Death & Dying Notifications: Education designed to fill the communication gap between providers and our patient’s family
I was 18 years old when I saw my first dead body. He was a thin, elderly man who succumbed to his long battle with cancer. When we arrived on scene his caretaker told us he had a DNR and the family was on the way to the house to say their goodbyes. At the time, I was an EMT Basic student, our paramedic handled the call and we were quickly back in service. Looking back on it now, this was a missed opportunity to learn from my preceptor how to communicate the death of a loved one with family.
Fast forward to today, I find myself in the paramedic role assessing our patients and delivering the unfortunate news to their family. Just like my predecessor before me I adapted the usual phrase “I’m sorry. Despite our best efforts your [insert relative here] has died.” Then, I would swiftly hand over the scene to the law enforcement officers to clear for the next call.
Recently, I have had the pleasure of a permanent partner on a steady truck. Over the last six months, we have had our fair share of calls and have learned a lot from each other. We decided early on in our partnership to develop a mantra to hold each other accountable. After every critical call we ask “What worked? What didn’t work? What can we do better next time?”
On one particular call we were dispatched to an elderly male who was unresponsive, cold to the touch. Since my partner is heading to paramedic school soon we discussed obvious signs and symptoms of death, what rhythms could possibly be found on the monitor, and what information to gather to notify medical control for a do not attempt resuscitation order. Once we cleared the call my partner asked “how do you know what to say to the family?” The short answer was “I just winged it with the usual phrase.” Holding true to our mantra we asked each other “how can we do better?”
After a quick internet search we learned about a course offered on the Emergency Resilience (www.emergencyresilience.com) website entitled Death Communications ® for First Responders: How to deliver unfortunate news. According to the website, this course was designed to teach “first responders how to communicate with and support the survivors of cardiac arrest patients”. Course creator, designer, and instructor, Alexandra Jabr, M.S., EMT-P, has adapted her evidence-based research, professional, and personal experiences to develop a course in an effort to fill the educational gap in EMS provider death notifications.
The course is divided into five modules, including one bonus module. Each module contains brief to the point videos followed by self-reflection and learning assessments.
Module 1: Whose job is it anyway?
Module 2: About grief?
Module 3: The impacts: Them and us
Module 4: Special considerations
Module 5: Putting it all together
Bonus Module: Occupational Resilience
Here are some top takeaways from this course to improve death notifications for EMS providers.
1. Course disclaimer. The introduction of the course offers a disclaimer prior to starting the modules of the potential recall of emotions or flashbacks you may have experienced in relation to death and dying. The web-based course allows pauses between sections should you need a break.
There are several resources available should you need help any anytime, i.e. 9-8-8 Suicide and Crisis Lifeline is available 24/7 (formally known as the National Suicide Prevention Lifeline 1(800) 273-TALK), local crisis center, peer support, family, etc. Please do not hesitate to reach out for help.
2. One size does not fit all. It is important to note within the course there is no definitive script every provider should follow when delivering a death notification to the family of a deceased patient. Instead, Jabr (2023) recommends tailoring your response “to your personality and clinical practice.” Often this can be as simple as rephrasing a provider’s response, such as, “be strong” change to “cry as much as you need” OR “you’re going to be okay” change to “who can I call to come be with you?” just name a few. It is also highly recommended to use the words “dead” or “died” to limit any confusion between the provider and the family.
3. Involve the family. Perhaps the biggest paradigm shift I had during this course was to invite the family to view and be involved in the resuscitation process, especially pediatric cardiac arrests. In the past, I was under the belief that I was protecting the family from a traumatic event which may lead to additional trauma by sheltering them. However, research has shown by inviting the family to be involved aids in the grieving process (De Stefano et al, 2016). All I had to do is simply give them the choice instead of deciding for them. Furthermore, if the family chooses to stay it is beneficial for the provider to communicate the resuscitation process, in turn, reassuring the family that everything is being done to help their loved one (Brasel et al, 2016). Keep in mind, this may not be ideal in all situations. Provider judgement and following local protocol is always advised to maintain safety and control of the scene (Jabr, 2023).
4. Types of grief. Some providers may remember during initial training we were taught the stages of grief that one will go through after a loss. This loss may be of a close family member, a job, or something of significance to the griever. What I was surprised to learn more about are the different types of grief associated with this loss, i.e. Anticipatory, complicated, and disenfranchised. Each one can lead to additional mental stressors resulting in a call to 9-1-1 for help. One’s ability to identify the types of grief in addition to the stages allows a better understanding of how to approach the situation to provide better support to our patients.
As mentioned in the course, death notification training is not incorporated into standardized training, however, we are expected to know how to deliver the news (Jabr, 2023). Here are a few suggestions that may help us prepare better:
· Update the National EMS Education Standards to include ‘Death Notifications’ under the heading Preparatory - Therapeutic Communication for the paramedic level. This will allow educators to create new modules or extend existing academic text in initial training to include up-to-date information on the techniques/benefits of family centered care in resuscitation efforts and death notification.
· Accept and add this topic to continuing education curriculum if not obtained in initial training courses. Providers can seek additional training on their own.
· Add this topic to guidelines or local protocols, i.e. DNAR, post resuscitation, etc.
Overall, this course is highly recommended for anyone looking to better understand and identify the dynamics of grief both professionally and personally. It provides the tools to incorporate changes in how we respond to death and dying. It allows for better communication with the family to help aid them in the grieving process keeping the patient and their families at the center of paramedic care.
References
Brasel, K. J., Entwistle, J. W., & Sade, R. M. (2016). Should family presence be allowed during cardiopulmonary resuscitation?. The Annals of thoracic surgery, 102(5), 1438-1443.
De Stefano, C., Normand, D., Jabre, P., Azoulay, E., Kentish-Barnes, N., Lapostolle, F., et al. (2016) Family Presence during Resuscitation: A Qualitative Analysis from a National Multicenter Randomized Clinical Trial. PLoS ONE 11(6):e0156100. doi:10.1371/journal.pone.0156100
Hobgood, C., Mathew, D., Woodyard, D.J., Shofer, F.S., & Brice, J.H. (2013) Death in the Field: Teaching Paramedics to Deliver Effective Death Notifications Using the Educational Intervention “GRIEV_ING”, Prehospital Emergency Care, 17:4, 501-510, DOI: 10.3109/10903127.2013.804135
Jabr, A. (2023) Death Communication® For First Responders: How to deliver unfortunate news. Emergency Resilience. https://www.emergencyresilience.com/
About the author:
Nicole M. Volpi, PhD, NRP, has experience in emergency medical services, law enforcement, military/civilian disaster response, and disaster management research. She currently works as a full-time paramedic for West Jefferson Medical Center EMS in Marrero, Louisiana.