The ICU team gathers for their morning rounds. One of their patients died the day before. The team members look at the room where the patient had been; perhaps it is empty, or perhaps it has already been filled with another patient and family. The day the patient died may have been filled with escalating therapies and vigorous resuscitation attempts that failed to save her, or perhaps the staff had been gently supporting a child and family through the night as technology was removed and comfort assured. For some on the team (maybe a student or resident) this could be the first patient they have cared for who died.1  For others (fellow, attending, ICU nurses), this may have become a more-common experience. Multiple team members may still be thinking about the events of the day before, remembering the patient or wondering about the outcome and why certain decisions were made.

Our ICU teams have developed a practice of debriefing a patient death at the beginning of patient-care rounds the following day. In effect, we “round” on the patient for one final day after the death. The patient’s primary resident or nurse practitioner begins with a 1- to 2-sentence description of the patient and events of the previous day, and then the attending facilitates a group discussion. We typically spend <10 minutes in the discussion, before moving on to current patients and daily work of the ICU. We have found these discussions help 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 (Table 1). In addition, the discussion the next day serves as a ritual, allowing 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.2  It may also allow time for health care providers to recognize their own emotions, to avoid the “experience [of] disenfranchised grief because loss and the resulting grief are not socially acknowledged.”3  Modeling coping skills for trainees in this way may help them provide more skillful, and likely more compassionate, support to future patients and families in similar circumstances, with the potential to impact long-term family outcomes.4,5 

TABLE 1

Example Goals of the Subsequent Day Postdeath Debriefing

Clarification and teaching regarding medical management and decision-making 
Discussion of protocols, logistics, and legal aspects of declaring death and organ donation 
Acknowledgment of emotional impact on team, health care provider grief 
Modeling and discussion of how to support families and guide end-of-life decisions 
Discussion of ethical issues 
Sharing of something memorable about the patient and family 
Ritual to acknowledge a patient death 
Clarification and teaching regarding medical management and decision-making 
Discussion of protocols, logistics, and legal aspects of declaring death and organ donation 
Acknowledgment of emotional impact on team, health care provider grief 
Modeling and discussion of how to support families and guide end-of-life decisions 
Discussion of ethical issues 
Sharing of something memorable about the patient and family 
Ritual to acknowledge a patient death 

Clinical teams use “debriefings” in a variety of circumstances. Some debriefings can occur immediately after an acute incident, such as a resuscitation or unanticipated event, others can occur days or weeks later to discuss difficult clinical or psychosocial situations.6  We have found that incorporating the debriefing into rounds the next day offers opportunities not available in the other 2 types of debriefings: (1) it involves many team members who cared for the patient leading up to the death and gives opportunity to disseminate relevant information; (2) it provides enough distance from the paperwork burden and chaos that often surrounds the hours after a death but is near enough that emotions and questions are still fresh, leading to a fruitful discussion; and (3) it takes advantage of the relative calm and active focus that often accompanies rounding.

There are drawbacks to this method of debriefing. Although the timing often works well for the rounding team of attending(s), fellows, residents, advance practice nurses, and students caring for the patient, many of the interprofessional team members (bedside nurses, therapists) who may have been closely involved in the previous day’s events may have a day off or be assigned elsewhere the following day. We adapted our practice to try to include as many interdisciplinary team members as possible by sending out a text page to all staff as the debriefings are starting. Incorporating the debriefings into rounds can be particularly difficult when a team has high census and acuity; although the debriefing can still add value, pressing decisions and patients who require the team’s attention can feel more pressing. For cases that are likely to require a lengthy discussion, we often scheduled a separate, dedicated debriefing at a later time. Doing so has been particularly useful on “switch days” when a new team of residents and fellows start, who are unfamiliar with the patient who died. We also send out e-mail bereavement announcements to all staff so that they are aware of the outcome.

Knowing how to care for a patient and family at the end of life is not necessarily intuitive; it is something that needs to be modeled and learned. Formal didactic programs for trainees regarding end-of-life care can be an important part of preparing clinicians for these challenging and emotional patient and family encounters.1,7  In addition, we and others have used regularly scheduled facilitated small groups or case discussions of challenging situations with trainees and multidisciplinary staff.810  Patient-specific learning and modeling such as occurs in our debriefings can supplement such formal programs by linking theoretical knowledge to practical tasks and immediate patient applications. Regularly scheduled group discussions help make sure that all trainees and staff will at some point in their career discuss the professional aspects of learning how to manage a dying patient, whereas the “just in time” patient-specific debriefings provide a needed reinforcement of those lessons in real time. Beginning with eliciting trainee questions and concerns helps guide discussion to the content that will be most valuable in the moment, and we attempt to address at least some component of both medical and emotional content in each session. Doing so helps to engage all present, even those who do not think they need the “emotional” part of the debriefing (who often turn out to be the ones who need it most). We encourage all team members to ask questions but also allow those who prefer to be silent to exercise that preference.

We have also learned that even the most-experienced clinicians can benefit from, and be surprised by, the discussions that occur. In one instance, a resident physician asked, “Is there something wrong with me because I didn’t cry?” giving the entire team a chance to talk about the emotional impact of each patient death and the balance between establishing boundaries and maintaining empathy. Too many residents might have similar concerns or self-doubt after a patient death without ever being able to discuss them. In another case, the long-term subspecialists joined a team for the debriefing and shared that experience with the parents during a bereavement meeting. The parents found it meaningful that the ICU took time to discuss the child after her death. The culture of debriefing in our ICU has led to resident advocacy projects attempting to extend a similar model to other areas of the hospital.

The importance of reflecting on a patient after a death is widely recognized,and there is never a perfect time to debrief. These events are thankfully rare, and those of us who are in the incredibly odd and privileged position of having been at the side of many patients and families through these life transitions bear a responsibility for helping others learn how to do so well. Our “rounds” the next day are one way that we share the lessons learned from our experiences with the next generation.

We thank Dr Mark Helfaer, who initiated the practice of “rounding the next day” at the Children’s Hospital of Philadelphia.

Drs Morrison and Madrigal conceptualized the manuscript, drafted the initial manuscript, and contributed to revisions; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Dr Morrison is supported by the Justin Michael Ingerman Endowed Chair in Palliative Care. Dr Madrigal is a coinvestigator on grant 1R01NR015831-01 (Hinds, principal investigator), “How Parent Constructs Affect Parent and Family Well-Being after a Child’s Death.” Funded by the National Institutes of Health (NIH).

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.