DEATH NOTIFICATION
Death notification is perhaps the most difficult, emotionally laden communication that physicians must perform. In most situations, the notification of death occurs during the first meeting of the emergency physician with the deceased patient’s family. The notification often comes after extensive resuscitation efforts, creating a upheaval of emotion for the physician and ED staff leaving the team emotionally and physically exhausted.1,2
For survivors, death notification is a life-altering event. The language used during the communication, the venue, and the characteristics of the individual delivering the news create indelible memories for the family.3
Because death that occurs in the ED is frequently sudden, unexpected, and often violent, survivors can develop complicated bereavement and/or posttraumatic stress disorder.4,5,6,7 Death notifications that provide limited or incorrect information about the death or occur in chaotic settings with limited support may exacerbate the grief reaction.6 When properly performed, death notifications may mitigate substantial negative effects on surviving family members.8 A well-delivered death notification can reduce the incidence of posttraumatic stress disorder in the families of patients who died suddenly, particularly notifications involving the loss of a spouse or the death of a child.9
Physicians find death notification physically and emotionally difficult, with evidence of increased heart rate, heart rate variability, and cortisol levels immediately after the event.10,11,12,13 Common emotional reactions in emergency physicians faced with the task of death notification are sadness (60%) and disappointment (38%), resulting in insomnia in 37%.13 The cause of death, the patient’s age, the presence of family, and the similarity to self are the most common reasons cited by emergency physicians for powerful impact of a recent death notification experience.13,14 The need to rapidly switch between the cool emotional state required to lead a resuscitation and that of a warm empathic informant bearing difficult and tragic news may exacerbate this situation for the physician. The following factors also increase the stress level for the physician: racial and ethnic differences between the physician and the family, lack of a clear family leader, a nontraditional family (e.g., broken or blended), and situations in which the physician is personally emotional or cannot control his or her own reaction.15
Skillful death notification is a priority in emergency medicine practice.2,3 Protocols to enhance communication skills for delivering bad news in the ED improve satisfaction of survivors.16 The use of successful methods to communicate effectively with families may also mitigate physician burnout and reduce stress on ED staff.17 First, providers must seek to understand and anticipate their personal emotions. Second, providers must learn to use compassionate communication methods in the delivery of this information. Third, providers must provide precise and complete information to families. Understanding and using compassionate methods of information exchange are critical to success. Providers must learn to recognize emotions, even when they are indirectly expressed, and allow these to be aired and displayed without judgment.18
GRIEV_ING© A METHOD FOR DELIVERY OF DEATH NOTIFICATION
The GRIEV_ING© mnemonic is a method for delivering concise and accurate death notification. This mnemonic provides physicians with an organized, sequenced approach to deliver the news of death (Table 300-1).19 The structured organization of communication elements provides a coherent sequence of information to the family that is easy for providers to remember and ensures complete information transfer to the family.
| G | Gather | Assemble the family in a calm, considerate place for the discussion. Gather as many family members as time allows. This mitigates the need for multiple episodes of information delivery. This step may be done by ED support staff. |
| R | Resources | Ask for any additional support available to aid the family (e.g., hospital chaplain services, family ministers, additional family and friends [especially if the survivor is alone], and, if needed, an interpreter). |
| I | Identify | Upon entering the room with the family: Identify yourself Identify the deceased patient by name Identify the family’s state of knowledge. Are they aware of the situation, or will news of the death be unexpected? |
| E | Educate | In a concise manner, educate the family about the events that have transpired since the patient entered care. EMS should be included in this description. Fire a “warning shot” by stating that you bring “very bad news.” Tell them the current state of their loved one. |
| V | Verify | Confirm the news of death. State emphatically that their family member is dead. Be clear! Use the words dead or died. Express your sincere condolences. |
| _ | Space | Stop talking. Allow the news to settle and give them time to process the information. |
| I | Inquire | After a brief interval, ask if they have any questions. Then take the time to answer all of them. |
| N | Nuts and bolts | Provide additional information on: Organ donation. Funeral service that will collect the body. The deceased’s personal belongings. Be sure to offer the family the opportunity to view the body. |
| G | Give | Give the family your card and contact information. Offer to answer any questions that they may have later. Return their call if contacted. Express condolences. |
As early as possible during the resuscitation, instruct ED staff, nursing, social work, or chaplain services to “gather” the family. Place the group in a quiet, private environment with few distractions. Assist the family with outreach to other family members or friends. Gathering allows the physician to deliver the information a single time, ensuring that everyone hears the same information. This also allows the family to support each other during this most difficult time.
Ask if there are any needs, and work to collect any needed items. Ask about desires for a chaplain, minister, or priest who may provide support for the family. Obtain interpreter services if needed.
Confirm that the deceased individual is properly identified. As the physician and staff join the family, they must clearly identify themselves and their role in the resuscitation. They must then clarify and confirm that the family is associated with the deceased individual. This can be done by saying the patient’s full name, for example, “Are you the family of Ellen Smith?” Ask the family members to state their relation to the patient. Identify the next of kin. All discussion moving forward is between you and the next of kin. Face that person directly and ask permission to discuss the events of the day in the presence of the extended family and those gathered in the room.
Ask for a brief statement of the state of knowledge of the family regarding the patient’s status. This final step is important because it allows you to begin your story of the day’s events at the point their knowledge ends. This assists you in providing complete and essential information. Depending on the prior state of knowledge, the family will process information differently and at different rates. Your story will be very different for family members who witnessed a complete arrest versus those who last saw their family member healthy. The following is an example of an introductory narrative:
“Good Afternoon, my name is Dr. Hobgood. I am the attending physician taking care of Mrs. Ellen Smith. Are you the family of Mrs. Smith? Thank you for coming. Would you mind introducing yourselves and your relationship to Mrs. Smith? Thank you. Mr. Smith, do I have your permission to discuss Mrs. Smith’s case in the presence of your family? Thank you.
Before I begin, it would be helpful to understand what you already know about what is going on. Can you tell me what you know about what happened to Mrs. Smith today?”
If possible, before you begin your discussion, ask the family to take a seat. You and your team should sit as well. Having the family sit reduces the risk of falling and sustaining injury during the notification. Position yourself across from the next of kin, preferably at eye level, and address the majority of the dialogue to that person. This posture creates open communication and allows you to assess understanding as you deliver the information. As a physician, a seated posture indicates that you are open to discussion and are willing to remain as long as needed.
