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 ONTARIO BASE HOSPITAL GROUP

OBHG Education Subcommittee Introduction:Quote “Life is a fatal condition with a 100% chance of mortality” - anonymous

OBHG Education Subcommittee 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

OBHG Education Subcommittee Introduction: Saves? What saves? What is the survival rate from prehospital cardiac arrest in Ontario? 5% (OPALS) US % (Eisenberg MS and Mengert TJ, 2001)

OBHG Education Subcommittee Introduction: Saves? What saves? If 95 % of cardiac arrest patients do not survive to hospital discharge, who are the real patients at these scenes?

OBHG Education Subcommittee 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.

OBHG Education Subcommittee 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.

OBHG Education Subcommittee 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)

OBHG Education Subcommittee 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?

OBHG Education Subcommittee 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

OBHG Education Subcommittee BE SURE! Does the patient meet the criteria for the TOR guideline? Shown to be >99.5% accurate in predicting medical futility.

OBHG Education Subcommittee 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

OBHG Education Subcommittee 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

OBHG Education Subcommittee 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?

OBHG Education Subcommittee 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.

OBHG Education Subcommittee 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

OBHG Education Subcommittee 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

OBHG Education Subcommittee 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.

OBHG Education Subcommittee 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.

OBHG Education Subcommittee 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

OBHG Education Subcommittee 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

OBHG Education Subcommittee Delivering Death Notification It matters less who delivers the death notification – it matters most how the news is delivered. OR

OBHG Education Subcommittee 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.

OBHG Education Subcommittee 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.

OBHG Education Subcommittee 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.

OBHG Education Subcommittee 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)

OBHG Education Subcommittee 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)

OBHG Education Subcommittee 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

OBHG Education Subcommittee 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

OBHG Education Subcommittee 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.

OBHG Education Subcommittee 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.

OBHG Education Subcommittee 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)

OBHG Education Subcommittee 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 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)

OBHG Education Subcommittee 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.

OBHG Education Subcommittee Concluding Remarks Keys to success: Understanding Caring Compassion Empathy Support Advocacy

OBHG Education Subcommittee Optional Role Playing Exercise Volunteers needed!

OBHG Education Subcommittee 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:

OBHG Education Subcommittee References Family Acceptance of field termination: 3. Schmidt TA, Harrahill MA. “Family response to out-of-hospital death”, Academic Emergency Medicine, 1995; 2(6): Meoli M. ”Supporting the bereaved: Field notification of death”, JEMS, 1993; Dec.: