The Journal
of Emergency
Medicine,
Vol IO, pp 225-229,
Printed In the USA
1992
Copyright
0 1992 Pergamon
Press Ltd
ON DEATH AND DYING IN THE EMERGENCY DEPARTIWENT Richard F. Edlich, MD, mo,* and Elizabeth Kiibler-Ross,
MD,*
Departments of *Plastic Surgery and *Psychiatry, University of Virginia School of Medicine, Charlottesville, Virginia Reprint Address: Richard F. Ediich, MD, PhD, Department of Plastic Surgery, Unwersity of Virginia Medical Center, Box 332, Charlottesville, VA 22908
the physician was present when the patient was brought into the ED. If no physician is available to give the next of kin the news, they may assume that the physician was not available when the patient arrived. Family members may wonder forever if their loved one might have been saved if the emergency physician had been available.
Several unique features distinguish a patient’s death in the emergency department (ED) from a patient’s expiration in the hospital. One important difference in ED deaths is that they are much more likely to be unexpected by the family. A previous study indicated that 65 % of ED deaths were unexpected as compared with 7% of inpatient deaths (1). Second, the patient and his family are often strangers to the ED staff, while hospitalized patients have become acquainted with the health care staff. Finally, the frequency of dying in the ED is usually greater than that encountered in most hospital settings. The development of hospices in our country has further limited the hospital staffs encounters with the dying patient. These notable differences emphasize the need for comprehensive treatment programs for bereaved families as well as for the ED staff. A functional framework for the care of the bereaved family involves eight steps: 1) selecting the appropriate setting, 2) contacting the family, 3) preparing to speak to the family, 4) death telling, 5) reacting to the family, 6) viewing the body, 7) coordinating the care of the deceased, and 8) planning for follow-up of the bereaved. The emergency physician who attended the dying patient has the ultimate responsibility for telling the family of the patient’s death as well as coordinating the care of the bereaved family (2,3). His presence indirectly acknowledges that he did everything possible to save the patient’s life. If the physician is there to inform the family, the family often concludes that
I. Selecting the Appropriate
Setting
A private setting, office or lounge, for speaking to the bereaved is mandatory. The room should be equipped with a telephone to allow the family to make telephone calls to the relatives, friends, clergy, and funeral home. Use of the hallway as a meeting place makes the family and emergency physician vulnerable to intrusion. The family of the deceased should be taken to this room where they can be told of the patient’s death by the emergency physician. The family should be informed as a group of the patient’s death so that they can mourn together. Even close friends should be asked to wait outside the room until the family is notified of the patient’s death. Unless the family decides otherwise, the discussion of the patient’s death is a private matter.
2. Contacting the Family When the family of the deceased is not in the ED, they are usually contacted by telephone. Consequently, the telephone provides the ED staff with a major communication modality. Because the tele-
This report is dedicated to the graduating Medical School Class of 1993, Charlottesville, Virginia.
Humanities and Medicine provides a venue for essays,poems, and other expressions of the medical humanities. Readers are encouraged to submit articles. This section is coordinated by Richard M. Ratzan, MD, University of Connecticut School of Medicine, Farmington, Connecticut. 0736-4679/92 $5.00 + .OO RECEIVED: 30 July 1991; ACCEPTED: 12 August 1991
=
225
226
phone call is an important first step in dealing with the family’s reaction to death, the person calling should be an experienced emergency physician or nurse who has received training in contacting family members (4). In all telephone contacts, the staff member should clearly state his or her name to the family and the name of the hospital, and then identify the name of family member. Whenever possible, the family members should be informed that their relative is seriously ill or injured and that they should come to the hospital. Someone other than the close relative or family member should drive the car. In most circumstances, the staff should not inform the family of the patient’s death over the telephone. The exceptions to this rule arise either when family members live hundreds or thousands of miles from the hospital or when weather conditions prevent the family from coming to the hospital. In those cases in which it is necessary to inform the family member about the death of a relative over the telephone, the staff member must be sure that the relative has an adult with him who can call for help or assist him if his reaction incapacitates him.
Richard F. Edlich and Elizabeth
KObler-Ross
of the patient’s condition. When relatives are in the ED at the time of the patient’s admission, the nurse may update the family on the process of resuscitation. This concerned communication with family members considerably facilitates death telling. The most direct approach to preparing the family for the outcome of the resuscitation is to ask selected family members if they want to view the resuscitation. While it is standard policy in most EDs to exclude family members from the treatment room during attempted resuscitation of cardiac arrest victims, one hospital has allowed selected family members to be present in the resuscitation room (6). On the basis of a three-year experience, the authors conclude that this practise appears to have benefits for grieving family members and leads to a perception that they have been able to help the person undergoing resuscitation. Such efforts may reduce the mystery associated with “resuscitation,” while assisting family members to gain a realistic view of resuscitation and death. A keystone to the success of this program was a dedicated and interested chaplain staff. 4. Death Telling
3. Preparing to Speak to the Family In preparing to speak to the family, the emergency physician must make a difficult intellectual transition from dealing with medical trauma to responding to the family’s emotional trauma in reaction to the news of the patient’s death (5). There are several effective methods for the emergency physician to prepare himself to deal with this transition. First, the physician must acknowledge and forgive his feeling of limitations in saving the patient’s life. Second, the physician should prepare notes that summarize in chronological order the patient’s illness and his response to treatment and procedures. Third, pertinent information about family members should be obtained, including their identities and their reactions to the patient’s illness or injury. Before entering the conference room, the emergency physician should enlist the assistance of a nurse or social worker who can share the emotional demands of the encounter. This preparatory process, no matter how short, helps the physician develop a calm demeanor that is necessary to communicate effectively with the family. In order to maintain this calm demeanor, the personal issues of guilt, failure, identification, fear of death, and concern with one’s presentation must be managed on some level. The family members may be prepared for death telling by the telephone contact that informed them
After entering the private room, the physician should introduce the health care team to each family member (7). The family members and health care team should be seated, giving the impression that they will remain as long as needed. The physician should allow at least five minutes for interaction with family members when telling them of a death. In many cases, the conversation may be initiated by the physician by asking the family what happened from their perspective. In chronologic order, the physician then tells the family what problems occurred, what actions were taken, and what the patient’s response was in simple terminology. This gentle and gradual factual informative approach in a chronologic manner facilitates an intellectual acknowledgment of death and a more cognitive basis from which to react with normal grief. Certain information may be added to the discussion that is not necessary to the understanding of the cause of death, but may be comforting to the family. Such information might include the valiant resuscitative attempts of rescue squads and that the patient was oblivious to pain and unaware of his injury. 5. Reacting to the Family The grieving process will begin after the survivors are informed of the patient’s death (8). Grief represents
227
On Death and Dying in the ED
intense emotions due to the loss. The expressions of grief will be influenced by the cultural mores. Some individuals will be hysterical with loud crying and sobbing; others will remain calm and cold, with little visible expression of emotion. The initial response for many is one of shock, disbelief, and numbness. Within minutes, the bereaved will display a variety of emotions. Some family members cry, while others react with anger and guilt, In unusual cases, the bereaved may become psychotic or develop a severe anxiety attack. Allowing the bereaved to express feelings is essential. An important part of communication with the bereaved is to accept the grieving process. Of all the attributes in physicians and nurses, none is more highly valued by the family than compassion. Although universally praised as a desirable attribute for the health professional, compassion extracts a personal cost often overlooked in medical education. The emotional price of compassion is the two Latin roots, con and passio, to suffer with another person (9). Through experiential identification with the deceased, the health professional is touched by the tragedy in a literal way. How many physicians and nurses can tolerate the thought of dying? Although they may never convey it precisely in words, some health professionals impart to the family that they are genuinely touched by the death. Presence is more important than words. Most importantly, the physician and nurse who can remain calm and quiet in the presence of weeping, angry, or bitter mourners are highly valued. A gentle touch is worth more than a thousand words. The health care team must avoid nullifying the family’s grieving (9). Clichts (“It’s God’s Will”), irrelevant reassurances (L(You’ve got two other children”), and exhortations (“Life must go on”) must be avoided. As the bereaved struggle to understand the loss of a loved one, their conversations may take different circuitous routes. They may begin an obsessive review of the events leading up to death and raise questions regarding the circumstances of the death. This questioning may lead to accusations that the staff was negligent and did not do all that was possible to save the patient’s life. The physician should be prepared to listen to these accusations without being defensive, guilty, or displaying acts of personal contrition. Ultimately, these angry feelings will resolve into feelings of sadness. A frequent initial reaction is one of denial. The bereaved may ask for proof of identity of the deceased or may refer to the deceased as if he were alive. This initial failure to accept reality should be tolerated patiently, allowing denial to give way to
reality. A request by the relatives to view the body is welcomed by physicians who believe that viewing the body is a way of accepting death.
6. Viewing the Body
Viewing the body facilitates the grief reaction and avoids prolonged grieving and disbelief about the patient’s death (2). The chance to view the body, even when mutilated, should be offered to the family members. If severe mutilation is present, they should be carefully warned. However, bandaging the injured area can minimize the disfigurement. The deceased patient’s eyes should be closed, blood wiped from the body, and all debris from the resuscitation removed before the body is viewed by the bereaved family. The body is generally covered and the hands and face left exposed. Tubes and catheters must be left in place in most states until the coroner or medical examiner has completed any necessary postmortem examination. These devices may provide some comfort to the family, providing further assurance that everything possible had been done to save the patient’s life. Children may also need to view the body if an older member of the family agrees to the request. When the bereaved are reluctant or unwilling to view the body, they should not be made to feel that their decision is wrong. In any event, a physician, nurse, or clergy should always accompany family members who wish to view the body. Viewing may be done as a group or in sequence by individuals. A family member may need to be left alone with the body of the deceased. Small moments of privacy in such a situation are often very important to family members. A staff member should remain nearby, just outside the room, to be available for additional support. The deceased should not be referred to as “the body” or “it,” but should be called by name.
7. Coordinating the Care of the Deceased, and 8. Planning for Follow-up of the Bereaved
After viewing of the body, the emergency physician should be available to answer any further questions. An immediate offer of medication to bereaved family members is not advisable (2). Rather than medications, verbal support and gestures of reassurance, such as placing a hand on the shoulder or arm, are often sufficient to calm a distraught family member. After the spouse of the deceased has communicated with the emergency physician, arrangements should
228
be made for someone to stay with the spouse for the next 24 to 48 hours. Because suicide is a real consideration for the spouse of the deceased, this individual should never go home alone. Survivors have been reported to commit suicide within 48 hours after the loss of a spouse, an act of desperation and grief that could have been prevented by the support of a family member (4). Support from another person permits ventilation of grief, expression of desperation, thoughts of suicide, and feelings of guilt. Discussing these feelings usually prevents people from acting on them. Before the family leaves the ED, there are other important decisions. The family or their clergy must contact the funeral home. A request for autopsy may be made to obtain definitive information for the benefit of the family and physician. The thought of autopsy may be as traumatic to the physician as to the family members (l,lO), but the physician must overcome this aversion in order to alleviate that of the family member. By referring to an autopsy as an examination after death, the physician stresses its diagnostic value. If the physician knows the family’s concerns, he may state that definitive knowledge may ease the family’s uncertainty or worry about the cause of death. It is comforting to tell the family that the physician performing this examination is a specialist with unique diagnostic skills (2). It also can provide valuable information for surviving children. The autopsy agreement should obligate the physician to share the results of the examination in a way that is understandable to the bereaved. The request for organs for transplants may be another uncomfortable part of dealing with the bereaved (11). The bereaved family will obviously be much more receptive to this request if they have good rapport with the medical staff. The physician making the request should avoid potentially offensive or misleading terminology. Terms such as “life support” and “brain death” may imply that life still exists. The word “death” should be used with the greatest clarity. “Harvest” should be replaced by the word “recovery” or “donation.” This decision is considerably facilitated if the deceased had completed his organ donor card or a living will. Once the family agrees to organ transplantation from the deceased, the transplant coordinator should be notified. The transplant coordinator will coordinate organ transplantation and provide follow-up information to the bereaved of their “gift of life,” which may provide some consolation to the loved ones. Leaving the door open for future contact is welcome to the bereaved. There is a need for greater
Richard F. Edlich and Elizabeth
KObler-Ross
family support at the time of the patient’s death. Several studies have reported increased morbidity and mortality in family members following a patient’s death (12-16). Morbidity and mortality are increased for a year or longer following the death. Their suffering may be manifest by increased somatic symptoms, drug and alcohol use, hospitalization, and even death. It is to be anticipated that the bereaved will continue to reflect on his feelings toward the deceased, examine his own wounds, and confront the task of continuing life without the deceased. To address the survivor’s needs, one hospital began a program in which the family receives a sympathy card from the staff who cared for their loved one (17). Follow-up telephone calls are made to the family throughout the year after the death. A letter is sent from the attending physician explaining the autopsy findings. The response of the families to this followup is very positive. Health professionals who attend the dying are not immune to discomfort. A dying person poses a threat to the health professional’s own human attachments. First, he realizes his own limitations. Second, the loss of a patient reminds him of his own past losses and of threatened losses. Because of the repeated stresses presented by these threats, health professionals develop defenses. One approach is to avoid involvement with patients in order to minimize personal loss or discomfort. What can be done to reduce this defensiveness of health professionals? Systematic educational training programs need to be undertaken to help health personnel deal with their feelings about suffering, disappointment, failure, and death (9). Ideally, these programs should be instituted early in training, so that repeated exposures to dying can be accompanied by emotional growth with its major features, compassion and equanimity. Education about death and dying should be incorporated into the medical school curriculum. Faculty should discuss all aspects of patient death, including anticipation and coping skills, death notification, and guidance of the bereaved. Open discussions of the emotional impact of patient death on health care providers should be an integral part of the education program. When we view the shadow of death, we face our own mortality and appreciate that life is finite. The dying person develops deeper meanings and priorities for his life, because he can no longer postpone opportunities. Consequently, he must make the most of every minute. Health professionals who care for the dying patient have the unrivaled opportunity to examine what makes life meaningful. As we share
229
On Death and Dying in the ED
our insights on dying, we fortuitously discover the joys of unconditional love in a glorious journey through life. For many physicians, problems of living become so complicated and overwhelming that this contemplation of our death may serve as an emotional rebirth, revitalizing our suppressed ambitions
and passions, and bringing to our lives new dimensions and meanings. by a generous gift from the Texaco Philanthropic Foundation, White Plains, New York.
Acknowledgment-Supported
REFERENCES 1. Tolle SW, Bascom PB, Hickam DH, Benson JA Jr. Communication between physicians and surviving spouses following patient deaths. J Gen Intern Med. 1986;1:309-14. 2. Kiibler-Ross E. Living with death and dying. New York: MacMillian; 1981:160-81. 3. Creek LV. How to tell the family that the patient has died. Postgrad Med. 1980;68:207-9. 4. Rund DA, Hutzler JC. Psychiatric emergencies associated with death. Emerg Psychiatr. 1983:231-41. 5. Robinson MA. Informing the family of sudden death. Am Fam Physician. 1981;23:115-18. 6. Doyle CJ, Post H, Burney RE, Maino J, Keele M, Rhee KJ. Family participation during resuscitation: an option. Ann Emerg Med. 1987;16:673-5. 7. Clark RE, LeBeff EE. Death telling: managing the delivery of bad news. J Health Sot Behav. 1982;23:366-80. 8. Dubin WR, Sarnoff JR. Sudden unexpected death: intervention with survivors. Ann Emerg Med. 1986;15:54-7. 9. Cassem NH. Treating the person confronting death. In: Nicoli AM, ed. The Harvard guide to modern psychiatry. 1978:579606.
10. Gall EW. The necropsy as a tool in medical progress. Bull NY Acad Med. 1968;44:808-29. 11. Randall T, Marwick C. Physicians’ attitudes and approaches are pivotal in procuring organs for transplantation. JAMA. 1991;265:1227-8. 12. Parkes CM. Effects of bereavement on physical and mental health-a study of the medical records of widows. Br Med J (Clin Res). 1964;2:274-9. 13. Parkes CM. The first year of bereavement: a longitudinal study of the reaction of London widows to the death of their husbands. Psychiatry. 1971;33:444-67. 14. Parkes, CM, Brown RJ. Health and bereavement: a controlled study of young Boston widows and widowers. Psychiatr Med. 1972;34:449-61, 15. Clayton PJ. Mortality and morbidity in the first year of widowhood. Arch Gen Psychiatr. 1974;30:747-50. 16. Helsing KJ, Saklo M. Mortality after bereavement. Epidmiol Rev. 1981;114:41-52. 17. Schmidt TA, Tolle SW. Emergency physicians’ responses to families following patient death. Ann Emerg Med. 1990;19: 125-8.
of Emergency
Medicine,
Vol IO, pp 225-229,
Printed In the USA
1992
Copyright
0 1992 Pergamon
Press Ltd
ON DEATH AND DYING IN THE EMERGENCY DEPARTIWENT Richard F. Edlich, MD, mo,* and Elizabeth Kiibler-Ross,
MD,*
Departments of *Plastic Surgery and *Psychiatry, University of Virginia School of Medicine, Charlottesville, Virginia Reprint Address: Richard F. Ediich, MD, PhD, Department of Plastic Surgery, Unwersity of Virginia Medical Center, Box 332, Charlottesville, VA 22908
the physician was present when the patient was brought into the ED. If no physician is available to give the next of kin the news, they may assume that the physician was not available when the patient arrived. Family members may wonder forever if their loved one might have been saved if the emergency physician had been available.
Several unique features distinguish a patient’s death in the emergency department (ED) from a patient’s expiration in the hospital. One important difference in ED deaths is that they are much more likely to be unexpected by the family. A previous study indicated that 65 % of ED deaths were unexpected as compared with 7% of inpatient deaths (1). Second, the patient and his family are often strangers to the ED staff, while hospitalized patients have become acquainted with the health care staff. Finally, the frequency of dying in the ED is usually greater than that encountered in most hospital settings. The development of hospices in our country has further limited the hospital staffs encounters with the dying patient. These notable differences emphasize the need for comprehensive treatment programs for bereaved families as well as for the ED staff. A functional framework for the care of the bereaved family involves eight steps: 1) selecting the appropriate setting, 2) contacting the family, 3) preparing to speak to the family, 4) death telling, 5) reacting to the family, 6) viewing the body, 7) coordinating the care of the deceased, and 8) planning for follow-up of the bereaved. The emergency physician who attended the dying patient has the ultimate responsibility for telling the family of the patient’s death as well as coordinating the care of the bereaved family (2,3). His presence indirectly acknowledges that he did everything possible to save the patient’s life. If the physician is there to inform the family, the family often concludes that
I. Selecting the Appropriate
Setting
A private setting, office or lounge, for speaking to the bereaved is mandatory. The room should be equipped with a telephone to allow the family to make telephone calls to the relatives, friends, clergy, and funeral home. Use of the hallway as a meeting place makes the family and emergency physician vulnerable to intrusion. The family of the deceased should be taken to this room where they can be told of the patient’s death by the emergency physician. The family should be informed as a group of the patient’s death so that they can mourn together. Even close friends should be asked to wait outside the room until the family is notified of the patient’s death. Unless the family decides otherwise, the discussion of the patient’s death is a private matter.
2. Contacting the Family When the family of the deceased is not in the ED, they are usually contacted by telephone. Consequently, the telephone provides the ED staff with a major communication modality. Because the tele-
This report is dedicated to the graduating Medical School Class of 1993, Charlottesville, Virginia.
Humanities and Medicine provides a venue for essays,poems, and other expressions of the medical humanities. Readers are encouraged to submit articles. This section is coordinated by Richard M. Ratzan, MD, University of Connecticut School of Medicine, Farmington, Connecticut. 0736-4679/92 $5.00 + .OO RECEIVED: 30 July 1991; ACCEPTED: 12 August 1991
=
225
226
phone call is an important first step in dealing with the family’s reaction to death, the person calling should be an experienced emergency physician or nurse who has received training in contacting family members (4). In all telephone contacts, the staff member should clearly state his or her name to the family and the name of the hospital, and then identify the name of family member. Whenever possible, the family members should be informed that their relative is seriously ill or injured and that they should come to the hospital. Someone other than the close relative or family member should drive the car. In most circumstances, the staff should not inform the family of the patient’s death over the telephone. The exceptions to this rule arise either when family members live hundreds or thousands of miles from the hospital or when weather conditions prevent the family from coming to the hospital. In those cases in which it is necessary to inform the family member about the death of a relative over the telephone, the staff member must be sure that the relative has an adult with him who can call for help or assist him if his reaction incapacitates him.
Richard F. Edlich and Elizabeth
KObler-Ross
of the patient’s condition. When relatives are in the ED at the time of the patient’s admission, the nurse may update the family on the process of resuscitation. This concerned communication with family members considerably facilitates death telling. The most direct approach to preparing the family for the outcome of the resuscitation is to ask selected family members if they want to view the resuscitation. While it is standard policy in most EDs to exclude family members from the treatment room during attempted resuscitation of cardiac arrest victims, one hospital has allowed selected family members to be present in the resuscitation room (6). On the basis of a three-year experience, the authors conclude that this practise appears to have benefits for grieving family members and leads to a perception that they have been able to help the person undergoing resuscitation. Such efforts may reduce the mystery associated with “resuscitation,” while assisting family members to gain a realistic view of resuscitation and death. A keystone to the success of this program was a dedicated and interested chaplain staff. 4. Death Telling
3. Preparing to Speak to the Family In preparing to speak to the family, the emergency physician must make a difficult intellectual transition from dealing with medical trauma to responding to the family’s emotional trauma in reaction to the news of the patient’s death (5). There are several effective methods for the emergency physician to prepare himself to deal with this transition. First, the physician must acknowledge and forgive his feeling of limitations in saving the patient’s life. Second, the physician should prepare notes that summarize in chronological order the patient’s illness and his response to treatment and procedures. Third, pertinent information about family members should be obtained, including their identities and their reactions to the patient’s illness or injury. Before entering the conference room, the emergency physician should enlist the assistance of a nurse or social worker who can share the emotional demands of the encounter. This preparatory process, no matter how short, helps the physician develop a calm demeanor that is necessary to communicate effectively with the family. In order to maintain this calm demeanor, the personal issues of guilt, failure, identification, fear of death, and concern with one’s presentation must be managed on some level. The family members may be prepared for death telling by the telephone contact that informed them
After entering the private room, the physician should introduce the health care team to each family member (7). The family members and health care team should be seated, giving the impression that they will remain as long as needed. The physician should allow at least five minutes for interaction with family members when telling them of a death. In many cases, the conversation may be initiated by the physician by asking the family what happened from their perspective. In chronologic order, the physician then tells the family what problems occurred, what actions were taken, and what the patient’s response was in simple terminology. This gentle and gradual factual informative approach in a chronologic manner facilitates an intellectual acknowledgment of death and a more cognitive basis from which to react with normal grief. Certain information may be added to the discussion that is not necessary to the understanding of the cause of death, but may be comforting to the family. Such information might include the valiant resuscitative attempts of rescue squads and that the patient was oblivious to pain and unaware of his injury. 5. Reacting to the Family The grieving process will begin after the survivors are informed of the patient’s death (8). Grief represents
227
On Death and Dying in the ED
intense emotions due to the loss. The expressions of grief will be influenced by the cultural mores. Some individuals will be hysterical with loud crying and sobbing; others will remain calm and cold, with little visible expression of emotion. The initial response for many is one of shock, disbelief, and numbness. Within minutes, the bereaved will display a variety of emotions. Some family members cry, while others react with anger and guilt, In unusual cases, the bereaved may become psychotic or develop a severe anxiety attack. Allowing the bereaved to express feelings is essential. An important part of communication with the bereaved is to accept the grieving process. Of all the attributes in physicians and nurses, none is more highly valued by the family than compassion. Although universally praised as a desirable attribute for the health professional, compassion extracts a personal cost often overlooked in medical education. The emotional price of compassion is the two Latin roots, con and passio, to suffer with another person (9). Through experiential identification with the deceased, the health professional is touched by the tragedy in a literal way. How many physicians and nurses can tolerate the thought of dying? Although they may never convey it precisely in words, some health professionals impart to the family that they are genuinely touched by the death. Presence is more important than words. Most importantly, the physician and nurse who can remain calm and quiet in the presence of weeping, angry, or bitter mourners are highly valued. A gentle touch is worth more than a thousand words. The health care team must avoid nullifying the family’s grieving (9). Clichts (“It’s God’s Will”), irrelevant reassurances (L(You’ve got two other children”), and exhortations (“Life must go on”) must be avoided. As the bereaved struggle to understand the loss of a loved one, their conversations may take different circuitous routes. They may begin an obsessive review of the events leading up to death and raise questions regarding the circumstances of the death. This questioning may lead to accusations that the staff was negligent and did not do all that was possible to save the patient’s life. The physician should be prepared to listen to these accusations without being defensive, guilty, or displaying acts of personal contrition. Ultimately, these angry feelings will resolve into feelings of sadness. A frequent initial reaction is one of denial. The bereaved may ask for proof of identity of the deceased or may refer to the deceased as if he were alive. This initial failure to accept reality should be tolerated patiently, allowing denial to give way to
reality. A request by the relatives to view the body is welcomed by physicians who believe that viewing the body is a way of accepting death.
6. Viewing the Body
Viewing the body facilitates the grief reaction and avoids prolonged grieving and disbelief about the patient’s death (2). The chance to view the body, even when mutilated, should be offered to the family members. If severe mutilation is present, they should be carefully warned. However, bandaging the injured area can minimize the disfigurement. The deceased patient’s eyes should be closed, blood wiped from the body, and all debris from the resuscitation removed before the body is viewed by the bereaved family. The body is generally covered and the hands and face left exposed. Tubes and catheters must be left in place in most states until the coroner or medical examiner has completed any necessary postmortem examination. These devices may provide some comfort to the family, providing further assurance that everything possible had been done to save the patient’s life. Children may also need to view the body if an older member of the family agrees to the request. When the bereaved are reluctant or unwilling to view the body, they should not be made to feel that their decision is wrong. In any event, a physician, nurse, or clergy should always accompany family members who wish to view the body. Viewing may be done as a group or in sequence by individuals. A family member may need to be left alone with the body of the deceased. Small moments of privacy in such a situation are often very important to family members. A staff member should remain nearby, just outside the room, to be available for additional support. The deceased should not be referred to as “the body” or “it,” but should be called by name.
7. Coordinating the Care of the Deceased, and 8. Planning for Follow-up of the Bereaved
After viewing of the body, the emergency physician should be available to answer any further questions. An immediate offer of medication to bereaved family members is not advisable (2). Rather than medications, verbal support and gestures of reassurance, such as placing a hand on the shoulder or arm, are often sufficient to calm a distraught family member. After the spouse of the deceased has communicated with the emergency physician, arrangements should
228
be made for someone to stay with the spouse for the next 24 to 48 hours. Because suicide is a real consideration for the spouse of the deceased, this individual should never go home alone. Survivors have been reported to commit suicide within 48 hours after the loss of a spouse, an act of desperation and grief that could have been prevented by the support of a family member (4). Support from another person permits ventilation of grief, expression of desperation, thoughts of suicide, and feelings of guilt. Discussing these feelings usually prevents people from acting on them. Before the family leaves the ED, there are other important decisions. The family or their clergy must contact the funeral home. A request for autopsy may be made to obtain definitive information for the benefit of the family and physician. The thought of autopsy may be as traumatic to the physician as to the family members (l,lO), but the physician must overcome this aversion in order to alleviate that of the family member. By referring to an autopsy as an examination after death, the physician stresses its diagnostic value. If the physician knows the family’s concerns, he may state that definitive knowledge may ease the family’s uncertainty or worry about the cause of death. It is comforting to tell the family that the physician performing this examination is a specialist with unique diagnostic skills (2). It also can provide valuable information for surviving children. The autopsy agreement should obligate the physician to share the results of the examination in a way that is understandable to the bereaved. The request for organs for transplants may be another uncomfortable part of dealing with the bereaved (11). The bereaved family will obviously be much more receptive to this request if they have good rapport with the medical staff. The physician making the request should avoid potentially offensive or misleading terminology. Terms such as “life support” and “brain death” may imply that life still exists. The word “death” should be used with the greatest clarity. “Harvest” should be replaced by the word “recovery” or “donation.” This decision is considerably facilitated if the deceased had completed his organ donor card or a living will. Once the family agrees to organ transplantation from the deceased, the transplant coordinator should be notified. The transplant coordinator will coordinate organ transplantation and provide follow-up information to the bereaved of their “gift of life,” which may provide some consolation to the loved ones. Leaving the door open for future contact is welcome to the bereaved. There is a need for greater
Richard F. Edlich and Elizabeth
KObler-Ross
family support at the time of the patient’s death. Several studies have reported increased morbidity and mortality in family members following a patient’s death (12-16). Morbidity and mortality are increased for a year or longer following the death. Their suffering may be manifest by increased somatic symptoms, drug and alcohol use, hospitalization, and even death. It is to be anticipated that the bereaved will continue to reflect on his feelings toward the deceased, examine his own wounds, and confront the task of continuing life without the deceased. To address the survivor’s needs, one hospital began a program in which the family receives a sympathy card from the staff who cared for their loved one (17). Follow-up telephone calls are made to the family throughout the year after the death. A letter is sent from the attending physician explaining the autopsy findings. The response of the families to this followup is very positive. Health professionals who attend the dying are not immune to discomfort. A dying person poses a threat to the health professional’s own human attachments. First, he realizes his own limitations. Second, the loss of a patient reminds him of his own past losses and of threatened losses. Because of the repeated stresses presented by these threats, health professionals develop defenses. One approach is to avoid involvement with patients in order to minimize personal loss or discomfort. What can be done to reduce this defensiveness of health professionals? Systematic educational training programs need to be undertaken to help health personnel deal with their feelings about suffering, disappointment, failure, and death (9). Ideally, these programs should be instituted early in training, so that repeated exposures to dying can be accompanied by emotional growth with its major features, compassion and equanimity. Education about death and dying should be incorporated into the medical school curriculum. Faculty should discuss all aspects of patient death, including anticipation and coping skills, death notification, and guidance of the bereaved. Open discussions of the emotional impact of patient death on health care providers should be an integral part of the education program. When we view the shadow of death, we face our own mortality and appreciate that life is finite. The dying person develops deeper meanings and priorities for his life, because he can no longer postpone opportunities. Consequently, he must make the most of every minute. Health professionals who care for the dying patient have the unrivaled opportunity to examine what makes life meaningful. As we share
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On Death and Dying in the ED
our insights on dying, we fortuitously discover the joys of unconditional love in a glorious journey through life. For many physicians, problems of living become so complicated and overwhelming that this contemplation of our death may serve as an emotional rebirth, revitalizing our suppressed ambitions
and passions, and bringing to our lives new dimensions and meanings. by a generous gift from the Texaco Philanthropic Foundation, White Plains, New York.
Acknowledgment-Supported
REFERENCES 1. Tolle SW, Bascom PB, Hickam DH, Benson JA Jr. Communication between physicians and surviving spouses following patient deaths. J Gen Intern Med. 1986;1:309-14. 2. Kiibler-Ross E. Living with death and dying. New York: MacMillian; 1981:160-81. 3. Creek LV. How to tell the family that the patient has died. Postgrad Med. 1980;68:207-9. 4. Rund DA, Hutzler JC. Psychiatric emergencies associated with death. Emerg Psychiatr. 1983:231-41. 5. Robinson MA. Informing the family of sudden death. Am Fam Physician. 1981;23:115-18. 6. Doyle CJ, Post H, Burney RE, Maino J, Keele M, Rhee KJ. Family participation during resuscitation: an option. Ann Emerg Med. 1987;16:673-5. 7. Clark RE, LeBeff EE. Death telling: managing the delivery of bad news. J Health Sot Behav. 1982;23:366-80. 8. Dubin WR, Sarnoff JR. Sudden unexpected death: intervention with survivors. Ann Emerg Med. 1986;15:54-7. 9. Cassem NH. Treating the person confronting death. In: Nicoli AM, ed. The Harvard guide to modern psychiatry. 1978:579606.
10. Gall EW. The necropsy as a tool in medical progress. Bull NY Acad Med. 1968;44:808-29. 11. Randall T, Marwick C. Physicians’ attitudes and approaches are pivotal in procuring organs for transplantation. JAMA. 1991;265:1227-8. 12. Parkes CM. Effects of bereavement on physical and mental health-a study of the medical records of widows. Br Med J (Clin Res). 1964;2:274-9. 13. Parkes CM. The first year of bereavement: a longitudinal study of the reaction of London widows to the death of their husbands. Psychiatry. 1971;33:444-67. 14. Parkes, CM, Brown RJ. Health and bereavement: a controlled study of young Boston widows and widowers. Psychiatr Med. 1972;34:449-61, 15. Clayton PJ. Mortality and morbidity in the first year of widowhood. Arch Gen Psychiatr. 1974;30:747-50. 16. Helsing KJ, Saklo M. Mortality after bereavement. Epidmiol Rev. 1981;114:41-52. 17. Schmidt TA, Tolle SW. Emergency physicians’ responses to families following patient death. Ann Emerg Med. 1990;19: 125-8.
