Continuing Education Activity

Health professionals frequently deal with the loss of a patient in the emergency department and in intensive care units. These deaths are often due to unforeseen violent circumstances, such as gunshot wounds, motor vehicle accidents, suicides, and homicides. Only after extensive, failed resuscitation attempts will the health professional team end their efforts. This harrowing experience takes not only a physical but emotional toll on the providers, as they are the last hope of survival for the patient. The loss of a patients life reflects immense personal and professional stress and anxiety on the health care team. However, they must put aside their grief to disclose the bad news to family members of a patient who has died unexpectedly. The clinician likely lacks a prior intimate relationship with the family. This lack of familiarity makes it important for health providers to be aware of and ready for various emotional reactions from the family so that he or she can alleviate extended grief and bereavement. This activity reviews the management of the grieving family and highlights the role of the interprofessional team in helping the family through the stressful event of losing a loved one.

Objectives:

• Explain how to use the GRIEV_ING mnemonic.
• Illustrate common grief reactions that family members who have lost a loved one may have.
• Articulate how to support family members experiencing common grief reactions.
• Explain the importance of interprofessional efforts to communicate in a clear and empathetic manner when notifying family members of a patient's death.

Introduction

Physicians frequently deal with the loss of a patient in the emergency department and in intensive care units. These deaths are often due to unforeseen violent circumstances, such as gunshot wounds, motor vehicle accidents, suicides, and homicides. Only after extensive, failed resuscitation attempts will the emergency department team end their efforts. This harrowing experience takes not only a physical but emotional toll on the providers, as they are the last hope of survival for the patient. The loss of a patient’s life reflects immense personal and professional stress and anxiety on the emergency physician. However, they must put aside their grief to disclose the bad news to family members of a patient who has died unexpectedly. The physician likely lacks a prior intimate relationship with the family. This lack of familiarity makes it important that health professionals are aware of and ready for various emotional reactions from the family so that he or she can alleviate extended grief and bereavement.[1][2][3][4][5]

Function

Death Notification

Having a planned approach to the unforeseen circumstances in the ED or hospital is useful for both the family of the deceased and the health professional in charge. The GRIEV_ING mnemonic provides an organized method for concise and accurate death notification; it delivers all the necessary information to the family and is simple to remember for clinicians. 

• Gather (G): Gather the family members and place them in a quiet, private environment. Assist the family and give information to everyone at one time, allowing for optimal support within the family. [6]
• Resources (R): Call for additional support resources available to assist the family (e.g., chaplain services, family ministers, additional family. and friends).  
• Identify (I): Identify yourself. Identify a deceased individual by name. Identify the family's state of knowledge, for example, are they aware of the situation? Will news of death be unexpected? Identify a level of open communication, for example, ask the family members to sit and you sit with them.
• Educate (E): Briefly educate the family about the events that have occurred in the emergency department. Educate them about the current state of their loved one. Educate in thoughtful language and do not use technical terms.
• Verify (V): Verify the death of the family member Be clear by using the words death, died, or dead. Do not use religious phrases to avoid offending family members.
• _ (Space): Stop talking and give the family personal space and time to comprehend what you said.
• Inquire (I): Ask if there are any questions or how you may help.
• Nuts and Bolts (N) Inquire about organ donation, funeral services, and personal belongings. Offer the family the opportunity to view the body. 
• Give (G): Give the family your card and contact information. Offer to answer any questions that may arise later. Always return their call.

Issues of Concern

Reactions to Expect

Reactions of grieving family members often differ. Some common emotional reactions observed during times of grief are feelings of numbness, sadness, anger, hopelessness, irritability, denial, guilt, fear, and anxiety. Some common cognitive reactions are difficulty concentrating, confusion, difficulty making decisions, and disbelief. Some common behavioral reactions are blaming others, avoidance of the situation, and acting out. Stay calm and be respectful of the family of the deceased as individuals express their emotions. If you choose to touch a grieving family member, the shoulders are the most appropriate location.[7]

Clinical Significance

When notifying the family members of patients who died suddenly, it is necessary to provide complete, correct information about the death. An accurate death notification may diminish the tendencies for survivors of the deceased to develop complicated health conditions, such as prolonged grief disorder (PGD) or posttraumatic stress disorder (PTSD).[8][9]

Proper death notification protocols are not only vital for family members but may also reduce adverse physiological and psychological responses experienced by clinicians in such stressful situations. Faced with delivering the difficult news of a patient’s death under their care, clinicians and nurses commonly experience the following: excess cortisol upset and irregular heart rate, combined with feelings of sadness and disappointment resulting in insomnia. This hindrance to attention and concentration will negatively affect the high quality of care expected.

Other Issues

Special Situations

Long Distance Notifications

Proceed with the aforementioned GRIEV_ING mnemonic. If the family of the deceased feel inclined to come to the hospital, request that they are accompanied and make certain someone is accessible to answer any of their questions.

Autopsy and Medical Examiner Cases

Depending on state laws, deaths meeting established criteria must be promptly reported to the medical examiner and coroner. Some examples are unexplained or unusual deaths, homicides or suicides, medical procedure deaths, pediatric deaths, accidents, or unnatural deaths. If a medical examiner and coroner case, resuscitative lines, and tubes must not be removed from the deceased. If the death is not a medical examiner and coroner case, the physician is still obligated to present the family with the opportunity for an autopsy.

Organ Donations

It is not the responsibility of the emergency physician to discuss organ procurement with the family of the deceased. The Joint Commission standards on organ procurement require specific hospital procedures and protocols. This entails the collaboration with organ and tissue procurement organizations. Allow a member of the organization to discuss all information relating to organ and tissue donations with the family of the deceased.

Witnessed Resuscitation

Clinicians should develop procedures that facilitate safe family-witnessed resuscitation efforts. Allowing family members comprehensive, real-time observation on the patient’s situation may provide families with closure, leading to less complicated grief responses. Family members should be escorted out if concerns emerge of them posing a risk to the safety of the healthcare team. [10]

Pediatric Deaths

Pediatric deaths are one of the most taxing situations faced by the team. Protocol for pediatric deaths is different from other deaths, in which clinicians and nurses are to provide a family-centered and team-oriented approach. The family should be allowed to be with the child during resuscitation efforts. The family should also be provided with appropriate resources and family planning. Clinicians should get in contact with the child’s pediatrician and disclose the circumstances of their death so the pediatrician can further support the deceased child’s family. Pediatric deaths meet the criteria to be reported to the Medical Examiner and Coroner. [11]

Enhancing Healthcare Team Outcomes

Complications with the grief and bereavement of family members of the deceased can be minimized with team-oriented care efforts. Physicians collaborating with nurses, social workers, and chaplains enable comprehensive death notification delivery; This interprofessional knowledge sharing provides family members with the additional support and resources needed to ensure proper communication and improved grief support outcomes.  [12]      

Nursing, Allied Health, and Interprofessional Team Interventions

Nurses should assist the family by:

• Acknowledging their feelings. Don’t pretend you understand as the family will appreciate your honesty about how devastating their loss can be.
• Ask questions about their loved one or ask them to tell you a little about their loved one.
• Ask them how you can help and what they may need. Most of the time they will not know but this gives the family the option to open up to you.
• Ask if you can help them connect with those who will provide support.
• Ask if they want to speak with the clinicians and arrange for a time for the family to speak with them.
• Ask if they would like to speak to a pastor or social worker.
• Ask if they would like to be with the deceased and say their goodbyes and do your best to make this time comfortable.
• Ask if they would like thumbprints, handprints, or hair locks.
• Ask if they have any questions about arrangements with the funeral home.
• Ask if they have any other questions.

Acknowledge that you may not know what to say. Families understand that you can't fix the situation. Give the family as much attention as they need but provide private time if needed. Remember to give them additional contacts after they have left the hospital as many are overwhelmed and may not have questions for several hours to days later. Don't be judgemental, remember that different religions and families have a variety of views on death and they may be very different from your own personal views.[13][14][15][16]