Unexpected Death in the Emergency Department: How to Tell the Family
Thomas Barry, MD Assistant Professor of Emergency Medicine Temple University Hospital Philadelphia, Pa
Emergency department physicians are often confronted with the deaths of their patients. Notifying the next of kin can be emotionally traumatic, yet physicians receive no training for it. Receiving training about how to give the death notification and understanding of the expectations, preferences, and likely reactions of family members can improve physicians’ skills and reduce their discomfort level. This article discusses key elements in death telling, including direct communication with loved ones in a private setting, referring to the deceased by name, allowing time for initial expressions of grief, answering questions, assuring family members that you—and they—did everything that could be done, allowing the family to see the body, and asking about tissue donation.
Each year, as many as 176,000 deaths occur in emergency departments in the United States.1 Of these, many medical deaths and virtually all traumatic deaths are not expected. This contrasts sharply with inpatient deaths, which are estimated to be unexpected in less than 7% of the cases.2 The emergency physician is in a unique, but unenviable, position. Delivering unexpected bad news is known to be a difficult experience for caregivers.3-5 Fewer than one third of residents report receiving training in the process of death pronouncement.6 Suboptimal preparation for and handling of this recurrent situation is problematic for both the staff and the public. Preparation, training, and even role-playing practice sessions have been shown to improve the experience.4,7,8 The goal of this article is to provide insight into the who, what, where, and how of delivering that news well. It helps to know what to expect and why to expect it (Table 1).
Family Perceptions Many families who have lost a relative in the emergency department report feeling that the staff was cold and unsympathetic.9 The death of a loved one is an important life event. Years after the encounter, loved ones can often recall where they were when they heard the news, who told them, and maybe even what that person was wearing. When possible, it is best to prepare both the setting and oneself for the encounter.
The CPR Paradox Physicians should not presume that having observed cardiopulmonary resuscitation (CPR) in the prehospital setting prepares the family for bad news. Statistically, only 15% to 20% of in-hospital cardiac arrest patients survive to discharge.10 Recent survival statistics for outpatient CPR range from 7.5% to 24%.11,12 These statistics may be bolstered by inexperienced civilians who start CPR on patients who are not actually pulseless and in cardiac arrest.
In stark contrast to these statistics, the public intuits that 65% of patients in cardiac arrest will survive.13 Studies of CPR survival depicted on popular fictional television series (such as “ER” and “Chicago Hope”) produce the same statistics: 65% of patients with cardiac arrest depicted on television survive, almost always with a good neurologic outcome.13,14 In surveys, the public cites television as their main source of information about CPR.15,16 The positive attitude of many “learn CPR” initiatives no doubt contributes to these optimistic expectations.
Physicians who might otherwise feel that the family would be prepared for a bad outcome because of the on-scene absence of vital signs and the necessity of CPR during transport should be aware of this striking difference in expectations between lay persons and physicians.
Optimizing Interaction with the Family Who should deliver the bad news? Evidence suggests that most people want it to be a physician,17 and that senior staff is best. People want to feel that everything was done and done right. Having a team to help with questions and disposition is helpful. Physician, nurse, social worker, chaplain, and specially trained volunteers might make up such a team.
In deciding where the encounter should occur, remember that privacy has been cited by families as important.18 No one wishes to be stared at by a roomful of strangers at such a difficult moment.
Death in the hospital is not an unexpected occurrence. Some emergency departments have a special grieving room. If space does not permit this, then alternative quiet spaces should be decided on in advance. A telephone to facilitate private contacts with friends and relatives is appreciated, especially in hospitals where cell phone use is restricted.19
You should know the deceased patient’s name and relationship to the visitor. If this needs to be clarified, someone other than the death teller should straighten it out before the encounter. Confusion, while possibly unavoidable initially, is not reassuring, and talking to the wrong people about the wrong patient is disastrous. Do not underestimate the emotional or legal consequences.
All bloodied coats and gloves should be removed. The blood will be recalled, rightly or wrongly, as the blood of the loved one, and the remembered image is not a good one.18
Whenever possible, an introductory meeting between the planned death teller and the family should take place before the actual pronouncement of death. In unfamiliar surroundings, it is comforting to the family to know who is in charge and what is going on. Others can continue the resuscitation process during this meeting. Many experienced clinicians take pains to leave the code room and speak with the family before terminating the code and making the pronouncement. Some adjustment of expectations can take place at this time. Leaving your name on a business card or written on a piece of paper is reassuring3 before you return to the resuscitation room.
When you must actually inform the family of the death, walking down the hall, stripping off your gloves, and shaking your head is drama best left to television. Sit if the family is sitting. Give a very brief summary of what was done, and tell them the patient is dead. Avoid euphemisms at this time.9 You do not want to say, “He’s gone,” and have someone with a different cultural vocabulary reply, “Gone where?” It is best to draw this line clearly and unambiguously.20 Based on my clinical experience, prolonged information and data gathering before revealing the death is later recalled with resentment by families. If information, such as contact information, private physician’s name, and patient’s home address, cannot be gathered during a preliminary encounter, it should wait until after the bad news is delivered, despite the added difficulty in questioning those who are already grieving.
The Grief Reaction Dr Kübler-Ross defined 5 usual stages of grief in her seminal works (Table 2).19,20
Expect an acute emotional spike after telling the loved one(s) of the death. It may be very brief or last 5 to 15 minutes. Try to say nothing for 30 to 60 seconds. You may consider a shoulder touch at this time. Although some find this comforting and human, others will withdraw, interpreting it as an intrusion into personal space. Anger may be directed at hospital staff. This usually dissipates in a short time; the bereaved should be allowed to ventilate without denials and explanations by the staff. Empathy and understanding are best.
Comfort the family and exonerate them. There is no benefit—and possibly long-term harm—in asking what the family did or did not do before the arrival of the ambulance. It is not unusual for family members to ask if it would have helped if they had tried CPR. If, on some level, you can find a way to tell the family that this final result was inevitable, by all means do so. What you say will have long-term ramifications; I question burdening someone with a lifetime of guilt to make a public health statement about the value of knowing CPR, whatever you think that value is.
Saying “I’m sorry” seems very natural in the presence of the grief stricken, but remember that when used by the medical provider it is sometimes misinterpreted. It is best to say “I’m sorry for your loss,” “You have my deepest sympathies,” or “I know this is hard for you.”
The grief reaction often presents itself as a quick progression through the 5 stages outlined by Dr Kübler-Ross,19,20 with a resetting and longer transition through each of the stages. Cultural differences vary from stoic, quiet acceptance to loud yelling, beating the walls, or falling to the floor. Most often these are just that—reactions that are accepted or expected within the specific culture. Vocal and physical grief reactions need not always be interpreted by a physician who has a more restrained cultural context as being a pathologic grief reaction requiring chemical sedation.
Medication and sedation requests Requests for sedatives are frequent, sometimes by the bereaved, often by their well-meaning friends. Grieving is an active process. Medications can only delay this process and disturb synchronicity with others. Reassurance, empathy, and explanation of the naturalness and necessity of the grieving process are often better responses than complying with medication requests.
Pathologic grief—a severe, persistent grief reaction with possible suicidal ideation—needs more than simple medication, and professional psychiatric intervention may be required.
Visiting the deceased Many family members wish to visit with the body of the deceased. In preparation, wounds should be bandaged, and a basic cleaning of the room should take place. Blood and secretions should be washed off. The family should be warned about tubes that cannot be legally removed at that time. Some medical examiners allow endotracheal tubes to be cut and pushed inside the mouth if they are not to be removed. Visitors should also be warned of possible color and appearance changes.
When the offer to view the loved one is made, the physician should say that viewing the body is not required and that it is alright if the family wishes to wait until the funeral director has tended to the body. When accompanying the family to view the body, it is good to touch the patient. It shows the family that it is alright and shows human caring.4 After a period of viewing, it is good to tell the family that it is time to go. Making this decision on their own is sometimes difficult, so setting a time limit can be helpful.
In cases of homicide, it is best to check with the local police. Family and friends may not be allowed to visit or touch the deceased.
Family Roles and Conflicts After a death, many decisions must be made. These include authorization for organ and tissue donation, release of the body to a funeral or cremation facility, and custody of personal effects. This responsibility usually falls on the next of kin, who is decided upon by legally proscribed hierarchy, with some local variation (Table 3).21 Be aware of local laws pertaining to next of kin and their role in decision-making as far as death is involved. Be sure the person making the decisions has the legal right to do so.21
When relatives become angry with each other during an emotional crisis, intervention by perceived authority figures, such as the physician or other staff, can encourage an often beneficial cooling-off period.
Autopsy and Organ Donation The family should be informed of the need to tell the medical examiner of the death. Many hospitals ask physicians to inquire about private autopsies. Be prepared to address questions of costs (if any) to the family of such a procedure and what medical knowledge it may provide to the family. Be ready to address questions about mutilation, embalming (you may assure them that morticians are well versed in the minor procedural changes necessary), and religious practices.
Statistics have shown that autopsies do not hurt the physician from a legal point of view.22 Until 1971, the Joint Commission on Accreditation of Healthcare Organizations required a 20% autopsy rate.23 Once this requirement ended, the autopsy rate dropped. One study showed an aggregate 12.4% autopsy rate among 418 participating institutions, and an 8.3% median autopsy rate.24
Emergency departments are usually not helpful in acquiring donors of hearts or kidneys, because of a lack of tissue perfusion.25 However, tissue such as the corneas, bone, skin, tendon, fascia, and valves can be posthumously harvested.26 Some harvest organizations find a standardized approach by their own representatives to be the most successful. Know your hospital’s procedures.
Most religious organizations either permit organ donation or leave it up to the individual.21,27 Many times individuals with no personal objections to transplant may misinterpret the formal tenets of their chosen religion. In 1983, the Moslem Religious Council rejected organ donation by followers of Islam, but it has since changed its position to require that donors consent in writing before death and that organs be used immediately and not be stored in organ banks. Judaism teaches that saving a human life takes precedence over maintaining the sanctity of the human body. Many orthodox Rabbis will support donation. The Watch Tower Society of Jehovah’s Witnesses notes that their religion does not encourage donation but leaves it up to the individual and specifies that all tissue must be completely drained of blood before transplant. Christian Scientists normally rely on spiritual rather than on medical healing but leave the question of donation to the individual church member. Rather than recite all this information, you can encourage the next of kin to consult their spiritual advisors regarding organ donation permissibility.
Follow-up All hospital paperwork should be completed and appropriate releases signed. Contact information for the family and the deceased’s primary care physician should be obtained. A telephone number and contact name at the emergency department should be provided to the family so that unanswered questions that sometimes plague survivors may be addressed. The family should be told to call a funeral director, because such an individual assists with most arrangements. You may inform them that federal law requires that price quotes be given on the telephone by funeral directors—information that may be helpful to the family.
Special Circumstances Occasionally, a death will occur before the family is aware of any problem and before the family has come to the hospital. When questioned, most people say they would have preferred to come to the hospital to be told in person if they lived within 1 hour of the hospital.21 You may say that the patient is critically ill, and suggest that someone else drive—carefully, with no speeding, or running red lights. Care should be taken to ensure that the staff is aware, available, and ready to meet the family when they arrive. Any confusion that can occur when a deceased patient’s name is removed from active patient lists must be addressed and eliminated.
If it would take the family more than 1 hour to get to the hospital, notification is usually made by phone. Ask if the family member is alone and if it is possible to get others on the phone.21 Tell them that you would like to call a relative, a neighbor, or a minister for them.
Conclusion Delivering bad news in a carefully planned fashion can improve the experience for both the giver and the receiver of the news. Proper techniques of death telling, as with many procedures in emergency medicine, can be learned and improved upon with insight, planning, and preparation.
Self-assessment test 1. All the following statements about CPR are true, except: A. Most outpatient CPR cases die B. Most inpatient CPR cases die C. Family members who observe prehospital CPR efforts are often prepared for a loved one’s death D. The public uses television as a primary source for CPR information 2. Who would most family members want to tell them of a loved one’s death? A. Chaplain B. Social worker C. Physician D. Mental health professional 3. Which of the following statements on death notification is best? A. “He’s passed on” B. “He’s gone” C. “He died” D. “He didn’t make it” 4. Of the following statements, which one should be avoided? A. “I know this is hard for you” B. “I’m sorry” C. “You have my deepest sympathies” D. “I’m sorry for your loss” 5. Which action is least appropriate in the emergency department setting? A. Giving a distraught relative a prescription for a sedative B. Allowing family members to view the body C. Intervening in an argument about the custody of personal effects D. Asking about organ and tissue donation
(Answers at end of references list)
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