Delivering news of sudden death: Make sure you inflict no harm
Training needed to help physicians deliver news effectively, empathetically
American physicians are recognized by many as leading the world in delivering the best medical care, but their expertise in delivering news of death to patients’ families is less than stellar, according to a death issues educator.
"I can’t tell you how many times I’ve seen doctors do just a horrific job at delivering death notification," says Lisa Dinhofer, MA, CT, CTBS, a Frederick, MD, grief counselor, transplant consultant, and educator on death issues. "But it’s not because they’re bad people; it’s a training issue."
She describes the death of a loved one as "a one-time opportunity."
"You only get one chance to handle it right, and it has to be as gentle, truthful, and honest as can be," Dinhofer says. And not only do botched death notifications result in hard feelings and lawsuits, she warns, they can cost the United States thousands of donor organs each year.
"The biggest of the standards of ethical practice is nonmalfeasance — to do no harm," Dinhofer explains. "And when you deliver a death notice badly, you are doing harm."
Bad outcome, then handling a difficult task
Notifying a family about a loved one’s death is one of the most stressful types of communication in all of medicine, says Cherri Hobgood, MD, associate dean for curriculum and educational development at the University of North Carolina at Chapel Hill School of Medicine.
According to Hobgood, physicians report coping with reactions of deceased patients’ families is a source of great concern to them, made even more stressful when the deaths are associated with grief reactions to the deaths or anguish over decisions regarding autopsy and organ donation, and when the cause of death is not known.
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Table 1. Pearls for Delivery of an Effective Death Notice
Source: Lisa Dinhofer, MA, CT, CTBS, Frederick, MD. |
Residents, she says, are particularly affected by these situations.
"This is a hard thing to do, to tell someone their loved one has died," Hobgood says. "But residents are particularly emotionally exhausted after leaving a code they worked hard on; and while it’s hard for any physician to lose a patient, residents feel particularly flat [when a patient dies], and then they have to do something else difficult: speak to the family about their loss."
Handled badly, everyone loses
Rather than being trained in school, most young physicians learn on the job how to deliver death notifications but that is not necessarily a good thing, observes Dinhofer.
"They learn on the job, but they’re taught by physicians older than they are who also received no training and who also do a terrible job at it," she says.
As a former family advocate within an organ procurement organization, Dinhofer often was not far away from physicians as they delivered news of patients’ deaths to family members.
"I remember being in the room with one young doctor who had no experience at delivering death notifications, and he was stumbling and bumbling, and as his anxiety went up, so did the family’s," she ays, "until he finally turned to me and said, Help me.’"
In educating hospital personnel on delivering death notifications, Dinhofer says she works with physicians to help them understand some truths about death and their role in families’ grief processes — starting with accepting death as part of health care and appreciating the lasting effect their delivery of the news of a patient’s death will have on the family. (See Table 1, on right.)
When a family already traumatized by the sudden injury or illness of a loved one is further hurt by poor delivery of the news that the patient has died, physicians, everyone involved loses, says Dinhofer.
"Health care providers and social workers have a duty to train their underlings to do this well, and I am sure risk management at any hospital would appreciate it," she says. "Oftentimes, an angry family’s first call when they get home is to their lawyer. Sometimes they call their lawyers right into the [hospital] unit.
"It creates bad [public relations] for the institution, because when patients’ families leave the hospital, they talk about that physician. They bring that physician home with them, and he or she stays in their experience [of the death] forever."
Standard operating procedures needed
Dinhofer says she is constantly surprised by the number of hospitals that don’t address death notification in their standard operating procedures (SOPs).
"That’s how you defend yourself when you get into court. Your lawyer says, Let me see your SOP and how you train your people and what quality measures you put in place to make sure this is done right,’" she explains.
"If you have a family leaving a hospital reeling from the way a death notification was given, and your hospital doesn’t have a SOP, you’re already behind the eight ball," Dinhofer adds.
While hospitals often don’t think about SOPs regarding death notification until they’ve been sued over a badly handled incident, she continues, hospitals should make death notification training a standard part of their training programs, and should establish SOPs that specify who tells families about patients’ deaths, how it should be delivered, what information to give (organ and tissue donations, what "brain death" means, etc.), and what resources (clergy, social workers) should be considered for involvement.
Straightforward, empathetic approach favored
Both Dinhofer and Hobgood point out that a badly handled death notification is not just one that is handled without empathy toward the family — timing, too, is important, particularly when organ donation is an issue.
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Table 2. GRIEV_ING Mnemonic for Conducting Death Notifications
Source: Cherri Hobgood, MD, University of North Carolina at Chapel Hill School of Medicine. |
Dinhofer says bringing up organ donation and autopsy before the family clearly understands that the patient is dead is one example of a badly handled death notification. Organ donation, she asserts, should not be brought up until the physician has done a death notification and the family clearly understands that their loved one is dead.
"How death notification is handled has a huge effect on organ and tissue donation," she says. "I can’t tell you the number of organs and tissues lost every year because of damage done by hospitals in their treatment of families before the organ procurement team even arrives."
On the other hand, death notifications handled skillfully can go a long way in winning family support for organ and tissue donation.
"Physicians should have a competence level to handle this very real part of health care," says Dinhofer. "Death is the natural outcome of every patient’s life story, and since that’s the eventual outcome, health care professionals need to broaden their definition of health care to include death."
Hobgood says physicians often find themselves worrying more about what information they need to give the family about the patient’s death than about how they deliver that information.
"The empathetic communication is overshadowed often by Was I supposed to tell them this? Am I supposed to tell them that?’" she says. "We instruct [residents] that when they deliver a death notification, they need to be clear and to say the words he died’ or she died.’"
Then, the physician should verify that the family understands what has happened, and only then should the topics of organ donation, funeral, and autopsy be broached, Hobgood says.
Because emotions run so high for physicians and families during these encounters, Hobgood says, many authors have suggested that physicians use an outline of potential topics to discuss during a death notification to make sure important information is conveyed and understood.
In response, Hobgood developed a tool to provide physicians with a framework to guide them through encounters with bereaved families. The mnemonic "GRIEV_ING" serves as a reminder of things to consider when delivering a death notification. The mnemonic serves as a checklist of steps to take, topics to cover, and resources to enlist in delivering the news of a patient’s death. (See Table 2, on right.)
Hobgood says that in a study of the mnemonic’s effectiveness, she found it worked well in the short and long term: Residents who learned the GRIEV_ING steps felt better prepared going into the encounter with families, said they performed the notification more effectively, and the mnemonic was retained well and still was in use consistently when residents went through a refresher course one and two years after first being trained.
"It’s helpful even to established physicians, because it gives them a structure," says Hobgood. "[Delivering news of death] is a hard thing, and it’s not something that gets easier with experience because of the emotional overlay."
Sources
- Lisa Dinhofer, MA, CT, CTBS, Certified Thanatologist, Transplant Consultant, and Death Educator; Owner, KoDen LLC, Frederick, MD. E-mail: [email protected].
- Cherri Hobgood, MD, Associate Dean, Curriculum and Educational Development, Office of Educational Development, University of North Carolina at Chapel Hill School of Medicine. E-mail: [email protected].
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