Chapter 300: Death Notification and Advance Directives

DEATH NOTIFICATION

Death notification is perhaps the most difficult, emotionally laden communication that physicians must perform. In most situations, the notification of death occurs during the first meeting of the emergency physician with the deceased patient's family. The notification often comes after extensive resuscitation efforts, creating a upheaval of emotion for the physician and ED staff leaving the team emotionally and physically exhausted.^1,2

For survivors, death notification is a life-altering event. The language used during the communication, the venue, and the characteristics of the individual delivering the news create indelible memories for the family.³

EFFECTS ON SURVIVORS

Because death that occurs in the ED is frequently sudden, unexpected, and often violent, survivors can develop complicated bereavement and/or posttraumatic stress disorder.^4,5,6,7 Death notifications that provide limited or incorrect information about the death or occur in chaotic settings with limited support may exacerbate the grief reaction.⁶ When properly performed, death notifications may mitigate substantial negative effects on surviving family members.⁸ A well-delivered death notification can reduce the incidence of posttraumatic stress disorder in the families of patients who died suddenly, particularly notifications involving the loss of a spouse or the death of a child.⁹

EFFECTS ON PHYSICIANS

Physicians find death notification physically and emotionally difficult, with evidence of increased heart rate, heart rate variability, and cortisol levels immediately after the event.^10,11,12,13 Common emotional reactions in emergency physicians faced with the task of death notification are sadness (60%) and disappointment (38%), resulting in insomnia in 37%.¹³ The cause of death, the patient's age, the presence of family, and the similarity to self are the most common reasons cited by emergency physicians for powerful impact of a recent death notification experience.^13,14 The need to rapidly switch between the cool emotional state required to lead a resuscitation and that of a warm empathic informant bearing difficult and tragic news may exacerbate this situation for the physician. The following factors also increase the stress level for the physician: racial and ethnic differences between the physician and the family, lack of a clear family leader, a nontraditional family (e.g., broken or blended), and situations in which the physician is personally emotional or cannot control his or her own reaction.¹⁵

Skillful death notification is a priority in emergency medicine practice.^2,3 Protocols to enhance communication skills for delivering bad news in the ED improve satisfaction of survivors.¹⁶ The use of successful methods to communicate effectively with families may also mitigate physician burnout and reduce stress on ED staff.¹⁷ First, providers must seek to understand and anticipate their personal emotions. Second, providers must learn to use compassionate communication methods in the delivery of this information. Third, providers must provide ...