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Abstract

• Death and bereavement are often poorly dealt with in emergency departments.
  
• Guidelines exist for optimal care of bereaved relatives.
  
• Establishing a limited bereavement program in a busy emergency department is quite feasible.
  
• Bereaved relatives appreciate a more "human" approach from hospital staff.
  
• Ultimately hospital staff also benefit from confronting issues surrounding death in the emergency department.

For relatives, the death of a loved one is difficult enough to cope with when it is expected. Deaths in an ED are often sudden and unexpected; the environment is confusing and unfamiliar; there may be difficulty getting information; and medical and nursing staff are usually strangers. This occurs in an atmosphere of high stress in which access to the patient may be restricted. All of these factors increase the likelihood that relatives will experience an abnormal grief reaction, with associated threats to physical and emotional wellbeing.^5-7

Here we review the current literature on care of unexpectedly bereaved relatives and outline the changes we made in improving this service in our hospital's ED.

What do relatives want?

• to receive prompt attention from staff on arrival and frequent updates on their loved one's condition;^6,7

• to be with the patient before death, including during resuscitation;⁸

• to know that the patient received prompt and appropriate treatment from prehospital and hospital staff;⁸

• to be informed of the death in a compassionate and unhurried manner;^7,8

• to be assured that the patient's belongings will be properly handled;^6,7

• to be told what to do next (eg, how to contact an undertaker; when to go home);⁷ and

• to have the opportunity for follow-up with the hospital to answer unresolved questions.^6,7

The best way to break bad news

Initial contact with the family. Initial contact with relatives is often made over the phone. A senior doctor or nurse should first identify himself or herself and then the relative answering the phone. In general, the relative should not be told over the phone that the patient has died (if this is the case) -- the caller should simply outline events, say that the patient is very ill and ask the relative to come as soon as possible.^5,7,9 The caller should try to ensure that there is somebody with the relative or able to drive them to the hospital. If informing relatives by phone is unavoidable^10-12 (eg, if they live a long distance away), the caller should make greater efforts to ensure that the relative receiving the call is not left alone (eg, by asking if there is anyone who can be with the person, or offering to call a friend or relative).⁵

A member of staff should meet the relatives on arrival, confirm their identity and show them to a private area.^7,12,13 This should be a comfortably furnished room with access to a telephone. If the patient is undergoing resuscitation, a senior member of staff should explain this early and prepare the relatives for the possibility of death.⁶ A member of staff should offer to contact a priest or other spiritual counsellor. The family should, if possible, be given the opportunity to witness the resuscitation -- many relatives feel strongly that they should be at the patient's side, or may simply want to confirm that everything possible is being done.^6,10 Relatives witnessing the resuscitation should be accompanied by a staff member to explain what is happening and answer questions.

Keeping the family informed. A member of staff should stay with the family, giving them frequent updates on the progress of resuscitation.^5,7,8

Informing the family of the death. This should be done by the doctor responsible for the patient.^5,7 The doctor's presence implies that everything possible was done to save the patient's life. Introducing oneself and sitting down indicates a willingness to spend as much time as the family needs. Next it is important to identify who is in the room and what their relationship is to the deceased. (Friends should generally be asked to wait outside.^5,10) The patient should be referred to by name as the doctor establishes what the family already knows, then fills in the details, beginning with what happened to the patient before arrival at the hospital.^5,7,10 It is quite appropriate to inform relatives of details, such as the fact that the patient was "unconscious and didn't feel any pain".^10,14 When informing relatives of the death, use plain English ("is dead" or "died") rather than euphemisms like "passed away", which some people misinterpret.^7,12,13

The doctor's next responsibility is to facilitate grieving.^5,7 The initial reaction will probably be shock. The doctor should allow some time for this to ease, but then the family should be encouraged to express feelings and ask questions. It may be best to just sit quietly for a while to share their grief.⁷ Sometimes it is appropriate to use touch, such as placing a hand on the arm to comfort a relative.^10,14 After the initial shock, one of three emotions usually predominates:⁵

• Denial -- this initial defence mechanism should be recognised and tolerated. It can allow time to adjust to the reality of death;

• Anger -- this may be directed at hospital staff. Usually, once expressed, the anger will diminish;

• Guilt -- this represents an inward expression of anger. Relatives may blame themselves. A simple statement from the doctor, exonerating the family, can provide much relief in the days and weeks to follow.

Viewing the deceased. Most families wish to view or hold the deceased and this can facilitate the grieving process.^5,7,10,13 If they do not wish to, this should be accepted.^7,13 Medical or nursing staff should spend time preparing the family, especially if the body has been mutilated or if medical apparatus has been left in place for postmortem examination. Staff should remain discreetly to answer questions before withdrawing.^7,10,13

Identifying "at risk" family members. Some family members are at greater risk of severe grief reaction, or even suicide, than others. Identifying these relatives can be difficult, but severe grief reactions are more likely to occur in cases where:^7,10

• the death was sudden or violent (eg, due to suicide or homicide);

• the person who died was a child;

• the person who died was a spouse or partner (especially if the relationship involved a high level of conflict or over-dependence);

• the relative feels he or she may have contributed to the death;

• the relative is particularly vulnerable because of past psychiatric illness or lack of a support network.

Relatives at high risk of experiencing a severe grief reaction should be encouraged to have a friend or relative stay for 1-2 days. Relatives openly expressing suicidal intent, or even psychotic reactions, may require urgent psychiatric intervention.

Concluding process. The family should be informed if a postmortem examination is needed. In Australia, coroner's department counselling services can be of assistance. The services of a funeral director need to be engaged and the deceased's personal property handed over to relatives.

As relatives may forget much of what is said, it is useful to provide a brochure containing information about the grieving process, notes on practical matters and a list of useful phone numbers.¹¹ Hospital staff should answer final questions and inform the family doctor. Many families need to be given "permission" to go home.^7,11

Follow-up. Many relatives appreciate contact with the hospital after they leave.^7,10,11 They may need further information to help resolve important issues, and they like to feel that the hospital actually cares.

The Sir Charles Gairdner Hospital ED bereavement protocol

The protocol

We aimed to provide a service that was relatively simple and easily absorbed into existing staff workload, of benefit to relatives and not intimidating to staff. It was also important to make the program as unobtrusive as possible for relatives and to provide some continuity with staff who were present at the time of the person's death (there is some evidence of an adverse effect on grieving if these factors are not taken into account¹⁷).

The main features of our program were:

• an education package for medical and nursing staff;

• intervention of a social worker at the time of death or by written referral out of hours;

• an information brochure for relatives, containing notes on the grieving process and practical issues, and contact details for useful agencies, including the name and number of the ED social worker;

• timely notification of the family's general practitioner by phone or fax, immediately or by the next working day;

• a sympathy card sent to the closest relative, handwritten and signed by the doctor and nurse most closely involved;

• a follow-up phone call by the social worker at one week to assess needs, and an offer for interview with the doctor involved;

• a further follow-up phone call at six weeks (relatives had been told that they would be contacted at this stage and were free to decline).

The program was administered through the Social Work Department, which was responsible for keeping records of when calls were due and for coordination with medical staff.

Practical issues to be dealt with included staff education (and overcoming staff resistance to the program), administration, and managing the extra workload for the social worker and medical and nursing staff. Because of the round-the-clock nature of the service, staff education and notification of the social worker sometimes created difficulties, especially at times of staff changeover. Initially, some staff saw the program as overly intrusive and "none of our business", and some vigorously opposed the idea of sending a sympathy card.

These problems were largely overcome when positive reactions from families were fed back to staff, or when staff received direct thanks or cards. The initial problem of locating the appropriate medical and nursing staff to sign cards was solved by getting the head of department or the program's consultant to sign. There was minimal additional workload for medical and nursing staff, most of the extra time being that spent with grieving relatives, once or twice a month.

Outcomes

Of 37 deaths in the ED in the first seven months of the program, three were not referred to the social worker and were not followed up. All 34 remaining families wished to be enrolled in the program and received a call and a card during the first week after bereavement. Two relatives declined a follow-up phone call at six weeks, feeling they had enough support. Others were very happy with the call at six weeks -- one relative commented that she had looked forward to it for days, while another telephoned to rearrange the timing, as she would be away during the sixth week. Three families requested further interviews.

We received much spontaneous positive feedback from relatives. Nearly all expressed gratitude verbally, and 10 relatives sent a written thank you as well. There was even an appreciative letter to the editor published in The West Australian newspaper, and one relative volunteered to join the hospital's Women's Auxiliary. Some comments from relatives were:

"I thought that my mother had died alone, as I wasn't at her side. When I got the card and phone calls I realised that she had died among caring strangers, and that was a source of great comfort to me."

"It was wonderful to get the card from Dr X. I'm glad my mother died at your hospital where everybody cares."

"I've told all my friends that, when they die, your hospital is the place to do it."(!!)

Tangible benefits of our program are hard to measure. As well as helping in the grieving process, for many people our program gave a positive image of the hospital as an institution which treated them as people with feelings and not just a "number". We hope this helps to make the face of emergency medical care in our community more "human".

We believe it was also a beneficial process for staff. Apart from the formal education, which was positively received, many staff members were surprised by the appreciation shown by relatives. Some had assumed that relatives and patients wanted a formal and "professional" approach to bereavement and had sought to maintain "emotional distance". To their surprise, they found that spending time and commiserating with the family and showing a more "human" side were very well received.

Conclusions

References

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