A 55-year-old man presents to your emergency department in cardiac arrest. Despite multiple rounds of epinephrine, CPR, and defibrillation, he does not regain pulses. You call time of death.
Shortly afterward, a nurse informs you that the patient's wife and children are gathered in the consultation room to hear an update on his status.
For the emergency physician, communicating difficult news is an important responsibility. Telling a family member that their loved one has died is never an easy conversation, and it requires careful thought and consideration.
After my first death disclosure, I was juggling thoughts about the medical case with the feelings I had about the ensuing family conversation. I wondered if I had said the wrong things, said too much, or said too little. Over time, I realized the content of my conversation mattered less than the way in which I communicated and the environment I established for these difficult moments.
These are some of the lessons I have learned and strategies I have found to help ease the difficult process of disclosing the death of a patient, both for the loved ones and for myself.
Planning
As with any endeavor in medicine, teamwork will ensure things go smoothly. Identifying your partners and engaging in collaboration is a must. Prior to the encounter, asking your hospital’s social worker and/or chaplain to gather family members in a quiet and secluded waiting room will give you time to prepare. Meet with the hospital chaplain, the emergency department social worker, and the patient’s nurse prior to the encounter to confirm the patient’s identifying information, and confirm with whom you will be speaking.
Identify any cultural or other customs relevant to the patient’s family that may affect their feelings about, and understanding of, the patient’s condition. During a painful and difficult conversation, incorrect information, confusion, or miscommunication are the last things you’d want to impart.
A Safe Space
For the family, gathering in a designated space with minimal distractions or interruptions will allow for collection of thoughts. Before entering, take a breath, pause, and gather yourself to transition from the intense experience of running a code to the emotionally challenging role of informing next-of-kin.
The Meeting
Families rushing to the ED knowing their loved one is experiencing a medical emergency are faced with a bombardment of information, compounded by emotional stress and a hectic environment. When entering the room for the first time, introduce yourself clearly as the emergency physician. Your partners from the ED should also introduce themselves at this time, if they have not already done so. Confirm the relationship of the present individuals to the patient.
During this initial encounter, use neutral body language, make eye contact, and speak in a soft tone. These communication signals aid in easing the tension in the room and help draw focus to the information being communicated.
A Difficult Disclosure
The key information should be stated clearly, without using medical jargon or complicated terminology. In an already complex environment, simplicity is vital. State the nature of the patient’s arrival to the ED, and communicate that your team did everything possible to save their life. State clearly that the individual “has died.” This direct statement is sufficient, and preferred, as it avoids any ambiguity or confusion. Avoid euphemisms for death, as these can often be misinterpreted and may, in extreme cases, lead some family to believe the patient is still alive.
As the family absorbs the difficult news, they naturally will have a strong emotional reaction, which can be highly variable. Offer your condolences and listen to their questions and statements. If appropriate, let the family know that they can visit their loved one in a designated viewing room.
As expressed earlier, this process is a collaborative one. At this point, allow the chaplain, nurse, or social worker to take over and continue to support and provide information on next steps. Restate your condolences, offer assistance with any further questions, and exit the room.
Reflection
In the emergency department, there is no shortage of unfortunate outcomes, sudden and unexpected deaths, and even expected ones. As emergency physicians, we are used to switching gears frequently to put out the next fire.
However, being the bearer of bad news and participating in emotionally taxing situations can take a toll on even the toughest of clinicians. After a disclosure, I try to take an immediate opportunity to sit and digest my thoughts. Even if it only lasts a few seconds, it allows me to process the experience and acknowledge what I went through before moving on to the next task.
There are inevitably some cases that linger in my mind, and I find it helpful to discuss these with my co-residents. Whatever your method of reflection may be, it is essential to find a process that works for you. If you find yourself persistently or unusually troubled by a patient case, seek help from colleagues, mentors, or mental health professionals. Always attend to your mental health after a difficult case.
As emergency physicians, we are uniquely equipped to handle difficult conversations, and we must be deliberate with our words and actions. Although nothing can lessen the impact of losing a loved one, providing a death disclosure in a respectful and effective manner can prevent further harm and distress to a patient’s family. Planning ahead, organizing the appropriate individuals, and securing a safe location are essential.
Finally, making sure to reflect and acknowledge our own thoughts can help digest the situation in a healthy way and lessen the emotional impact on physicians.
References
- Quest TE. (2016). Case 5: Death Disclosure. In: Martin M, Heron S, Moreno-Walton L, Jones A. (eds) Diversity and Inclusion in Quality Patient Care. Springer, Cham. 2016.
- Shoenberger JM, Yeghiazarian S, Rios C, Henderson SO. Death Notification in the Emergency Department: Survivors and Physicians. West J Emerg Med. 2013;14(2):181–185.