Communicating Death
in EMS
Kerry Evens RN, BSN, CFRN, CEN
Chief Flight Nurse
North Colorado Med Evac
How Do you Say IT??
American Cultural Bias
• Death is the Enemy:
• “When someone is born we rejoice. When
someone is married, we celebrate. But when
someone dies, we pretend nothing happened”
Margaret Mead
• Reality = Death is a part of life.
Objectives
• Identify sources of provider discomfort with
communicating death
• Discuss a personal case
• Discuss cultural differences in death
• Review grief stages
• Learn specific methods of effectively
communicating death
“When someone dies,
we’re suddenly
confronted with our
own mortality –
something we never
talk about, and that
most of us are afraid to
think about.”
My Story
• I’m not a trained psychotherapist/counselor
• ER/PICU/Transport RN for 20 years
• Estimate that I’ve been involved in over 1000
deaths in my career
• Professionally experienced with breaking the
news of death
• Most impactful – my own experience with a
family death
My Story
Jan. 5, 2002
• Climber Killed near “The Fang” in Vail
I was at work…
• 10 years later – I can recall perfectly
• Vivid snapshot memories of those moments
– Small room
– Social worker
– Telephone – news from my friend
– Ride to Summit County
– Viewing his body
– Pile of cut up clothes
What I Felt
• Variety of emotions:
– Fear
– Panic
– Confusion
– Worry
– Numb/Detached and Alone
– I felt like I was going to die
– I felt like I wanted to die
– I wanted answers, but I dreaded them
What I wanted
• Someone to just be straight with me
• I wanted the cold facts
• I wanted to be sought out an TOLD
information
• I wanted reports/X-rays and first hand
accounts
• Someone to treat me like I was a part of the
tragedy
What I Didn’t Want
• I didn’t want to be shielded
• I didn’t want to be asked “how are you
doing?”
• I didn’t want to hear “everything happens for
a reason” or “he’s in a better place”
Memorializing and Moving On
• I became very functional
– Coping/Survival
•
•
•
•
•
Scholarship fund
Tibetan fund
Donation to RMNP – bench/funds
Spreading ashes around the world - friends
Writing on leaves
EMS – You Can’t Die!
• Cultural Bias – in general - American
• Death is Bad – Resuscitation is Good!
• EMS is there is “Save Your Life”, “Everyday
Hero’s” Blah, blah, blah……
• Reality TV ER shows don’t help this
perception
• Reality is that 1.76 persons die per second
worldwide.
Training on Death/Grief and
Communication????
• How much training to we get in EMS?
• Fewer than one third of medical residents
report receiving training in the process of
death pronouncement
• Because of lack of training we are
uncomfortable
• As soon as that pt. is pronounced –
everyone…….
Scatter Like Roaches……
“A Good Death does Honor to a
Whole Life”
Petrarch
How Do WE Deal with Death?
•
•
•
•
•
•
•
Educational desensitization
Humor
Language Alteration
Scientific Fragmentation
Escape into Work
Rationalization
EMS tend to be Altruistic personalities
You Know it’s a Bad Call
•
•
•
•
•
Pre-emptive – when you arrive at the call:
Introduce yourself quickly
Reassure – “We will do all we can.”
Builds a relationship and trust
Designate a “communicator” to keep the
family informed.
• Think ahead in your care – the family will “see
this”
The Call Ends “Badly”
• Now what?
• Prepare yourself:
– Be “Present”
– It’s natural to feel inadequate
– Be genuine – tell the truth
– Slow down and listen to the needs of the family –
stated and unstated
– Be aware of your own physical/emotional needs
Setting
•
•
•
•
Setting: Private, quiet
Consider your own appearance
Who is the right one to break the news?
Be focused on the people you are talking to
– Sit down
– Make eye contact
– Physical touch if appropriate
• A word on litigation
Those 2 Minutes
• 30 second – 2 min. to relay information
• Critical that the key points are delivered
initially
• Know the name of the deceased!
• Avoid euphemisms
• Use words “Dead”, “Died” and “Death”
• Memory of first moment vs. first days
Those 2 Minutes
• Reassure – everything possible was done
– Briefly/simply explain what you did
•
•
•
•
Understand/address initial feelings of guilt
Explain what caused the death
Answer questions
“If you want to heal folks, lay ears on them”
Next Steps
• Explain what will happen next
– Calls to be made
– What happens with the body
– Offer resources if your department provides
Local Cultures
•
•
•
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Anglo
Latino
Somalia
Asian
Grief Stages
• Shock and Denial – Protest
– I can’t believe this
– We need to listen in this phase
– Offer safe environment to express feelings
– Support
• Pain and Guilt
– Overwhelmed
– “What if” or “If only”
Grief Stages
• Anger and Bargaining
– How could they leave me?
• Depression, Deflection and Loneliness
• Acceptance and Hope
Grief Stages
• Initial: Acute emotional spike typically lasts
about 15 minutes
• Exonerate the family if appropriate
• Avoid the words “I’m Sorry”
• Be prepared for initial reactions
What About Telling Kids?
• In EMS cases – it should be the family’s
decision
• Children thrive in a climate of realism
• Let them see that is OK to show emotion
• Be ready to answer questions
• Use simple and direct descriptions:
– “Stopped working”, or they “wore out”
What About Telling Kids?
• < 3 y/o:
– They Understand sadness
– Think of death as reversible
• 3-6 y/o:
– Magical thinking
– Death is a “taker” that “gets you”
• 6-9 y/o:
– Better comprehension
– Need clear/simple explanations
What About Telling Kids?
• 9-12 y/o:
– Death may be a punishment
– Feelings of guilt
• Teenagers:
– Understand concept of death
– Much like adults
– Need support and outlet
“It is the nature
of all things
that take form
to dissolve
again.”
Buddha
Questions?
References
•
•
•
Book: “How do we tell the children?” Dan
Schaefer Ph.D & Christine Lyons
Book: “American Book of Living and Dying”
Richard Groves and Henriette Klauser
Emergency Medical Technicians - body,
funeral, life, time, person, human, Types of
EMS Providers, Training Standards, Roles,
and Responsibilities of EMTs
References
• http://www.deathreference.com/DaEm/Emergency-Medical-Technicians.html
• http://www.fhp.org/fhpdocs/CrossCulturalRes
ourceGuide.pdf
• http://www.hcplive.com/publications/Residen
t-and-Staff/2007/2007-04/2007-04_01
• http://findarticles.com/p/articles/mi_m0MJU/
is_2_9/ai_93610991/pg_8/?tag=mantle_skin;
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