Family Medicine: Grief, Loss and Death at Christmas

"All mankind is of one author, and is one volume; when one man dies, one chapter is not torn out of the book, but translated into a better language; and every chapter must be so translated...As therefore the bell that rings to a sermon, calls not upon the preacher only, but upon the congregation to come: so this bell calls us all: but how much more me, who am brought so near the door by this sickness....No man is an island, entire of itself...any man's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee."  ....John Donne, Meditation XVII

"Are you willing to sign the death certificate on ________?," the county coroner's representative asked me a week or two before and again a few days after Christmas, during one December.  They need to know if the patient had a medical condition that could be lethal under certain circumstances, or do they have to consider making the death a coroner's case.  I reflect in my mind on the conversation I had with the emergency physician about my patient who had a respiratory infection that suddenly overwhelmed the lungs, weakened by chronic disease, leading to respiratory failure.  Their efforts to revive my patient were unsuccessful and I felt empty, reflecting on a ten plus year relationship with a unique person and their family.  Three generations of the family are patients of mine, too.  The same is true of the person who died a few days after Christmas, both having children and grandchildren who have a relationship with me and my family medical practice.

Loss is difficult for families at any time, but often seems to hit harder at Christmas time.  I frequently see patients in December who can't wait for "the holidays" to end.  They lament the loss of their grandmother, mother, father, grandfather, child, favorite aunt, sister, brother, etc. which overwhelms their senses during the anniversary day, week or month.  The grief often is prolonged for years, generally not generating a focused attempt to integrate it into their "in fond memory" files.  It may even get the mental status of a post traumatic stress syndrome (PTSD) person with lingering emotional pain instead of positive life lessons.  I know their pain is a legitimate situation in their life.

Some of the most difficult situations with Christmas Grief come with multiple losses over the years near Christmas that get "stacked" into one grief reaction.  Individual losses may become tolerable as time passes and the patient reflects on the meaning of the deceased person's life, but stacked grief puts several grief reactions into one inseparable pile, making the grief less likely to be resolved.

In these situations of stacked grief, when the patient has enough energy to deal with grief, I ask them to list the losses and schedule times on their calendar when they will grieve each individual loss, as their brain and heart allows.  "Get the grief off your head, where it sits like an anvil, and put it into your calendar", I suggest, in an attempt to make the grief more understandable for the individual.  "Calendaring" the losses frees the patient from continuous grief, giving them freedom to live their life when not in a scheduled grief appointment with themselves.  Separating the grief reactions may allow resolution of some grief while pointing out areas where special counseling might help.

Pathologic grief often requires the help of counseling professionals (including clergy) to effect the best outcome.  Many grievers, however, put off recommended counseling for years, sometimes stating that it would dishonor the deceased if they didn't feel miserable.  The suicide of a child, spouse or parent comes to mind as the intense type of grief that requires special skills and lots of time.  Sometimes the brain just blows the facts of the loss into separate brain areas, preventing the whole story from being mentally reconstructed until there is enough life energy to handle it.  Soldiers with PTSD are a special group who provided counselors and physicians with broader insights into how the brain protected itself from intolerable mental anguish.

Physicians grieve for patients, both living and deceased, at times and places away from usual patient care.  The professional "auto-pilot" may turn on to get through a loss situation to finish "the work" before processing the grief.  We must also schedule the grief for a specific time in the calendar to avoid "Non-Grief", which could be detrimental to our patients and ourselves.  This also includes Christmas Grief of and by the physician, professionally and personally.

We all share the same humanity and seek peace in our lives.  We periodically should again reflect on the words of John Donne as a reminder:

 "No man is an island, entire of itself...any man's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee."