Patients who go to treatment for substance use disorders are getting help for a chronic, potentially fatal disease. And sometimes, they die—usually after they have been discharged, and all too frequently because they have relapsed. Sometimes the death is caused by another illness, such as HIV/AIDS or cancer. Sometimes they take their own life deliberately. And recently, there has been a tragic trend toward fatal overdose when people return to using opioids after abstinence-based treatment.
How can and should treatment providers respond when a patient dies? Professionals shared their own personal experiences with us for this article, and experts offered advice and words of caution. When a patient dies, the people who treated that patient need to mourn, providers say.
Shirley Beckett Mikell has seen many patient deaths over the course of more than three decades as a treatment provider, mainly in the field of methadone maintenance. She remembers two deaths with particular poignancy: one patient who committed suicide and one who died from hepatitis C.
“There were many, but these were the most traumatic to me,” says Mikell, who is a consultant to NAADAC, the Association for Addiction Professionals, where she was the longtime manager of the certification program and the general overseer of professional ethics.
The patient who committed suicide was “a pillar of society” who did not want his status as a methadone patient to be known publicly, says Mikell. This occurred in South Carolina 10 years ago, in a methadone clinic where Mikell served as the man's counselor. As in many states even today, opioid addiction and treatment with methadone were highly stigmatized.
“We tried to shield him from the community at large,” sayst Mikell, a social worker. “But after a year, it became obvious to him that people were going to find out.” He had take-home doses, and needed to go to the clinic only once a week to get them, but this was still a challenge.
“When his suicidal thoughts became more complex in the clinical sense, I had a safety plan for him,” she says. But what was traumatic was the way that he died, on the same day she had her last session with him. “I believe he ran his car into an 18-wheeler,” Mikell says. “They say it was an accident. But I knew the state of mind that he was in. There was an agreement that he would meet his wife and son five minutes from our facility. A psychiatrist and myself had a 45-minute session with him, and had him re-sign his safety contract.” The plan was for the patient to transfer to another methadone clinic, so that he would not face as much exposure in his town.
“They labeled his death as an accident to make it easier for his family and for the community at large,” says Mikell. Calling it an accident instead of suicide meant there would be no problems with life insurance. It made it easier for the clinic too. “We didn’t have to say that one of our opioid-dependent clients committed suicide, or have that as a public pronouncement,” she says. Like many methadone clinics, this one already had been subjected to neighborhood opposition to its presence.
“I knew in my heart of hearts the state of mind he was in, and that somehow he maneuvered that accident,” says Mikell. For months, she mulled over what she could have done differently. “Should I have kept him there? Should I have insisted to the psychiatrist that he be committed for evaluation? Should I have insisted to the family that they come to the clinic rather than let him drive?”
Ultimately, her supervisor said she had to go into therapy herself to deal with these issues.
The first patient of Mikell’s to die was a patient with hepatitis C. “We didn’t know back then that it was hepatitis C, because everything was HIV, but when he died, I went to the funeral,” she says. Like the other patient, this patient’s methadone treatment status was not known to the community. So Mikell asked her supervisor whether she should acknowledge the death in any way—by sending a card, or attending services. Her supervisor told her to call the family and ask.
“The family was so relieved when I called,” she says. “They wanted me there, but they were scared to ask.”
Mikell, however, was “devastated” by the death, and felt that “if I had known more, he would still have been alive.” She had been a counselor in the methadone clinic for less than two years, and this was the first death for the program. Afterwards, it was hard for her to talk to any patient without bursting into tears.
“Every time I saw a sore, or when someone seemed in bad health, I kept wondering if they would die,” she says. It took her a year to work through her supervision with a psychiatrist, who told her it was OK for her to talk to her patients about it—other patients in the clinic knew that the man had died. This proved therapeutic, not only for her but for her patients.
“They started to understand that I had concerns for them, that I was empathic, and they started to take better care of themselves,” Mikell recalls.
“The main issue with patient deaths is secondary trauma to counselors,” says Marvin Ventrell, JD, executive director of the National Association of Addiction Treatment Providers (NAATP). “Some treatment centers deal with this better than others.” If affected counselors don’t get proper care, they won’t be able to provide good care themselves, says Ventrell.