Rituals of Unburdening

Death in the newborn intensive care unit, as elsewhere, is often marked by rituals. Some, like the cadence of a code or helping parents with their grief, are included in both the formal and informal education of physicians. Among these, though perhaps not named as such, is the "unburdening" of the parents—an attempt to relieve them of misplaced guilt. A parallel ritual that is seldom taught or discussed, however, is the unburdening of the physician who has tried and failed to save a child. The unburdening of parents, typically done by the child's physician, is strikingly similar to the unburdening of the physician, done by one or more colleagues. As with so many rituals surrounding death, both may address an emotional need and provide some relief to those left behind.

A baby girl is born at 2:00 a.m. with life-threatening medical problems. The neonatology team resuscitates her and places the necessary lines and tubes. Initially her vital signs stabilize, but the honeymoon is brief. The team works for hours to reverse her downward course. The attending physician brings the parents to their daughter's bedside and tells them gently but clearly that he believes the child will probably not survive the night. They ask that everything possible be done to save her. They understand, they say, that the chance of success is low, and that even if she were to survive, she could be left with permanent disabilities. Still, they ask that everything possible be done. "How could we live with ourselves otherwise?" the father asks.

The attending watches as the neonatology fellow, almost an attending herself, expertly directs the team. He stands just behind her and off to her left, occasionally making suggestions, fine-tuning her management. He knows he is fortunate to have such an excellent group. The fellow, nurse, nurse practitioner, pediatric resident, and respiratory therapist are all experienced and skilled in their respective roles. Also, each of them has confidence in the attending's clinical judgment. As stressful as these situations can be, there is some comfort in having a veteran physician, and the clinician ultimately responsible, right there with you making sure you're doing it right—making sure you don't miss anything. This is an advantage they all share, save one.

The oxygen saturation drifts downward. Eventually the baby's heart rate begins to slow. The team initiates a code, but in truth all their efforts since the child's birth could well be described as one long code. Despite their best efforts, the situation continues to worsen. Its hopelessness seems apparent, and the fellow asks the attending how much longer they should proceed.

Acceptance seems to work its way up the ranks. The one who has the final responsibility is often the last to acknowledge that the patient will not survive. But in time the attending calls it, and efforts cease. He thanks the team and tells them they did a great job. He truthfully reassures them that they gave the baby the best chance she could have had. As the nurse gently removes the tubes and tape and machines, preparing the baby to be held, the attending sits with the parents and tells them what happened, offers condolences, answers their questions, and assures them he did everything he could.

He also unburdens them as much as possible. Parents of infants who are born sick, premature, or with congenital defects often fear they are somehow to blame. This is particularly true of mothers, who may feel they have failed in their responsibility to nurture and deliver a healthy baby. Parents often wonder what they did to cause such a catastrophe. Perhaps worse, they sometimes believe (almost always mistakenly) that they already know what they've done wrong, but are afraid to ask lest they have their theory confirmed. When their concerns are anticipated and their misplaced sense of guilt is addressed, the relief in their eyes is apparent. And then, sometimes, specific questions emerge, about having painted the apartment or missed prenatal vitamins, or something else usually unrelated to the child's death.

The attending in this case knows the...