Communicating Death in EMS Kerry Evens RN, BSN, CFRN, CEN Chief Flight Nurse North Colorado Med Evac.

Communicating Death in EMS

Kerry Evens RN, BSN, CFRN, CEN

Chief Flight NurseNorth 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

• 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/Da-Em/Emergency-Medical-Technicians.html

• http://www.fhp.org/fhpdocs/CrossCulturalResourceGuide.pdf

• http://www.hcplive.com/publications/Resident-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;content