ED staff may spend significant time managing deaths in the prehospital setting via the EMS units and personnel they supervise. The patients (or surrogate decision makers) frequently do not want resuscitative efforts or further acute medical interventions. Yet standard practice in many areas is to proceed with resuscitative efforts and, in most cases, to transport the patient to the ED. While this may be unavoidable in situations where the death occurs in public, ED leadership has a number of methods to lessen this problem with expected deaths that occur in homes and skilled nursing facilities (SNFs).
Expected deaths at home may be associated with patients enrolled in home hospice or receiving other end-of-life treatment. In these cases, neither patients nor their caregivers desire additional, often expensive, discomfiting, and intrusive medical interventions other than palliative care. Yet EMS and police protocols often require that ambulances respond and crews provide treatment and then transportation to the ED. This “last rite” from emergency medical providers is neither welcome nor viewed positively by the public.
To remedy this situation, managers should consider implementing an easily used, readily available Prehospital Advance Directive (PHAD). This allows the EMS to not institute resuscitative measures in appropriate situations and to permit them to pronounce death on the scene rather than transport the body to an ED. Many PHAD examples exist, with Arizona's statute being a clear and simple model that has been successfully used for nearly 20 years (www.galenpress.com/extras/extra1.htm). Written by an emergency physician, the law's passage demonstrated the type of coalition both useful and often necessary to successfully change existing systems.1 The coalition included the state medical, nursing and bar associations; the AARP; and some elder care groups. Three unique elements of the statute are that it requires only an adult witness rather than a healthcare provider's agreement, it is available online, and only a “good faith effort” is needed to identify the patient. Alternatives to working through the legislature are to implement PHADs through the state Department of Health or the regional EMS council.
Skilled Nursing Facilities
Death frequently visits SNFs. Most of their patients with dementia reside there at the end of their lives, and many (along with their surrogate decision makers) have no desire to receive acute medical treatment other than palliation, if necessary. Yet frequent ED visits are the norm, rather than the exception. Patients, surrogates, EMS personnel, and ED staff wonder about the benefit of these visits. The ultimate abuse results when patients dying an expected and natural death are sent to the ED “for resuscitation.” Everyone involved understands that this travesty contravenes the duty to first do no harm but feel powerless to prevent it. ED leadership can change the situation by working with SNFs and the EMS to implement a system whereby SNF providers can write “Do-Not-Hospitalize” (DNH) orders (Figure 24-1). Successfully used for decades, these documents spare everyone the travesty of participating in the futile exercise of trying to resuscitate the “truly dead.”2-5
Do-not-hospitalize order (sample).
Patients requiring resuscitation constitute most of those who die (or try to die) in the ED. (Relatively few patients come to the ED to die and refuse resuscitative efforts—unless it is done via surrogate decision makers or the discovery of a previously completed advance directive.) The clinical efforts surrounding resuscitations vary, but, unfortunately, there is little variation in the abysmal way that relatives and others accompanying the patient are treated. This leads to survivors' negative feelings about the ED and an often less-than-gracious interaction with the ED staff. From an ED management viewpoint, this is both unnecessary and correctable.
Those awaiting news of their loved one often complain that they lack adequate and timely information about what is transpiring. Added to that, the room in which they are sequestered—if they aren't relegated to the waiting room—is often at some distance from where the resuscitation is occurring.
ED management can help ameliorate this situation. One way is to have key relatives witness resuscitation attempts; this produces remarkable results (Figure 24-2).6 Pioneered decades ago in pediatric intensive care units, increasing numbers of EDs and ICUs now permit this. The procedure is to ask 1 or 2 key relatives if they wish to observe the resuscitation in the company of an experienced clinician (nurse, social worker, chaplain) who can answer their questions; they may leave whenever they want. They are told that they must not interfere with the medical team, but in reality this is never a problem.
(Source: Iserson KV. Grave Words: Notifying Survivors About Unexpected Deaths. Tucson, AZ: Galen Press, Ltd.; 1999.)
The resuscitation team is told that “family is in the room” so they are not surprised. On every occasion, the resuscitation becomes one in which only vital communication is done and staff concentrate on what they are doing even, if possible, putting in a bit more effort. The caveat for the team is that they may not ask the relatives the clinical/professional question of whether they should stop, but only inform them that “we must stop.” From the survivors' viewpoint, they never have to ask, “Was everything possible done?” They saw what transpired; that is enough.
For resuscitations involving only the ED staff, management can make family attendance department policy if the physician and nursing staff “buy in” to the practice. It helps to also have the chaplains and social workers join in discussions, since they may be active participants. For resuscitations involving others, such as a trauma team or pediatric intensivists, they also need to be involved in the discussions regarding possible implementation.
Experience shows that, while there may be initial reluctance to initiate this policy, once the ED staff have some experience with it, they become enthusiastic supporters. How often do ED staff get thanked after an unsuccessful resuscitation attempt? It only seems to happen when survivors have observed their efforts.
ED deaths may occur after a resuscitation attempt or when patients are brought in dead. Death, especially when it is sudden and unexpected—as often happens in the ED—shocks and devastates patients' family and friends. For them, it is a seminal, life-changing event, with every nuance burned into their memories. Furthermore, although they may not consciously acknowledge it, ED personnel may also be deeply affected by such losses, despite their almost constant exposure to life's disasters. This emotional component makes death notifications and dealing with the survivors both vitally important and very difficult.7
Even though notifying survivors of a sudden, unexpected death is one of the most difficult parts of emergency clinicians' job, they rarely are taught the skills necessary to perform this task. Whether in-person or via telephone (Figure 24-3), notifying survivors is emotionally draining: 70% of emergency physicians find death notifications to be personally difficult. Perhaps this is because only one-half received any type of death notification education in medical school and only one-third received any such training during residency.7,8 Moreover, there are a variety of significant barriers to successful death notification in EDs (Figure 24-4).
(Source: Iserson KV. Bereavement and grief reactions. In: Wolfson AB, Hendey GW, Henry PL, et al, eds. Harwood-Nuss' Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:817-820.)
Barriers to effective ED notification.
(Source: Iserson KV. Grave Words: Notifying Survivors About Sudden, Unexpected Deaths. Tucson, AZ: Galen Press, Ltd.;1999:171 [with permission].)
Death-notification protocols can assist ED staff when they must notify survivors, either via telephone or in-person.6,9-11 Why use protocols? It has been claimed that “effective grief support cannot be reduced simply to a protocol-driven response.”10 It is true that no protocol can anticipate every eventuality; every notification will differ in some way. Neither can it enable notifiers to break bad news painlessly. It can, however, help notifiers prepare for their task and understand what to expect. Protocols combined with staff education have had a significant effect on how survivors perceive and respond to sudden-death notifications.6,11
Obviously, optimal survivor notification, especially in cases of sudden unexpected deaths, includes the staffs' emotional commitment to and personal investment in the process. There must also be a way to begin learning this difficult task and to measure the quality of notifications. Protocols fulfill these 2 goals.
For many in the healing professions, as well as other professionals tasked with notifying survivors of sudden, unexpected deaths, protocols have become a standard method of learning complex material. Certainly, as they become more experienced, these professionals will deviate from the protocols to meet the needs of individual situations. But protocols provide both notifiers and death educators a framework to build on.
ED management must make such protocols readily available, use educational sessions to practice using them in simulations, and openly discuss the anxiety felt when performing this difficult task. Possibly even more difficult than death notification is asking for organ and tissue donations, but here, protocols can also be useful.9 (The process is so difficult that specially trained personnel now often assume this task.)
ED managers should involve EMS personnel and chaplains/social workers in these educational sessions, since separate death-notification protocols exist for these groups.6,9 Also, the experiences and comments of these professionals during the sessions provide substantial validation to the importance of learning this material.