Words by Charlie Gadd
Paramedics are often called to scenes involving death and dying, and are tasked with not only instituting life-saving interventions, but also deciding when to terminate their resuscitative efforts (1). In Australia alone, there are more than 25,000 out-of-hospital cardiac arrests recorded each year and, with a worldwide survival rate of approximately 10%, many death notifications (DN) are delivered by paramedics in the field (2,3).
One of the most important aspects to consider when caring for a deceased patient is informing family and friends of the loss of a loved one. DNs are one of the most difficult and stressful messages that paramedics have to communicate and are often delivered after potentially long and emotionally draining resuscitative efforts. The negative emotions invoked by performing DNs are also exacerbated by having no margin for error as well as the inability to develop significant relationships with family and friends prior to delivery (4).
Each year, approximately 77% of paramedics deliver at least one DN (5). In a study by Campos et al, emergency services clinicians who delivered 1-5 DNs in the previous 12 months had a 36% greater chance of experiencing burnout, with those who delivered > 5 demonstrating 73% greater odds of burnout compared to clinicians who had not delivered any (5). Additionally, among paramedics who had delivered one DN in the previous 12 months, those that received DN training as part of continuing education had a 29% reduction in odds of burnout (5).
Alongside professional burnout, multiple studies have described feelings of anxiety, guilt, sadness, discomfort, or frustration post-delivery that can result in the development of mental health conditions (6). Insensitively or inadequately handled DNs can also impede survivors’ long term adjustment, with higher rates of anxiety and depression seen in survivors who received a poorly communicated DN (7,8).
For survivors experiencing loss, receiving a DN can be a lifechanging event (6). The words and expressions used, characteristics of the notifier, and setting it is performed in can all significantly impact how survivors cope with the bad news (3). From the survivors perspective, the need for improvement in clinician delivery of DN’s is apparent (9). In a study of family members’ experiences post-DN in the emergency department (ED), one-third rated their satisfaction with the care and emotional support received as average or less than average. Furthermore, they described staff as unsympathetic, cold, and non-reassuring (9). As such, it is extremely important for paramedics to receive adequate education and training to improve confidence and competence in DN delivery. Ongoing education for DNs not only reduces odds of burnout, but it also improves the ability of survivors to cope with their loss (5). Most paramedics do not receive education in DN and some rate their educational experiences as inadequate (10) (11).
To improve paramedic delivery of DNs, Hobgood et al proposed the GRIEV_ING mnemonic (12). This recall device for DNs has been demonstrated to effectively improve emergency medicine resident, medical student, and paramedic confidence and competence (12). This mnemonic is discussed below and in Table 1.
The GRIEV_ING mnemonic stands for gather, resources, identify, educate, verify, space, inquire, nuts and bolts, and give (12). Initially, we need to gather the necessary family and friends that are present into a calm environment. If time permits, we can also notify any extended family and friends on behalf of the immediate individuals there so that they can decide to be present as well. We then want to bring in any additional resources. This can be difficult in the out-of-hospital setting compared to an ED, but may include police, undertakers, or other healthcare workers involved in the care of the patient. Paramedics then need to identify themselves and their role in the care of the patient, prior to having all family and friends identify their relationship to the deceased. Once in a private, comfortable room, family and friends should be given a warning shot that you will be delivering bad news, before briefly educating them on the events leading up to the death and explaining in non-medical terms what interventions were used. When talking, it is important to remain at eye level, and use clear and simple language as well as an empathic tone of voice.
The death must be verified after a brief explanation is provided. This must be done using the words “dead” or “died”, making sure to avoid euphemisms which may allow for confusion or denial. It is at this stage that empathy can be extended towards the survivors. Notifiers should avoid giving unsolicited advice or encouragement for a rapid recovery and should not endorse any specific emotional attitude or attempt to identify with the survivors’ experience. This can be interpreted as insensitive and trivialise their experience. A simple phrase such as “I am so sorry for your loss” or “I can’t imagine how difficult this must be for you” are small but powerful pieces of emotional support that validates their emotions.
After confirming the death, it is important to give time and space for the family and friends to absorb and process the information. In this stage, it is natural for healthcare workers to feel uncomfortable; however, it is important not to fidget, interject, or lose focus whilst survivors process the bad news. When the family is ready, inquire about any questions they may have, making sure to answer these openly and honestly.
The nuts-and-bolts section gives rise to the logistical tasks that must be carried out post-death. This can include providing information regarding where to go from here, contacting a doctor for the death certificate, notifying the coroner, arranging undertakers and funeral services, or organising organ donation. This does not have to be immediate and will depend on the patient’s unique situation. At this point, it is important to extend the offer to the family and friends to see the patient if appropriate, making sure to leave the body in an acceptable manner unless the death is notifiable. Lastly, give contact details for any crisis helplines, social support, or mental health services to those affected.
Delivering a DN is one of the most difficult interventions a paramedic can perform. Saying the right things, at the right time, in the right way can make a huge difference to both the survivor’s and paramedic’s wellbeing and is something that can be taught and learned. This article has highlighted these points and provided a memory aid that will give clinicians a foundation to adapt to their own communication styles.
Table 1. GRIEV_ING mnemonic
References
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2. Gräsner J-T, Lefering R, Koster RW, Masterson S, Böttiger BW, Herlitz J, et al. EuReCa ONE-27 Nations, ONE Europe, ONE Registry: A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation 2016;105:188-95.
3. Wallace SK, Abella BS, Shofer FS, Leary M, Agarwal AK, Mechem CC, et al. Effect of time of day on prehospital care and outcomes after out-of-hospital cardiac arrest. Circulation 2013;127(15):1591-6.
4. Walker E. Death notification delivery and training methods. Journal of Paramedic Practice 2018;10(8):334-41.
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