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Epidemiology of death and dyingOne hundred years ago, the predominant pattern of dying was a rapid, precipitous death from infectious diseases and accidents.

With modern medical advances, chronic diseases have become part of the last years of life for most peopleThree diseases:

Heart disease, cancer, and strokeaccounted for 60% of deaths in the United States in 2000

Epidemiology of death and dying

In Western culture, death has become

“medicalized” in the last 50 years.

Modern technology often allows human control

over the timing, site, and pace of dying.

About half of deaths in the United States occur

in a hospital and another quarter in nursing

homes.

Definitions of death

Biologic definitions of death are currently the

subject of considerable debate.

Twenty years ago, cardiorespiratory failure

defined

death because this was rapidly followed by

brain death (which could not be directly

measured) caused by failure of oxygenation and

perfusion.

Death was a distinct biologic event because all

vital

systems stopped when one of them failed.

FutilityIn the United States at present, when

cardiopulmonary arrest occurs, physicians proceed with full resuscitative measures

unless there is a clear understanding that this is contrary to the patient’s wishes.

Delivering bad news The goal of skillfully breaking bad news is :Reduce the severity and the duration of stress and encourage engagement of coping mechanisms, for physicians and for patients and their caregivers

According to a theoretic construct proposed by Ptacek and Eberhardt, staff and physician stress often peaks just before transmission of the bad news, whereas patient or caregiver stress emerges after delivery of the bad news.

Delivering bad news

Many providers feel inadequately prepared for

death disclosure or delivery of bad news.

Skilled resuscitation, diagnosis, and treatment

of patients are key to management of the

external sources of provider stress.

Delivering bad news

Anticipatory stress of delivering bad news may

be reduced by use of a structured protocol, with

practice, and by being intentional about the

physical and social aspects of the setting.

Delivering bad news Several initiatives to improve delivery of bad news have been introduced. These encourage: Training in communication skills Explicit instructional sessions Role playing Use of standardized patients Observation of colleagues who are

comfortable with this aspect of patient care

Delivering bad newsThe steps listed can help you think critically about how best to communicate at a time when stress is high. Step 1: Physician preparationStep 2: What does the patient know?Step 3: How much does the patient want to know?Step 4: Sharing the informationStep 5: Responding to feelingsStep 6: Planning and follow-up

Quality of life and a “good” deathWhereas almost 95% of people express the wish to die at home , more than 70% die in an institutionFive topics predominate in people who are dying:1. pain and other symptoms adequately

relieved2. avoiding inappropriate prolongation of dying3. achieving control4. relieving others of the burden of their dying5. strengthening personal relationships

End of life

Death in the emergency department is different :

(1) deaths are likely to be unexpected

(2) the patient, family, and their values are often unknown to the emergency department staff

(3) trust needs to be established rapidly

(4) the emergency physician often has to act on limited medical information

End of lifeSeveral end-of-life skills are important in EM Establishing goals of care

Wishes for interventions at a time of crisis. Spiritual , economic, and community factor National Education in Palliative and End-of-Life Skills of discerning the burdens of illness for an

individual Determining the kind of relief Understanding how to best care for each patient Even how a "good death" would look to apatient with

terminal disease..

Death in the emergency department

Every emergency physician will be required to

communicate bad news to patients, family

members, and caregivers.

The manner in which this is done may make a

difference in the course of subsequent grief

and coping. Compassionate communication can

strengthen trust and foster collaboration in

planning between the medical team and the

patient and family.

Death notification

One particularly difficult form of “bad news” is

death notification.

Practice can help clinicians perform this task

more smoothly.

In general, the format can follow the guidelines

for delivery of bad news from

Families do not have time to adjust or to think

about options, and the news cannot be

softened.

Death notification Death notification usually occurs after an

unsuccessful resuscitationattempt. Physicians should be sure that they are

presentable and wear a name badge.

I f possible, ascertain beforehand the names of the persons who will receive the

notification, their relation to the patient, and what they know about the

patient’s condition.

Family presence during resuscitation

It is increasingly common to invite a close

family member to attend resuscitation

attempts. Offering of this option has been

endorsed in the 2010 AHA Emergency Cardiac

Care guidelines and by the EPEC curriculum.

Emerging evidence suggests that presence

during procedures and resuscitations may be

beneficial

to surviving patients and family members who

choose to stay and are not harmed.

Death notification

When giving the news, physicians should use

clear “dead” or “died” language to be sure that

there are no misunderstandings about the

outcome being conveyed.

Death notification

Those at the scene should be assured, if at all

possible,that their responses to the emergency

were appropriate, that the medical care team

did all that was possible, and that the victim did

not experience unnecessary discomfort.

It is important to express appreciation for their

presence in the ED or during the resuscitation

attempts.

Elements of an empathic death disclosure

1. Introduce self/role.2. Sit down.3. Assume comfortable communication

distance.4. Use acceptable tone/rate of speech.5. Make eye contact.6. Maintain open posture.7. Give advance warning of bad news.8. Deliver news of death clearly (use

dead/died).9. Tolerate survivor’s reaction.10. Explain medical attempts to “save” patient.

Elements of an empathic death disclosure

11. Use no medical jargon; use language that is clear and easily understood.

12. Offer viewing of deceased.13. Offer to be available to survivor.14. Conclude appropriately.

Viewing of the body

The family should be offered an opportunity to

view the body.This may be the first exposure to

the body for the survivors and can make an

abstract and unreal

notification more concrete. Although a majority

of survivors find viewing of the body helpful, no

attempt should be made to force this on

survivors, and a few are not comforted by

seeing the

deceased.

Viewing of the bodyIf possible, the body should be moved to a small room, preferably away from the main treatment area.This makes the family feel more at ease. Family members should be warned of what to expect, such as color and temperature changes, injuries or invasive premortem procedures, and the presence of endotracheal and intravenous tubing.With sufficient preparation, most people are not shocked by the deceased person’s appearance

Viewing of the body

A staff member should remain in the room or

within close range at all times. This contact

allows the staff to help make the viewing an

important and supportive aspect of the grieving

Process

At times, it may be necessary to touch the body

to assure the family that this is appropriate.

Survivors should be allowed to remain with the

body for as long as seems appropriate

Viewing of the body

When gross disfigurement has occurred, the

viewers should be warned about this, and the

body should be discreetly covered when

possible.

Survivors may even find that helping to clean

and prepare the body (particularly with a

pediatric death), holding a loved one, or

preparing for transport may allow a final

expression of caring.

Viewing of the body

Less consensus exists among providers, and

they often express discomfort with the concept.

If resuscitation is to be witnessed by a family

member, a staff member who is dedicated to

supporting that person should always be

process.

Sedation for survivorsRequests for tranquilizers, sedatives, sleeping

medications, or just “something for the

nerves” are common. The grieving process is

important and difficult work. Prescriptions for a

light sedative for

a few days may be appropriate but usually

require direct evaluation of the survivor by the

physician. The survivor needs to know that the

psychic pain is to be expected and where to

turn for help and support during this difficult

time.

Grieving and bereavement

Grief is defined as emotional pain induced by

sorrow and loss. It is associated with a

constellation of symptoms and behaviors that

are influenced by cultural background, current

and past personal

stressors, and relationship of the survivor to the

deceased Bereavement is the situation of

having experienced the death of a significant

person in a survivor’s life.

Grieving and bereavement

The initial response to any death, whether

expected or unexpected ,is acute psychic pain

that is associated with shock,

disbelief ,numbness , and inability to process

further information.

Some persons display anger, loud screaming,

crying, and occasionally acute anxiety or

syncope.

Grieving and bereavement

Others experience a calm dissociation

or no reaction. The medical team may also

recognize other , more cognitive reactions,

including denial, guilt, sadness, fear , shame,

and anger.

Grieving and bereavement Reactions may vary with the cultural and

personal backgrounds of the survivors. A wide range of

expressions is normal and expected. There is no “right”

way to grieve, although, in the ED, outward reactions are often

perceived as problematic and disruptive. The goal of the emergency

physician is to support survivors as much as they permit and to

avoid taking personally

Phone notificationIf the first contact with survivors of an ED death is by telephone, it is recommendedThe survivor be told to come to the ED if at all possible. Although family members may ask or even demand to know if death has occurred, allowing some time for assimilation of news by delaying information about the final outcome may be more helpful for the grieving process.