death notification for paramedics

Death Notification for Paramedics

Greg Soto, BA, ACP

Education Coordinator, Niagara Base Hospital

David Cooke, ACP

Sunnybrook-Osler Base Hospital

Presentation developed for TOR Study Group

ONTARIOBASE HOSPITAL GROUP

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OBHG Education Subcommittee

Introduction: Quote

“Life is a fatal condition with a 100% chance of mortality”

- anonymous


Objectives

Introduction Medical futilityMastering resuscitation with survivors in mindFamily acceptance of field pronouncement

Patient fit for TOR ruleGrief and sudden unexpected deathDelivering the death notificationSupporting survivorsHelpful/hurtful phrasesCultural diversity and grief


Introduction: Saves? What saves?

What is the survival rate from prehospital cardiac arrest in Ontario?

5% (OPALS)

US 2 - 33% (Eisenberg MS and Mengert TJ, 2001)


Introduction: Saves? What saves?

If 95 % of cardiac arrest patients do not survive to hospital discharge, who are the real patients at these scenes?


Introduction: Just who is our patient?

The forgotten ‘patients’ at resuscitation scenes are often the families, loved ones and friends of the cardiac arrest victim.

In short – the survivors, for whom the experience will live on, often for the remainder of their lives.


Introduction: Medical Futility

Reasons to reconsider transport of cardiac arrests where continued ED efforts would be futile :

1. Risk

2. Costs

3. Time crew is out of service

4. Paramedics can effectively deliver death notification and support survivors.


Medical Futility: Why stop?

Transporting out-of-hospital cardiac arrest patients who have failed an adequate trial of (prehospital) care creates an unethical act. “How could the same protocols possibly succeed in the ED?” (p. I-17, ACLS Guidelines 2000)


ACLS Guidelines 2000 recommendations in cases of persistent asystole:

During Resuscitation Ask:1. Time to terminate resuscitation efforts?2. Are BLS/ACLS interventions completed? (CPR, defib,

ventilation, oxygenation, IV access, appropriate meds given)

3. Has asystole persisted for several minutes; no specific time criteria but default approach should be shorter time requirements, not longer.

4. Consider differing family attitudes toward stopping efforts. (I-17)

Medical Futility: When to stop?


Medical Futility: When to stop?

NAEMSP, ACEP and AHA:

support field termination under similar circumstances

physician pronouncement

death notification and family support by paramedics

training for paramedics in providing grief support


BE SURE!

Does the patient Does the patient meet the criteria meet the criteria for the TOR for the TOR guideline?guideline?

Shown to be Shown to be >99.5% accurate >99.5% accurate in predicting in predicting medical futility.medical futility.


2. Mastering Resuscitation with Survivors in Mind

a) Know thyself (where are you with death?)“in dealing with death you have to be aware of your own feelings and biases because if you don’t you’ll to wind up dealing with yourself first and other people second” (Iserson, K, Grave Words: Notifying survivors about sudden unexpected deaths)

b) Know thy protocols, skills, drugs (technical proficiency before empathic proficiency)

c) Know where each code may be headed


2. Mastering Resuscitation with Survivors in Mind

d) Inform the survivors throughout code - use nonmedical terminology to explain

e) Involve survivors if possible/practical

f) Prepare the family for possible termination (e.g.: prior to BHP patch)

g) Let the BHP decide termination


Family Acceptance of Field Termination

Does it matter who delivers the news or does it matter how its done?

Is field pronouncement accepted by survivors?

Can paramedics perform death notification and survivor support well?

Is death notification something that can be trained?


Family Acceptance

What is known?

Family members can be accepting of termination of unsuccessful out-of-hospital cardiac arrest.

Satisfaction expressed with emotional support received from EMS.

Many stated they knew the patient was dead when they called 911.

More comfortable grieving at home around family and loved ones.


Family Acceptance

Felt closer to deceasedKnew more about what was happeningSome expressed that deceased would have wanted to die at homeConversely, family members of transported patients:Expressed less positive interactions with EMS & ED staffFelt anxiety in rushing to ED


Family Acceptance

Felt lonely sitting in waiting room waiting for informationFelt futility in going to hospital when patient was often declared quickly

Grief scales:Trend to more positive emotional adjustment for families of nontransported patients VS families of transported patients


Family Acceptance

It mattered less to survivors who delivered death notification – more important was the manner in which news was delivered.

Less rushed, more personal communication appeared to produce a positive perception by bereaved.

Ability of family to be present during resuscitation facilitated their adjustment to death and the grief process.


Family Acceptance

Conclusion

Paramedics:

Informed survivors of death.

Provided answers to questions regarding treatment protocols.

Provided care not only to patient but survivors including grief support.


Grief and sudden unexpected death

Disbelief, even denial, that the deceased is really gone (even common in expected death)

Sense of being lost – not knowing what to do

Sense of being suspended from life

Inability to concentrate

Indifference to immediate needs


Don’t automatically exclude family from resuscitation

Do allow others freedom to watch if they wish – unless they interfere with efforts

Don’t use complex medical terms

Do use history gathering interviews as an opportunity to update family and help prepare for possible death/pronouncement

Interacting with the family during resuscitation


Delivering Death Notification

It matters less who delivers the death notification – it matters most how the news is delivered.

OR



So the BHP has called the code, what’s next?Prepare yourself:

Take off your gloves, tuck in your shirt and wipe the sweat off your face.Softening – the switch from resuscitator to death notifier (from clinical to empathic).Direct yourself to spouse, parent, family member or friend.Put yourself on the same level (sitting or standing).Make eye contact but don’t stare.



Deliver the death notification by using the ‘D’ word: dead, died, death. (helps avoid denial)

Deliver quickly – don’t drag it out.

Allow a pause for survivor response.


Supporting Survivors

Using Touch:

Generally touching key survivor’s hand, shoulder or arm is sign of closeness.

Take survivor’s lead from there.

Hugging the survivor works for some paramedics – especially women. Gauge the situation appropriately.



Describe what you did and why.

Listen to how the survivor feels and what they need.

Answer with honesty (not brutal) & in a nonjudgment way. Omit clichés.

Do not reinforce denial of death

Restrain violent survivors only enough to protect them and you. (involve police)



Offer to make tea, coffee, get drinks.Offer to call relatives if needed.Don’t feel you have to keep talking – just being there is usually sufficient.Offer the family the chance to say goodbye, including touching deceased (consult with police).Place the body in an appropriate location such as in bed. (if local coroner/police authorities allow)



Have partner clean up and prepare for next callExplain local policy for certification of death and removal of bodyExplain role of police, family MD and coronerOffer to call or call (when needed) local victim/crisis services staff to respond to scene and provide grief counselingIf you transport, don’t leave survivor behind without a ride to hospital


Helpful phrases

I can’t imagine how difficult this is for youI know this is very painful for youI’m so sorry for your lossIt must be hard to acceptIt’s harder than most people thinkYou must have been very close to him/herHow can I help?Most people who go through this react just as you are


Hurtful phrases

Comments to avoid:

God clichés such as “It was actually a blessing because…”

Unhealthy expectations such as:

You shouldn’t feel/act that way.

Aren’t you lucky that at least…

You must get a hold of yourself.

You must focus on your precious moments.


Hurtful phrases

Disempowering statements:You don’t need to know that.I can’t tell you that.

Ignorance:Let’s not talk about that.S/he died because of…His/her death was for the best.Things always work out for the best.


Hurtful phrases

Basic Insensitivity:I know how you feel. My died last year.We all have to deal with loss.At least s/he died in their sleep.S/he had a very full life.Everything is going to be OK.I’m sorry. (in isolation = pity)


Cultural Diversity and Grief

There are almost as many different religious practices and beliefs related to death and treatment of the deceased as there are religions.

For example:1. Judaism: the body is to be buried (not

cremated) within 24-48 hrs of death.2. Islam: the body is to buried without coffin,

not cremated, as soon as possible.3. Hinduism: the deceased should be placed

as close to the ground as possible. (Source: Religious beliefs and death)


Cultural Diversity and Grief

It is not essential to study and know all cultural and religious practices and their implications following a death in the field.

It is important to ask questions and listen to survivors and family members of decedents.

It is important to make every effort to respect the wishes of family members where possible and practical to do so.


Concluding Remarks

Keys to success:

Understanding

Caring

Compassion

Empathy

Support

Advocacy


Optional Role Playing Exercise

Volunteers needed!


References

Family Acceptance of field termination:1. Delbridge TR et al, “Field Termination of

Unsuccessful Out-of-Hospital Cardiac Arrest Resuscitation: Acceptance by Family Members”, Annals of Emergency Medicine, 1996; 27:5

2. Edwardsen, A et al, “Family Perspective of Medical Care and Grief Support after field termination by EMS Personnel: A Preliminary Report”, Prehospital Emergency Care, 2002;6: 440-444


References

Family Acceptance of field termination:

3. Schmidt TA, Harrahill MA. “Family response to out-of-hospital death”, Academic Emergency Medicine, 1995; 2(6): 513-8.

4. Meoli M. ”Supporting the bereaved: Field notification of death”, JEMS, 1993; Dec.: 39-46.

death notification for paramedics

Documents

obhg education subcommittee2

support survivors

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prehospital cardiac

resuscitation scenes

cardiac arrest victim

notifying survivors

family support