Supporting Providers After Drug Overdose Death

Common emotions experienced by providers after a patient suicide include shock, disbelief, guilt, shame, fear of blame, and self-doubt (21–24). One survey of psychiatrists found that 50% of respondents who had a patient in their practice die of suicide had stress levels in the weeks following the suicide that were comparable to those of people seeking treatment following a parent’s death (25). In that study and others, younger providers with less experience had higher levels of stress after a patient suicide when compared with older providers with more clinical experience (25, 26). Other factors associated with increased levels of provider stress after a patient suicide include having felt close to the patient, direct exposure to the suicide through seeing the deceased patient’s body, and inadequate support after the suicide (26). Support after suicide is a variable that has been found in several studies and commentaries to influence providers’ reactions. Clinicians in solo practices who were more isolated from colleague support were more likely to have increased symptoms of grief (23, 27). Another theme in the literature regarding provider experiences after patient suicide is the ways in which the provider’s clinical practice is affected (22–24, 28–31). A study based on structured interviews of 20 therapists who had a patient suicide in their practice (29) found that 85% were much more direct in their assessment of suicidality after they had a suicide in their practice. Countertransference reactions described in the literature that can arise when continuing to work with suicidal patients include being overly protective and conservative in assessing risk, avoiding discussing suicidality, or avoiding patients at risk for suicide (22–24, 30).

In considering provider reactions after suicide and the similarities between suicide and drug overdose deaths, it follows that providers like Drs. Smith and Jones in the vignette are likely to experience similar emotional reactions. Now that medications are available to treat opioid use disorder and can be provided in less restrictive settings, such as office-based practices, in which providers may be in a small or solo practice, some providers may be relatively isolated after a patient drug overdose death. Providers who are working in a small or solo practice with individuals with opioid use disorder may benefit from being more deliberate in creating a peer supervision/support network for emotional support and supervision to increase awareness of countertransference reactions should a drug overdose death occur in their practice.

As noted earlier, younger providers with less clinical experience are likely to be more affected by patient suicide. A survey of residents (28) found that exposure to a completed suicide during their training had an impact on their emotional health and on their view of the profession, and it increased their awareness of the medicolegal aspects of psychiatry. One finding from that study that is concerning is that trainees were reluctant to use formal support, such as employee assistance programs, because of concerns about confidentiality and insurance. Another survey of trainees (32) found that 27% felt unable to ask for help after a patient suicide despite the fact that all had a supervisor to contact in an emergency and that the majority felt that someone was available to help. Although most training programs (70%) have a clear requirement that a supervisor be notified after a patient suicide, program directors may be involved less often; surveys of chief residents and program directors found that only 32% to 66.5% of programs recommend or require that the training director be notified in a timely manner (33, 34).

Few training programs have written protocols to guide trainees and educators on steps to take to support trainees after a patient suicide. In a national survey of chief residents (34), training programs that had written protocols to follow after a patient suicide were found to be more likely than programs without written protocols to have implemented procedures to support trainees, such as timely notification of the program director, process sessions, therapy or counseling, and emergency leave. An example of a training program protocol, created by the National Capital Consortium psychiatry residency in response to an increased rate of military suicides, has been described in detail (35). Written protocols on procedures to follow after adverse events such as a patient suicide or drug overdose death may help programs better support trainees. Additionally, because residents may struggle to reach out for support after a suicide or drug overdose death, it is important that training directors be notified of such adverse events, as Dr. Jones notified Dr. Smith’s training director in the vignette. This allows the training director to reach out to the trainee and to monitor the impact of the death on the trainee over time, since supervisors like Dr. Jones may not work with individual trainees longitudinally.

In studies in which residents and training programs were surveyed about training on suicide, most (91% to 94%) reported that formal teaching on suicide risk factors was provided (33, 36). However, training in postvention—interventions to support the bereaved after suicide—was less common and existed in only 25% to 47% of programs (33, 36). Several postvention curricula have been described in the literature (37–39). These programs have been well received by residents and were found to be associated with improved knowledge on how to cope with a patient suicide (37, 38) as well as increased self-competence in how to manage the emotional, clinical, and medicolegal issues that arise after patient suicide (37). As the field of psychiatry works to increase trainee interest and training experiences in addiction psychiatry, the literature suggests that it is important for training programs to develop or strengthen postvention curricula to support trainees after suicide and drug overdose deaths.

Concern from family members or close friends is often the catalyst that leads individuals with substance use disorders to engage in treatment, and social support is a key component to helping patients sustain change. At the point of initial treatment engagement, providers should encourage the patient to involve a support person in their care. At a minimum, this would include a release of information, allowing information to be shared between the provider and the support person should concerns arise. Opening lines of communication between the provider and the support person can be important if the patient is struggling in treatment.

After an adverse outcome such as death from drug overdose, providers may assume that families will blame them, and they may feel reluctant to reach out to or meet with the patient’s family. One study in which therapists of patients who died by suicide were surveyed (24) found that most therapists expected anger and criticism from families. However, as in the case of Drs. Smith and Jones in the vignette, when these therapists met with families, most of the relatives were not critical of the therapist and expressed gratitude for the help provided. If a provider is contacted by a family after a patient drug overdose death, it is important to respond. In a review of litigation after suicide, Gutheil (40) noted that families were sometimes motivated to file a malpractice suit to access information to help them understand their loss when providers were not responsive to family members’ attempts to contact them.

If a family member was part of the patient’s treatment, it is important for providers to offer the option to meet with family members, since families may feel isolated by stigma as they grieve. If a patient’s family was not part of their treatment but it was clear that the family knew that the patient was in treatment, reaching out with a telephone call or a condolence card are ways to recognize the patient’s death and communicate a willingness to support family members in the initial grieving process. Condolence cards have been identified as one way to help families and physicians cope with a patient’s death (41). When interacting with family members, providers need to be aware that the confidentiality provisions of the Health Insurance Portability and Accountability Act continue after the death of the patient. If it is unclear whether a patient’s family knew that the patient was engaged in substance use treatment, it is important to honor the patient’s confidentiality and not contact the family until this can be elucidated.

When communicating with families, providers should focus on addressing the family members’ feelings about the patient’s death to help support the family’s grieving process (42). If a full release of information is on file for a family member, as there was for Mr. A’s parents in the vignette, or the family member is the legal executor for the patient, a provider can answer specific questions about a patient’s course in treatment. In states with apology statutes, providers can express sadness and sympathy without fear of malpractice, since expressions of sympathy are not admissible as evidence of an admission of liability in a civil lawsuit (43). When communicating with a contentious family, it is important to avoid self-incriminating or self-exonerating statements, since this can cause additional stress to the family (42).

Providers can also consider attending a patient’s funeral after a drug overdose death, as Drs. Smith and Jones did. Surveys of providers who experienced a suicide in their practice found that funeral attendance was relatively uncommon, with rates ranging from 2% to 14% of providers (21, 28, 31, 44). The literature does suggest, however, that funeral attendance after a patient suicide can help families and providers mourn and work through their grief after suicide (24, 31, 45, 46). As noted by two primary care providers (47), funeral attendance is a gesture of respect to the deceased that is appreciated by families. Furthermore, they describe experiences where their funeral attendance allowed family members to follow up with the providers to discuss their experience surrounding the death, which may help family members process their grief. In a commentary describing the psychiatrist’s role after patient suicide, Kaye (46) described feeling welcomed by a patient’s family at the funeral and finding it helpful to learn more about the patient through other people’s memories.

As noted earlier, it is important for providers to receive support from colleagues after a drug overdose death. After a patient suicide, providers have found it helpful to discuss the case with colleagues and to hear other providers’ experiences with patient deaths from suicide (48). This can also be helpful after an overdose death, as in the example of Dr. Jones listening to Dr. Smith discuss Mr. A’s case and sharing his experiences after patient overdose death. Although it may be tempting to provide reassurance to a provider after a patient’s drug overdose death, premature reassurance that a provider did nothing wrong after a patient’s suicide has not been shown to be helpful (23, 24). In addition to colleagues, a provider’s family and friends have been identified as a source of support after a patient suicide (28, 31). While patient confidentiality regulations limit what information can be shared, providers can still disclose that an unexpected death occurred and can discuss their emotions about the death with family and friends.

If a provider is working within a treatment system, it is important to file an incident report after a patient drug overdose death, as Dr. Jones did in the vignette. A quality assurance and improvement meeting after the incident report can be helpful to facilitate learning, improve patient care, and bring closure to the provider who treated the deceased patient (46). Quality assurance and improvement meetings are confidential, and the content that is discussed in the meeting is privileged information that cannot be subpoenaed in a malpractice lawsuit. Care needs to be taken to be sensitive to the timing and tone of the quality assurance and improvement meeting to avoid shaming the provider or worsening provider doubt (49).

Providers working in a small or solo private practice should consider contacting their malpractice insurance carrier regardless of whether there was a contentious interaction with the deceased patient’s family.

Providers who work with patients with opioid use disorders need to be prepared for a drug overdose death in their practice. Providers should consider their practice setting, develop a protocol of steps to take after a patient drug overdose death, and identify and strengthen their support system. It is important that providers seek support for themselves after a patient drug overdose death to minimize the psychological trauma associated with the death. They also need to be prepared to support colleagues who worked with the deceased patient, as well as the deceased patient’s family.

The larger health care system also has a role to play in supporting providers by creating a culture that supports routine reviews of adverse outcomes to identify opportunities for change and improvement. For providers in private practice, this may involve incorporating quality improvement and assurance discussions into peer supervision, or perhaps establishing opportunities for consultation with local psychiatric societies. There could even be a role for incentives from malpractice insurers or health insurers to provide discounts or greater reimbursement, respectively, for providers who incorporate into their practice quality assurance and improvement projects or reviews after adverse events.

There is a need for increased research on the impact of drug overdose deaths on providers and families. Formal training in postvention needs to be strengthened in residency training programs as well as in continuing medical education, particularly when education on evidence-based practices for the treatment of opioid use disorder is being provided. Finally, we would all benefit from discussing adverse events more regularly, so that no one is worrying alone about a past event or the possibility of a future adverse event. Provider distress after an adverse patient event is particularly relevant in the current era of increasing rates of provider burnout, since distress after an adverse patient event can be a contributing factor (50). We need to do better with supporting one another and to work together collectively as a field to identify ways to improve our practices and system of care as we care for patients at risk for adverse events such as unexpected death.