You are in: eMedicine Specialties > Emergency Medicine > PSYCHOSOCIAL Grief Support in the EDArticle Last Updated: Jan 14, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Eric Isaacs, MD, Director of Quality Improvement, Department of Emergency Services, San Francisco General Hospital; Clinical Professor, University of California, San Francisco Eric Isaacs is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine Coauthor(s): Peter D'Souza, MD, Clinical Instructor and Attending Physician, Division of Emergency Medicine, Stanford Hospital and Clinics Editors: Edward A Michelson, MD, Program Director, Associate Professor, Department of Emergency Medicine, University Hospital Health Systems in Cleveland; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Robert C Harwood, MD, MPH, Program Director, Chair, Department of Emergency Medicine, Christ Hospital and Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago Medical School; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School Author and Editor Disclosure Synonyms and related keywords: bereavement care, grief support in the ED, grief support in the emergency department, grieving family members, death in the ED, death of a family member in the emergency department INTRODUCTIONSection 2 of 10
  A worried father is brought to a private waiting area. The physician arrives and says, "Your daughter is dead and your wife is in the ICU." Common sense would dictate otherwise, but this approach to delivering bad news occurs regularly in busy EDs where staff are emotionally fatigued and training on grief support is lacking. The ED approach to the support of family and friends of patients who are dead or dying is based on common sense, but an organized framework for speaking with surviving family members and friends will ease the process for all concerned. Additionally, information may be needed from family members, such as the patient's wishes or their wishes with regard to organ donation or autopsy. Having a rehearsed, systematic, and consistent approach to the situation of grief in the ED is helpful to both the practitioner and the family. ED personnel are entrusted not only with the care of the patient but also with family members. Many studies show that an unhealthy grief response may lead to increased morbidity and mortality among grieving family members. Words and actions of ED staff have a tremendous impact on the grief process; the family gives tremendous weight to the words they hear, often remembering them for the rest of their lives. A survey found that when a loved one died, 70% of survivors felt they had received good care in the ED, but the other 30% complained that staff members were nervous, evasive, guilty, cold, and clinical in their interactions. Death in the ED takes its toll on staff and family. The death of a patient produces feelings of guilt, anger, and a sense of failure. Staff may be reminded of personal losses or threatened losses. Over time, ED staff develop emotional defenses to minimize discomfort, and, in extreme cases, develop cynicism, numbness, and professional dissatisfaction. Specific education and training can help health care workers deal with feelings about suffering, disappointment, failure, and death in a satisfactory way. For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education article Grief and Bereavement. WHY IS DEATH DIFFERENT IN THE ED?Section 3 of 10
Emergency physicians (EPs) see more death experiences than any group except oncologists. In 2004, 176,000 deaths occurred in US emergency departments. Yet, one third of EPs surveyed in 1993 reported no specific residency training to help them with the emotions of caring for dying patients. The ED presents special challenges because of its setting and type of patients. Often, family is present when a patient dies in the ED; EPs notify families 75% of the time. In an inpatient ward, doctors notify the family in person 20% of the time. The comfort provided to the family and physician by an existing physician-patient relationship may be missing in the ED because the hospital, physician, and staff most often are unfamiliar and may not have the family's full confidence. Deaths in the ED often are sudden and unexpected; neither family nor staff has any opportunity to prepare for the death or the interactions that follow. In one study, only 7% of deaths were unexpected in the inpatient setting. The amount of time an EP can spend with a bereaved family may be limited because unexpected deaths typically bring ordinary patient care activities to a standstill. When a resuscitation effort is stopped, other patients waiting a long time must be evaluated. The physician can feel a tremendous pressure to get back to work. The ED is where medical staff are most likely to encounter the death of a child. In children who do not survive their first year of life, sudden infant death syndrome (SIDS) accounts for one third of deaths. Trauma accounts for half of deaths in children aged 1-15 years. These factors make the ED a unique place with particularly difficult conditions in which physicians and other staff must deal with death and dying. FRAMEWORK FOR CARE OF THE BEREAVED FAMILYSection 4 of 10
Providing care to bereaved family and friends of a patient who dies in the ED includes many components. Preparation Before facing the family, personal issues of guilt, failure, and fear of death must be privately faced and personally acknowledged; if not they interfere with effective communication. The family wants, and has a right to expect, a calm and professional demeanor from the treating physician. To avoid presenting a cold clinical impression, caregivers must make a transition from medical crisis to the process of responding to a family's emotional trauma. Before speaking to the family, prepare notes summarizing, in chronological order, the illness and the patient's response to treatment efforts and procedures. Seek out pertinent information regarding the identity of family members. Enlist the assistance of a nurse, chaplain, or social worker to share the emotional demands of the encounter. If a language barrier exists, attempt to obtain a translator from outside the family and prepare the translator. If a family member is the only translator, acknowledge how difficult a task it is to hear bad news about a loved one and to explain the news to someone else. When family is not present In many EDs, a social worker or nurse makes the initial contact when family members are not present. How much information should be divulged at the time of the initial call is not always clear. One approach is as follows: Give your name, the hospital's name, and the patient's name over the phone. Verify that the person on the telephone is a relative (or responsible close friend) of the patient. Ask what the person already knows. Give a brief description of events and treatment using understandable terminology. Recognize that family members usually imagine the worst (eg, their loved one is in pain, terrified, or otherwise suffering). Try to reassure the family using calm, relaxed, professional tones. If the patient is alive, explain the current condition. If the patient is dead, a decision to divulge this information over the telephone must be made. No clear-cut consensus among experts exists. Some providers place truthful immediate notification above competing concerns. Others feel that death-telling should be done in person, where additional resources may be used to help the grieving family. Make sure family members understand what has been said. Solicit questions and repeat what is necessary. Find out whether anyone is available to give support; encourage family members to call a friend to drive or offer to call a taxi. Give directions to the hospital, have the family report to you, and tell them not to drive dangerously on the way to the hospital. If the family must be notified of a death over the phone, find out early in the conversation if another adult is present. If necessary, give the same directions to the adult responding. When family arrives in the ED If possible, the family should be greeted by a staff member who can remain with them throughout their stay in the ED. Many families have expressed anger and feelings of helplessness when initially seated in a waiting room and then ignored. If possible, show the family to a private room with access to phone, tissues, and writing materials. Condition updates Keeping the family updated on the status of the patient while a resuscitation effort is underway is important because omission is a frequent complaint. Balancing the needs of the patient and the family can be difficult. Usually, someone can be sent to the family with a message of explanation that includes intubation, defibrillation, and invasive procedures. In some centers, family members have been permitted to attend the resuscitation effort. This practice can introduce new difficulties, but it is becoming increasingly accepted, particularly in pediatric cases. The subject of family presence during the resuscitation is addressed later in this article (see Family presence during resuscitations). Telling of death A few basic concepts can be adapted to fit the personal style and preferences of each individual caregiver. The physician attending the dying patient has the responsibility to tell the family of the patient's death. This responsibility should not be delegated unless absolutely necessary, as the presence of the responsible physician is an important way of communicating to the family that the care of their loved one was taken seriously and that everything possible was done. Without sufficient time for interaction, communicating about death in a careful and caring way is difficult. In a survey of provider practice, the average time allotted for telling of death was 15 minutes. Some providers reported that they spend as little as one minute with the family after a patient dies. The manner in which the news is delivered is very important. The medical facts are less important than compassion. Survivors have said they would rather be informed by a nurse who seemed to care that their loved one had died than to be told by a physician who was knowledgeable about the facts but who seemed not to care. Whenever possible, all family members should be informed as a group. Unless the family decides otherwise, friends should be asked to wait outside the room until the family has been notified. Unless the situation is hostile, move away from the door. If possible, make sure everyone is seated, including the health care team. The team members should be introduced and family members should be explicitly identified. Begin by asking family members their perspective of what happened. If additional history is needed, this is an appropriate time to request it. Obtaining any historical information may become impossible to obtain after the death has been acknowledged. Briefly, in chronological order, tell problems that occurred, actions taken and the patient's response to each intervention. Include the efforts of rescue squads. The gentle and gradual delivery of factual information facilitates an intellectual acknowledgment of death, after which survivors can react with normal grief. Deciding how much detail to give to a family involves a delicate balance. Clinicians sometimes think details are unnecessary and disquieting, but survivors frequently complain that they did not receive explicit enough details of the patient's prehospital and hospital care. To whatever extent possible, reassure the family that the patient did not suffer or did not suffer greatly. Confirm that their family member has died. It is extremely important to be clear by using language such as "dead" or "died." Allow silence. After you have delivered the news, try to say nothing for 30-60 seconds, thus providing time for the family to absorb the information. Ask if the family has any questions, and address each question asked. Family reaction Mourning is a culturally-based expression of grief. Some cultures consider it wrong to show too much emotion. In others, extreme outbursts are expected or required. Family members may react to news of death in different ways, with calm or hysteria, shock, anger, disbelieving, numbness, crying, or even with violence. The response of physicians and medical personnel must be adapted to the needs of the situation. Some common reactions that may need to be addressed include the following:
Viewing the body Viewing the body can be painful but can reduce prolonged grieving by creating an increased sense of the reality of death. Before allowing viewing, blood should be wiped from the body, eyes closed, and resuscitation debris removed. Any devices that must be left in place for a medical examiner's review should be properly explained before they are seen. Rather than disturbing the family, their presence may actually reassure them that everything possible was done. When speaking of the dead person, use the person's name, "him," or "her", but never "body" or "it." Warn the family that the patient may look different from their expectations. Give explicit permission to touch the deceased. Families of mutilated patients should be warned carefully, but viewing still should be offered. Bandaging the injured area can minimize the need for family members to confront the fact of disfigurement. If possible, some whole body area should be available for the family to touch. Viewing can be done in a group or individually. If possible, it should take place in a private place away from the treatment area. Initially, somebody should accompany the family to view the body. If privacy is desired, the person may withdraw but remain nearby. Children should be allowed to view the body if the family agrees. Reluctant or unwilling family members should be reassured that viewing is a highly personal decision and that a decision not to view the deceased person may be best for many people. If the patient was a child, after wrapping in a blanket or dressing in pajamas, parents should be given the opportunity to hold the child. When parents are brought to see their deceased child, an attendant should be present, as this reduces additional grief. Concluding process Give the family an opportunity to ask last-minute questions and leave the door open for future contact. A business card will give them a contact in case questions should arise in the next few days. Several issues should be addressed before they leave the ED.
RED FLAGS: SCENARIOS OF CONCERNSection 5 of 10
Certain situations and presentations give rise to heightened concern for the safety and well being of survivors or staff. These situations may call for immediate intervention or efforts to arrange increased support.
When there are special concerns, possible interventions should include psychiatric consultation, short-term hospitalization, placing a helper with the family, arranging follow-up counseling, and calling out-of-town relatives to assist. FAMILY PRESENCE DURING RESUSCITATIONSSection 6 of 10
Family members have been invited to attend the resuscitation effort with increasing frequency in some centers, particularly in pediatric cases. The presence of family members in a tense and often chaotic resuscitation room is controversial, with strong arguments both in favor of and opposing the practice. Hospital surveys show physicians are generally more likely than nurses to oppose family presence, with less experienced physicians objecting more. Common reasons cited for opposing the practice include increased stress during an already demanding situation, risk of family interference, and medicolegal concerns. Proponents of the practice cite several arguments in rebuttal of the opposition. Stress during resuscitations is a very subjective and personal experience, and family presence can have a variable impact on performance. In the Foote Hospital research, 30% of staff members who were surveyed reported feeling hampered in their efforts due to anxiety from being observed. Physical interference by family members has rarely been reported, and almost always occurs in institutions with no formal plan for allowing family presence. Family members who are present during resuscitations may be less likely to pursue legal action when they see that great efforts were taken and everything was done to help save their The presence of family members during resuscitation remains controversial. While the American College of Emergency Physicians does not have a formal policy on the practice, they recommend each ED create their own policy. Recent surveys indicate only approximately 5% of hospitals in the United States have formal policies on family presence. The 2000 American Heart Association guidelines support the option for family members to be present. Formal programs can help create a more structured setting for an otherwise potentially chaotic situation. Hospitals wishing to create a program should designate a staff member to help assess a family's suitability and wishes, help prepare the family members for what they will see, explain the process when they are in the room, and provide support before, during, and after the experience. SPECIAL POINTS FOR THE DEATH OF CHILDRENSection 7 of 10
Holding the baby Parents need sufficient time to hold and rock their baby for the last time. Sudden infant death syndrome SIDS is a diagnosis made after autopsy and, therefore, cannot be made in the ED. Religious rites Inquiry should be made regarding religious preferences and any religious ceremony the family would like performed. Nursing Nursing mothers should receive information on delactation. The mother's obstetrician should be called. The local La Leche league or SIDS foundation is usually an excellent resource. Siblings Parents often do not know how to inform children of a sibling's death. Initially, parents may want to keep the news from surviving siblings in an attempt to protect them, but this rarely is helpful; parents should be encouraged to take an open and honest approach. Parents should be aware that siblings often feel rejected or may blame themselves for another child's death. Several books have been written to help parents and siblings through the grieving process that follows the death of a child. Mementos Parents may be offered the opportunity to gather mementos, such as a lock of hair, a photograph, or a footprint. PROCEDURES ON NEWLY DEAD PATIENTSSection 8 of 10
Only a decade ago, the practice of using newly dead bodies for training in emergency medicine was thought to be common at most emergency medicine training programs, often without consent. The practice has met with increasing controversy over the last several years as the importance of issues such as disclosure and informed consent at the time of death is better recognized. Approaching a grieving family to obtain consent to perform procedures on a newly dead patient is difficult; debate continues on the necessity or practicality of such a practice. Training in emergency medicine requires learning a variety of procedural skills, many of which are invasive. Some procedures, such as cricothyrotomy and venous cutdown, are essential skills that are rarely encountered during clinical training. Proponents argue newly dead bodies provide the most realistic opportunity for learning invasive procedures and are preferable to training on living patients with no risk of harm or financial cost. Some experts argue that consent should be implied unless specific instructions not to perform procedures exist. They argue that obtaining consent is not feasible and may add to the distress of grieving family members. Others argue that alternative training models are available and that such procedures should not be performed on any patient without consent from the patient before death or from the family at the time of death. Some research into the topic has focused on patient and family attitudes toward using the newly dead. Many adults find the practice to be acceptable and would be willing to have procedures performed on themselves or relatives shortly after death. Supporters of the practice felt like they would be able to contribute to education after they died. However, most feel that some type of consent should be obtained prior to any procedures. Some options have been suggested for providing consent such as provisions in a living will or carrying a card similar to an organ donor card. Other ethical issues also arise from cultural differences in treating the bodies of the newly dead, as certain cultures believe the body is sacred, including after death. Currently, no universal guidelines or official policies exist on the practice. Current practice is variable, with a few institutions having a formal policy and the rest leaving it up to the judgment of the clinician. FUTURE CONTACTSection 9 of 10
What happens in the weeks and months to follow? Many studies suggest increased morbidity and mortality among survivors for at least a year after the death of a loved one. Morbidity may manifest as increased somatic symptoms, increased alcohol and drug use, overt depression, work and social dysfunction, and increased hospitalizations. All of these problems are improved by social support and are less common when a healthy grief process occurs. Several EDs have developed specific grief support programs that have improved staff attitudes and decreased the sense of isolation experienced by survivors. Easy-to-implement efforts that have been particularly well received include sending a sympathy card from the ED team, sending a letter explaining autopsy findings, and making a follow-up call several weeks later to see how they are doing. REFERENCESSection 10 of 10
Grief Support in the ED excerpt Article Last Updated: Jan 14, 2008 |
