Chapter 2: Addressing work-related grief stress

Grieving a non-optimal outcome

We couldn’t get ahead of the pain. We tried everything. It was so difficult for the family watching him die that way. – Canadian Paramedic

They hoped she’d live long enough for her sister to arrive. We gave her oxygen, but the patient died an hour before she arrived. – Canadian Paramedic

She begged us not to take him to the hospital, but he needed pain control we couldn’t provide. She’d promised him he’d die at home, but the physician agreed he needed to come in. – Canadian Paramedic

There will always be situations you can’t fix, symptoms that can’t be controlled. If someone is going to die imminently, there’s nothing the patient, family or paramedic can do to change that. The more invested you are in controlling the outcome (e.g., "All my patients will die well"), the greater the negative impact when that doesn’t occur, even if for reasons beyond your control.

Guilt and unrealistic expectations

Not all calls go as we’d hope. There’s not always a clearly right or best approach – sometimes there’s little you can do. Working in stressful, high pressure situations with many moving pieces can naturally lead to missteps. In some cases, you may feel responsible for a poor outcome on a palliative care call, or a family member may hold you accountable for a situation they believe was “preventable.”

Feelings of guilt or failure, or of letting someone down, can be very troubling and can impact work-related grief. For instance, a totally pain-free death may not have been possible, or the patient may not have died at home as they had wished. You may feel you failed the patient or family in some way. If you’re struggling with these feelings, consider discussing the case with a colleague or ask for a case review. 

Is your guilt reasonable?

There’s a place for reasonable guilt. This emotion encourages accountability for one’s actions; there may also be lessons to be learned from guilt. Taking this kind of guilt seriously requires allowing yourself time to reflect on how you’d approach a similar situation differently and how you can improve your practice. 

However, there is also exaggerated guilt, which is pervasive and doesn’t fit reality. It’s very common to feel guilty about events beyond one’s control, but this can keep you caught in the past as you repeatedly replay a certain event in your mind. This loop can prevent you from looking at what’s underneath – which is usually linked to anxiety.

The challenge is to identify the underlying cause of exaggerated guilt. For example, this degree of guilt sometimes provides a shield that protects you from acknowledging how frightening and beyond your control the world can be.  

Guilt is a choice

Feeling guilty is a choice. Holding on to guilt about a certain event can result in being stuck in the past. When this happens, people’s lives become smaller as they define themselves by the event and are diminished by it. It’s possible, instead, to move towards an enlarged life in which you learn to be more accountable to others, yourself and your work.

Reflective exercise

Based on the work of psychologist James Hollis, these prompts may help foster a personal reflection on guilt.

What is guilt making me do in my life? 

What is guilt keeping me from doing in my life?