Pronouncement Done. More Work to Do.

I remember the first pronouncement I was involved in.  It was at my first job, for a private EMS service in the burbs.  It was early one morning that we worked a 60-year old female who ‘woke up dead.’  I was so new that I was third-riding as an EMT; I wasn’t even partnered with a medic at that point.  Even at that shiny, new part of my career I remember thinking that our crew had performed the process wrong.

The patient was worked in a bedroom while the family sat in the living room waiting.  She was probably an asystolic arrest that we gave a round or two of meds to before calling it – I don’t know, like I said, I was a new EMT.  I remember that the medics and firefighters pronounced the patient, cleaned up their mess, and began taking equipment out to the bus.  Through the living room.  Past the patient’s family.

Before we notified them of the negative outcome of our efforts.

When one of the paramedics did tell the family about the patient’s status, he told them that she had “moved on.”  I recall vividly that her husband asked where she went.  He wanted to meet her there.  I think in his mind, the experts arrived because his wife wasn’t breathing.  Then the experts were leaving, so she either was better or was transported – maybe out through the bedroom window or something?  Brains don’t always make sense under stress.

In the years since, I had two main points that I taught to new medics.  My goal was to avoid situations like this.  First, don’t ease into it.  It is easier for providers to have a little throwaway conversation before we get to the hard stuff.  The problem is that introductory conversation to a medics involves something like, “So, has she been sick lately?”  You have just tied any answer that the family member has to her death.  “Oh, God, I knew I should have made her get checked out!  This is my fault!”  The second main lesson that I pushed is to use the word “dead” at least three times.  Dead, death, or died are your only choices.  Don’t use euphamisms like “gone to a better place” or “no longer with us.”  Be clear, say dead, and it takes three times to sink into a grieving brain.

'Inconsolable Grief, oil on canvas by Ivan Nikolaevich Kramskoi (1837-1887). Public domain.

A few years ago, however, I ran across the GRIEV_ING mnemonic.  It works similarly to what I was doing.  Gather.  Resources. Identify. Educate.  Verify. Space. Inquire. Nuts and bolts. Give card.

Gather: Get all of the family together.  Ensure that everyone is there and optimize the environment.  Make sure it is quiet and private.  Have everyone sit down – fainters are hard to preidentify.  Get at their level.  Make eye contact.  Gather yourself too – tuck your shirt back in, wipe the sweat off your forehead, and slow your pulse rate if needed.  You are transitioning from hardcore street medic to comforting social worker.  Lower your voice to that of normal conversation.  Speak clearly.

Resources: I think this one is out of order.  This step is to call for additional support resources, like chaplains, other family, etc.  To me, this should be after the Inquire step, but then the mnemonic makes no sense.

Identify: Tell them who you are and identify the patient by name.  “My name is Bill, and I am a paramedic with the city.  I was in charge of taking care of Joe.”  Use the patient’s name; never refer to the dead as another word: the arrest, the patient, the body, your mom, whatever.  He is Joe and that is how you should refer to him.  I hope that is common sense.  But it really is important to be able to use the deceased’s name.

Educate: Update the family about what was found and what was done.  Explain that you found them without a pulse and not breathing.  “We performed all the same treatments that would occur in any hospital.  We put a tube in his lungs to breathe for him, performed CPR, and gave him powerful medications.”

Verify: Use the word “dead” or “died.”  I still go with the three times rule: “I’m sorry to tell you that even with all that, Joe has died.  All of the treatments we performed could not save his life.  Joe is dead.  It looks like he died peacefully in his sleep during the night.”  (If it doesn’t look like he died peacefully, don’t say that.  Trust me.  Experience talking here.)

Space: Give them space to absorb the information.  Don’t leave, because they will have questions.  Just shut up for a while.  Be a professional, sit there, and console them one human to another.  Put your hand on theirs.  Put a hand on their shoulder, maybe.  Even just sit there and witness their grief, if that is all you can muster.  However their bereavement manifests, do not take it personally.  Some people wail, some people strike out, some will throw themselves to the floor, and some people just stare.  Do not restrain them unless they are a danger.

Inquire: Ask if they have questions about the situation and if there is someone you can call for them.  “Is there anyone that I can call to help you, like a minster or a family friend?”  They may have questions that you can’t answer, like what caused their death.  Don’t guess – say you don’t know if you don’t know. 

Nuts & bolts: Explain the process from here.  This is system-specific, so make sure you know your jurisdiction’s rules.  In my system, any out of hospital death needs police involvement and a coroner’s consult.  Explain that to the family.  I explain that “the police are well versed in the process and will take good care of them.  Joe will probably have to go to the medical examiner’s office.”  Explain that your treatments have to stay in place for now, so the IV line and breathing tube are still there. 

If the police officer is good with it, give the family a chance to go sit with Joe and say their goodbyes.  In my system, the ability to do this is dependent on factors that the police know, but I don’t.  So I leave it up to the cop.  It’s something that I wouldn’t have realized, not wanting to do it myself, but it can be deeply helpful for some people to be able to say goodbye directly to their loved one.

Give card: This step is really more for victims’ advocates who deal in death notification.  If you want to give a card, knock yourself out.  But one way or the other, I would replace this by handing off the care of the family to another professional.  Introduce them to the police officer.  Wait on scene with them for the officer to arrive, if need be, and introduce them. 

Relating back to the pronouncement I explained at the beginning of this post, don’t start moving equipment or responders out until at least the ‘Space’ step.  Duh.

Good things to say:

“I can’t imagine how difficult this is.”

“I’m so sorry for your loss.”

“It must be hard to accept.”

“How can I help?”

“I know this is very painful.”

Dumb things to say:

Anything religious: “This is a blessing because…”

“You’re lucky that at least…”

“Get a hold of yourself.”

“You don’t need to know that.”

“I can’t tell you that.”

“Things always work out for the best.”

“I know how you feel. My __ died last year.”

Many articles that explain the death notification process suggest allowing the family to view the resuscitation process.  It makes some sense, theoretically, in the right setting.  Even a fairly incompetent resuscitation seems skilled to a layperson.  The family gets a feeling that “everything possible was done.”  They probably won’t know that you can’t get the tube unless you say. “Dammit, I can’t get this tube!”  It makes me a little uncomfortable, though.  My practice is to update the family at several points during the resuscitation if I can.  There can be times when we’re just waiting for the 2 minute cycle of CPR to get done and can go give a situation report to the family then.  Think of this as prepping them for the potential notification.

The final point I want to make: Don’t be a wimp.  This is part of your job.  Hitch your big boy or big girl pants up and go do it.  Do not transport futile resuscitations in order to pass off the notification process to an ED.  Family members of pronounced patients report who were transported report less positive interactions with providers and more anxiety rushing to the ED than did pronounced patients.^1,2  You’re giving the family hope when you drive off with their loved one, sirens wailing and lights flashing.  Remember, no notification is easy but you have one of the relatively easier ones.  Picture how much more difficult it is to a police officer who has to knock on a door, wake someone up, and start from scratch.  Surprise!  And then throw in body identification.  Picture how much more difficult it is for a physician to explain brain death versus death death to someone grieving.  Or organ donation requests right after the notification. 

Your skill at giving death notifications has a huge impact on how the deceased's family will process the change in their lives.  Do it right.

1. Edwardsen A, Chiumento S, Davis E. Family Perspective of Medical Care and Grief Support after field termination by EMS Personnel: A Preliminary Report. Prehosp Emerg Care. 2002;6: 440-444

2. Schmidt TA, Harrahill MA. Family response to out-of-hospital death. Acad Emerg Med. 1995; 2(6): 513-518.