14
Care of the bereaved
Introduction
It is estimated that there are some 25 000–30 000 resuscitation attempts in the UK every year (Resuscitation Council 1996, Royal College of Nursing 2002). Dealing with the suddenly bereaved in Emergency Departments (ED) is difficult for all staff, no matter how much experience they have. This chapter will consider approaches to the management of sudden death in ED. It will examine the literature surrounding this subject, before exploring the process of care for those who have been suddenly bereaved. It will also outline the care of staff that have cared for the suddenly bereaved.
Background
The literature surrounding the subject of sudden death is vast (Royal College of Nursing 2002, Mushtaq & Ritchie 2005, Moons & Norekval 2008, Kingsnorth-Hinrichs 2009). Death is the permanent cessation of all vital functions, the end of human life, an event and a state. Dying is a process of coming to an end: the final act of living (Thompson 1994). Wright (1996) defined sudden deaths as those occurring without warning – the unexpected death. Deaths that result from acute disease, accidents, suicides and homicides fall into this category. It is these sudden deaths that are most frequently encountered in ED.
The Royal College of Nursing and British Association for Accident and Emergency Medicine (1995), in the largest study of its kind, considered the facilities in ED for the bereaved. A questionnaire was sent to all 267 ED in England and Wales to identify the systems, facilities and training provided. Of the 248 (93%) departments that responded, it was possible to estimate that two to three attendances per 1000 new attendances involved relatives who were bereaved following a patient dying in the ED. Forty per cent of the departments that responded stated they had two to three deaths per week, with a further 25% having four to five deaths per week. In terms of workload and impact on the average ED, sudden death can be significant for staff as well as for relatives.
The concept of a trajectory of death was developed by Glaser & Strauss (1965, 1968) to refer to the pattern of death. They distinguish between ‘quick’ and ‘slow’ dying trajectories. Generally, in ED, the patients have a ‘quick’ death trajectory, which is unexpected by the family, even when it is the result of a long-standing medical condition, such as heart disease. Lindemann (1944), in a classic study of bereavement, suggested that people who fear the death of a loved one often begin the process of grieving before any loss actually occurs. The acute reactions to loss include an initial period of shock followed by intense emotional pangs of grief. Lindemann identified the following symptoms of normal grief:
• somatic distress, such as feelings of tightness in the throat or chest
• preoccupation with the image of the deceased
These symptoms will be familiar to ED staff who have looked after recently bereaved relatives. Lindemann’s work stemmed from a fire at the Coconut Grove nightclub in 1942 that claimed the lives of 474 people. He found that the fire resulted in a crisis for all individuals closely involved, including staff. Scott (1994) suggested that caring for distressed relatives following a sudden death is perhaps one of the most emotionally draining of nursing interventions. Wright (1996), in a study of relatives’ responses to sudden death, found nine common emotional responses identified by nurses as difficult to manage, including:
It is noteworthy that five of the emotional responses that cause difficulties for ED nurses also correspond with what Kubler-Ross (1973) described as the stages of grief, i.e., denial, anger, isolation, bargaining and acceptance. Kubler-Ross was careful to point out that these stages do not happen in a particular order, and can occur side by side. These stages do not just affect dying patients but, as can be seen above, affect relatives and staff as well.
There is, however, debate regarding the usefulness of identifying emotions in an attempt to define the manifestation of grieving as this may lead people to think of grief in a simplistic way. Thus the theories and emotions attributed to grief should only be used as a guide to inform the possible reactions experienced by those who are bereaved (Kent & Dowell 2004, Oman & Duran 2010). That noted, people experiencing the sudden unexpected death of a loved one are at risk of more pronounced and prolonged grief reactions than those who had been expecting death. There is also a higher morbidity rate among these people in the following two years after the death (Kent & Dowell 2004).
Preparing for receiving the patient and relatives
With growing improvements in communications technology, staff are increasingly informed of the impending arrival of critically ill or injured patients by ambulance control or the ambulance crew en route from the scene. This enables staff to prepare the resuscitation room and contact the on-call medical, paediatric and anaesthetic teams as appropriate. In accordance with advanced life-support principles, staff should be designated specific roles for the management of the patient (see also Chapter 2).
The 5–10 minutes’ forewarning also serve to mentally prepare staff for the arrival of patients and their relatives. This time can also be used to provide support and guidance for more junior staff about what they might expect. A member of staff should be allocated to receive relatives. This nurse should not have any clinical responsibilities in the management of the resuscitation (Box 14.1).
When anxious relatives arrive, they should be met by a named link nurse and not be kept waiting around at reception for the department’s communications to be established (Purves & Edwards 2005, Oman & Duran 2010). While the term ‘relatives’ is used throughout this chapter, it is important to note that in some instances close friends or partners of either sex may be severely distressed and should be handled in the same way as the relatives.
Witnessed resuscitation
Witnessed resuscitation, the practice of enabling relatives to stay in the resuscitation room while their loved one is being resuscitated, remains controversial (Boyd & White 1998, Royal College of Nursing, British Medical Association and Resuscitation Council 2002, Emergency Nurses Association 2009, Kingsnorth-Hinrichs 2009, Oman & Duran 2010). In a review of 117 studies into family presence, as witnessed resuscitation is also known, the Emergency Nurses Association (2009) found the following:
• there is some evidence that patients would prefer to have their family members present during resuscitation
• there is strong evidence that family members wish to be offered the option to be present during invasive procedures and resuscitation of a family member
• there is little or no evidence to indicate that the practice of family member presence is detrimental to the patient, the family or the healthcare team
• there is evidence that family member presence does not interfere with patient care during invasive procedures or resuscitation
• there is evidence that healthcare professionals support the presence of a designated healthcare professional assigned to present family members to provide explanation and comfort
• there is some evidence that a policy regarding family member presence provides structure and support to healthcare professionals involved in this practice
• family member presence during invasive procedures or resuscitation should be offered as an option to appropriate family members and should be based on written institution policy.
Dolan (1997) has argued that ‘enabling witnessed resuscitation is about having enough faith in ourselves as carers to show we are not afraid of others seeing us losing the battle for someone’s life’, and Connors (1996) suggests that the advantages of allowing relatives to be present in the resuscitation room appear to outweigh any potential disadvantages. Boxes 14.2 and 14.3 outline healthcare professionals’ concerns about allowing relatives into resuscitation rooms as well as reasons why relatives should be allowed in the resuscitation room.
Witnessed resuscitation was first documented by the Foote Hospital Michigan, after they introduced the system in 1982 following two incidents when family members insisted on being present (Doyle et al. 1987). They questioned recently bereaved relatives and found that 72% would have liked to have witnessed the resuscitation attempt. As a result, a programme of witnessed resuscitation began; however, there was resistance from many staff members. In an audit three years later, staff were questioned about their views and 71% endorsed the practice even though some felt it had incurred an increased stress level, largely because the patient undergoing resuscitation becomes ‘more human’ in the presence of family members. In a follow-up paper, Hanson & Strawser (1992) argued that in their nine years of facilitating acceptance of death and grieving by this method, staff members continued to find it a humanizing and workable experience.
A UK study by Robinson et al. (1998) found there were no adverse psychological effects among relatives who witnessed resuscitation, all of whom were satisfied with the decision to remain with the patient. The trial was discontinued when the clinical team involved became convinced of the benefits to relatives of allowing them to witness resuscitation if they wished. Psychological follow-up at three and six months found fewer symptoms of grief and distress in the group who had witnessed resuscitation than in the control group. Of the patients who survived, none believed that their confidentiality had been compromised.
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