Transcript Death Notification and Survivor Support for Paramedics

ONTARIO
BASE HOSPITAL GROUP
Death Notification for
Paramedics
Greg Soto, BA, ACP
Education Coordinator, Niagara Base Hospital
Sunnybrook-Osler Base Hospital
David Cooke, ACP
Presentation developed for TOR Study Group
Introduction:
Quote
“Life is a fatal condition
with a 100% chance of
mortality”
- anonymous
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Objectives
Introduction
Medical futility
Mastering resuscitation with survivors in mind
Family acceptance of field pronouncement
Patient fit for TOR rule
Grief and sudden unexpected death
Delivering the death notification
Supporting survivors
Helpful/hurtful phrases
Cultural diversity and grief
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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)
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Introduction: Saves? What saves?
If 95 % of cardiac arrest
patients do not survive to
hospital discharge, who are
the real patients at these
scenes?
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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.
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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.
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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)
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Medical Futility: When to stop?
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)
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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
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BE SURE!
Does the patient
meet the criteria
for the TOR
guideline?
Shown to be
>99.5% accurate
in predicting
medical futility.
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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
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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
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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?
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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.
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Family Acceptance
Felt closer to deceased
Knew more about what was happening
Some expressed that deceased would
have wanted to die at home
Conversely, family members of
transported patients:
Expressed less positive interactions with
EMS & ED staff
Felt anxiety in rushing to ED
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Family Acceptance
Felt lonely sitting in waiting room waiting
for information
Felt 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
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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.
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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.
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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
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Interacting with the family during
resuscitation
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
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Delivering Death Notification
It matters less who delivers the death
notification – it matters most how the
news is delivered.
OR
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Delivering Death Notification
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.
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Delivering Death Notification
Deliver the death notification by using
the ‘D’ word: dead, died, death. (helps
avoid denial)
Deliver quickly – don’t drag it out.
Reassure about resuscitation efforts (if
started): “We did every medical
procedure possible, but were unable to
revive him/her”.
Allow a pause for survivor response.
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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.
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Supporting Survivors
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)
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Supporting Survivors
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)
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Supporting Survivors
Have partner clean up and prepare for next
call
Explain local policy for certification of death
and removal of body
Explain role of police, family MD and coroner
Offer to call or call (when needed) local
victim/crisis services staff to respond to
scene and provide grief counseling
If you transport, don’t leave survivor behind
without a ride to hospital
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Helpful phrases
I can’t imagine how difficult this is for you
I know this is very painful for you
I’m so sorry for your loss
It must be hard to accept
It’s harder than most people think
You must have been very close to him/her
How can I help?
Most people who go through this react just as
you are
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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.
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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.
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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)
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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)
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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.
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Concluding Remarks
Keys to success:
Understanding
Caring
Compassion
Empathy
Support
Advocacy
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Optional Role Playing Exercise
Volunteers needed!
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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
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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.
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