My client is dead

Sooner or later, one of your clients will die. Waiting until it occurs to consider how this might affect you would be unwise.

Death of clients might be inevitable (f you work in palliative care), an acknowledged risk (if you work in psychiatric settings) or very rare. The cause of death may be deliberate action, accidental or ambiguous.

However hard you strive for “professional detachment”, the need to establish a rapport with your client means establishing a bond for which you may grieve when it is irrevocably lost. Inevitably, junior staff have more time to form such a bond, but have less experience to draw upon in dealing with the consequences.

Considering in advance how the death of a client might affect you will help you better manage both your feelings & responsibilities.

Expected deaths

Staff working with people whose conditions are terminal will be aware that death is likely. They may even be more aware than the client of when death will occur. Services dealing with inevitable death on a regular basis may have protocols for staff support and you should be made aware of these.

Whether or not there is official support available to staff, an established staff group is likely to have evolved its own coping mechanisms which may not be obvious to, or even shared with new and junior members, especially where the service has a low staff turnover or junior staff stay for only a short period.

Quizzing colleagues as to their coping strategies might not be the stuff of coffee room chats, but taking some private time (supervision or other 1:1 interactions) for such discussions is advisable. Be aware that there is no guarantee that even the most experienced staff have coping strategies which would work for you or that you would choose to use even if effective.

Therapists familiar with the dynamics of bereavement will be aware that, in the case of expected deaths, much of the work of grieving may be performed in advance. When a death occurs “on schedule”, those close to the deceased can be surprised by their quick acceptance: they have been preparing unconsciously for months.

When an expected death does not occur “on schedule”, the unconscious preparation & anticipatory grieving may be undone. The expectation becomes that the client will survive and the death may hit as hard as an unexpected death when it finally occurs.

Unexpected deaths

Sudden deaths may be a result of illness, accident or deliberate action. Sudden deaths are more likely to elicit feelings of anger & guilt in addition to the expected sadness.

People with chronic and terminal illnesses are still subject to the same risks and diseases as anyone else.

I was once shocked by the death of a client with a degenerative neurological disorder who suffered a fatal heart attack. This was not part of the profile of their disease and therefore seemed much more shocking. In retrospect, my client had all the markers of a high coronary risk, but the degenerative disorder seemed to override this in everyone’s eyes (including the client’s).

Accidental deaths may be related to treatment. Complications of a necessary operation or prescription of dangerous medication may kill a client and may have been accepted as a risk by the client. You and other colleagues may have held a different view and, however much you respect the client’s right to choose, there may be lingering resentment which might colour your professional interactions.

Distinguishing between an unfortunate outcome of a necessary treatment and the fatal outcome of poor practice can be hard, even for professional ethics boards. Where you harbour a grudge against the therapist responsible for the fatal intervention, you should ensure that you discuss this with senior colleagues: you may be being unfair or there may be a case of professional misconduct which should not go unaddressed.

Where the death appears to be a consequence of your action or inaction, this must again be addressed if you are to continue to practice to the best of your ability. If you were in error, this should be corrected. If you were not, you need to be sure of this to avoid self-doubt clouding future decisions. Discussing possible errors is difficult at the best of times, even without a death as a consequence, but you have a professional responsibility for good practice.

Death by design may be suicide or homicide. The killing of a client by another client would be the most complex scenario imaginable in terms of the implications for therapist and the service, but suicide is a risk in most mental health services and is arguably the cause of death for which you should be best prepared.

Suspicious deaths

Deaths which occur without witnesses may be not be fully explained or explainable. If a depressed client is hit by a car whilst walking drunkenly along the side of a road, was it suicide or accident? If a distracted, anxious client dies from a borderline overdose of a dangerous prescription medication, was it suicide or accident?

Where the true intentions of the dead person will never be known, there is room for doubt and self-blame on the part of the therapist, especially where contact was ongoing but even when the client had not been seen for months or years. Could I have anticipated and prevented this? The same question will occur to friends, relatives and perhaps even colleagues.

Many suicidal acts do not result in death, while impulsive suicidal gestures may be fatal. The true motivations of clients are known only to the client, whatever story they may offer if they survive, and possibly not even to them if they were intoxicated or otherwise out of control of themselves.

As noted above, it may be difficult or impossible to rule out the possibility that you could have averted a suicide. Regardless of the level of uncertainty, you are likely to harbour some feelings of anger or guilt (normal responses to an event outwith your control) which you should be able to address either with your supervisor, colleagues or some other reliable and confidential support.

Depending upon your involvement with the client and the nature of their death, you may be required to provide evidence to an inquest, a professional ethics hearing or even a criminal trial.

Your casenotes may be scrutinised or even removed. You should be aware of your employer’s and your profession’s standards regarding the retention of casenotes, as well as your duties of disclosure and confidentiality, following the death of a client.

Both legal and emotional support for staff affected by the death of a client tends to be poor. Ascertaining the levels of support available to you, and finding additional supports if necessary, should help you continue to practice effectively.

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