residents nor specifically ask
about debriefing around specific deaths as did this study.27
Khaneja and Milrod found that 100% of resident physicians
and 90% of attending physicians expressed a need for further
support in dealing with death and dying, which thus led to
The Journal of Pediatrics  August 2004
their recommendation that debriefing should occur after every
death.4 Multiple professional societies emphasize debriefing as
an important coping mechanism, although this has not been
critically evaluated.8,10,11
Residents in this study were most likely to debrief with
faculty and resident colleagues. Although the survey question
was worded as to whether the individual sought out
a colleague, some of the qualitative comments revealed that
debriefings may have been initiated by the attending physician
of the team (as in the neonatal intensive care unit). Because the
questionnaire focused on peer support, it may have un-
derestimated the times that residents debriefed with non-
medical family or friends. These results differ from Scurry et
al, who found that another house officer was the most likely
source of support, with the least likely being a faculty member,
spouse, or friend.27 Healthcare professionals may turn to
colleagues when their families or friends dont want to hear
repeated stories of deaths.18 Physicians, more than other
healthcare providers, may be less skilled at asking for or
receiving emotional support,28 and their status and sex tend to
make it difficult for them to share their vulnerabilities with
nonphysicians.13 Just as families experience poor functioning if
they repress feelings about a death, so too will healthcare
professionals.13 The cost of not addressing but instead
repressing ones emotions may lead to stress, distancing from
families, burnout, or compassion fatigue for the provider.13,18
Allowing oneself to experience grief reactions and seeking out
colleagues to share feelings and experiences are thought to
represent ways of adapting and integrating the death
experience.18 Institutional commitments that allow schedul-
ing of debriefing activities need to occur.5 Educators need to
help train future physicians to recognize and accept their
reactions, understand them as a normal part of their work, and
acknowledge the importance of talking with others18 so they
can incorporate these concepts into their professional de-
velopment and utilize these skills throughout their careers.
There were several limitations to this study. Although
the data were obtained by resident self-report and were
dependent on residents perceptions, their perceptions may
reflect the most important outcome. The study was subject to
recall bias because residents were asked to remember the
previous 18 months of residency. Both self-report and recall
bias also may have led to inaccuracies, either under- or
overestimates of the number of deaths, resident reactions, or
debriefing experiences. Although the residents knew the
principal investigator of the study and thus may have been
prompted to answer in what they considered a socially
desirable way, the anonymity of the survey should have
minimized this limitation. This study was conducted at a single
training program, and there may be biases in place that make
these results less generalizable to other training programs,
such as the fact that the study was conducted 18 months after
a seminar on death and bereavement that may have increased
resident awareness toward debriefing. The lack of a validated
survey instrument may have led to various interpretations to
the questions. For instance, the question about the number of
patients who had died may have been interpreted differently
One Method of Coping: Resident Debrieng After the Death of a Patient
by different respondents. As patient relationships are complex
and residents care for patients in many settings, the
relationships could have ranged from a 5-minute encounter
in the ED to knowing a patient for several years. Likewise,
residents may have interpreted the question about debriefing
in different ways. However, because all residents who
responded to the survey had attended the seminar and
debriefing had been discussed there, this seems less likely.
Because this was a cross-sectional study causative effects could
not be determined, only associations.
I thank the pediatric residents for their participation in completing the
surveys and their compassionate care of patients every day.
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50 Years Ago in The Journal of Pediatrics

MENINGOCOCCAL INFECTIONS: WITH PARTICULAR REFERENCE TO FULMINANT
MENINGOCOCCEMIA (WATERHOUSE-FRIDERICHSEN SYNDROME) TREATED
WITH CORTISONE AND NOREPINEPHRINE
Grifn JW, Daeschner CW. J Pediatr 1954;45:264-72

Neisseria meningitidis remains one of the leading causes of bacterial meningitis and sepsis worldwide. In this case series
the authors describe 32 patients with documented or presumed meningococcal infections. Two aspects that are worth
remembering from this description are the significant risk of intrafamilial transmission (as documented by one family that
had four members affected) and that the microorganism can be cultured from skin lesions (as reported in four cases).
Five children developed the Waterhouse-Friderichsen Syndrome, two of whom died. This severe, highly fatal course,
characterized by rapid cardiovascular deterioration, is associated with meningococcal infections but can also be caused by
other gram-negative and gram-positive organisms. Pathogenesis includes endotoxin triggering of the inflammatory
cascade leading to damage and thrombi of microvessels and DIC with severe impairment of the adrenal function due to cell
death and/or hemorrhage. Why do some individuals respond with such a fulminant course and others do not? Current
investigation suggests that individuals with polymorphisms in genes associated with TNF-a, plasminogen, and/or
neutrophil receptors may be predisposed to a more severe clinical course. Further studies focused more on the host than the
microorganism can be envisioned for this and other infectious diseases in the future.
The article details a case of a child admitted with meningitis and shock who responded rapidly to therapy that included
norepinephrine and steroids. Whether the child survived because of the treatment, an individual response to infection, or
both, is an open question. This and the other two children that survived had meningeal involvement, a clinical feature that
has been associated with a more favorable outcome. In any case, this represents one of a series of initial reports from the
early 1950s describing survival of fulminant meningitis associated with the use of adrenergic drugs and steroids. The
significant advances in cardiovascular and respiratory support and fluid management during these 50 years have certainly
saved many lives of both children and adults with meningococcal infections.
Meningococcal infections will be controlled with the development and delivery of effective vaccines. The polysaccharide
meningococcal vaccines developed in the 1970s perform poorly in young children. Newly-released conjugate vaccines have
been highly efficacious against N meningitidis C in young children and adolescents. The challenge remains for conjugate
vaccines against serogroup A responsible for the large pandemic outbreaks and the majority of disease in sub-Saharan
Africa. Serogroup B antigens are poorly immunogenic and for this serogroup a vaccine different than a polysaccharide-
based antigen will most likely be required.

Miguel ORyan, MD
Microbiology and Mycology Program, Institute of Biomedical Sciences
Faculty of Medicine, University of Chile
Santiago, Chile
YMPD1011
10.1016/j.jpeds.2004.06.020

234 Serwint The Journal of Pediatrics  August 2004