blaze1306

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This may be a stupid question and I apologizie if it is. When was your first next of kin notification of a fatality and how did you handle it? Was it as a med-student intern or in residency.As a pre-med i'm almost certain I want to go into EM, I want to make sure i'm the type of person that can handle it.
 

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blaze1306 said:
This may be a stupid question and I apologizie if it is. When was your first next of kin notification of a fatality and how did you handle it? Was it as a med-student intern or in residency.As a pre-med i'm almost certain I want to go into EM, I want to make sure i'm the type of person that can handle it.
Third year medical student.

mike
 

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Never done this yet, I have told 2 patients that they have HIV though. The one opportunity I had to see an attending do this an overeager student (going into Ortho, not too much death there) talked to the attending before I could.
 
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Did it as an EMT-Intermediate on several occasions, including an unusual case where we were forced to terminate the resuscitation on scene after consultation with medical control (middle of a blizzard, no transport, giant clusterf--k). It's the only time I have ever heard of an Intermediate Life Support crew using the termination of field resusciation protocol.
 

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I've done it several times, and unfortunately it doesn't get easier. I hate telling people that their loved ones have died. I learned a 4-step process in medical school that seems to work the best:

1. Ask them what they know of the situation (get them to tell you what's they think is going on, what they witnessed, etc.);

2. Summarize things that you did and what you think happened;

3. Inform them that their loved one has died (using the word "die" to eliminate any confusion);

4. Console and leave room for questions (specifically ask if they have any questions).

Then I allow them to see their loved one.
 

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What do you guys do when family isn't already in the hospital? I always hate what follows in the 3 am phone call- "Mrs. Smith, can you please come to the hospital?" I don't like telling people on the phone, but they have often guessed when you wake them up.
 

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Annette said:
What do you guys do when family isn't already in the hospital? I always hate what follows in the 3 am phone call- "Mrs. Smith, can you please come to the hospital?" I don't like telling people on the phone, but they have often guessed when you wake them up.
There are some times that it's better to tell a person over the phone (i.e., they live 60 miles away). I hate informing people over the phone though, but I have done it before.
 

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First time was as a MS3.

Many times as a resident. It never gets easier. Phone, in person- at the time, or later.
 

blaze1306

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So it seems the first time was as an MS 3? Thats seems a little early in medical training, but if i'm going into EM i'd rather get used to the idea earlier rather than later. The four step method seems to very useful. I do have a question about the word "die". Does that seem to work better than "passed away"? I know your job is not to soften the blow but is there really a lot of confusion at the notification?
 

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Yeah they teach all of us that when breaking news you have to be clear and the term passed away sometimes has people think that they are just asleep. You do use the words "die" etc. Words that have only one meaning.
 

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blaze1306 said:
So it seems the first time was as an MS 3? Thats seems a little early in medical training, but if i'm going into EM i'd rather get used to the idea earlier rather than later. The four step method seems to very useful. I do have a question about the word "die". Does that seem to work better than "passed away"? I know your job is not to soften the blow but is there really a lot of confusion at the notification?
"Passed away" can still be misinterpreted by some cultures.

I once told a Spanish family that their father was about to go upstairs (meaning he was being admitted and going to a room on the ninth floor). I couldn't figure out why they broke into tears until someone who spoke Spanish talked to them and later told me they misinterpreted "going upstairs" as their father dying.
 

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I have given many notifications as an EMT and patient advocate for my town's volunteer EMS service. Our PAT (patient advocate team) consists of about 8 EMTs who will respond to really bad calls such as cardiac arrests, serious MVAs, calls involving kids, etc. Once on scene we help explain things to family members, bystanders, etc so the medical crew can focus on the patient. If a code is called or there is a DOA, we offer to stay with the family and explain the medical examiner/funeral home procedures, help call other family or friends, and generally be supportive. We also occasionally help the poice department give death notifications.

The four steps listed above are a great basic outline. Every situation is different and people react very individually to hearing of the death of a loved one. I have seen people walk away in denial, lash out to hit EMTs, crumble to the ground, and accept peacefully that their loved one is now in a better place. It can be impossible to tell what the reaction will be until you say those words. It is never easy to give bad news of any kind. However, I have found that most people appreciate direct, confident statements. Some people want to know every detail you can provide and this gives them closure. Others do not want to know any details. Take your cue from the family and you will be fine. Usually, the most comforting words you can give the family is letting them know that everything that could be done was and that the people trying to save their loved one cared.
 

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blaze1306 said:
So it seems the first time was as an MS 3? Thats seems a little early in medical training, but if i'm going into EM i'd rather get used to the idea earlier rather than later. The four step method seems to very useful. I do have a question about the word "die". Does that seem to work better than "passed away"? I know your job is not to soften the blow but is there really a lot of confusion at the notification?
No, you should tell them they "died."

I disagree with some of the others, it does get easier with time; maybe it's because I kill too many people.

You alleviate most of the physician stress when you realize that there's no "good" way to rip someone's life apart by telling them a loved one died, only a humane way.

I also usually allow 2 people max to be present when I give news; I don't go out into a crowd of 15 people to give notification, it can and has become a mob scene. I am especially cautious with trauma patients. I usually have them put in the grieving room and kneel in the doorway and tell them (so it looks like I'm being the good doctor by "sitting down") where I can also bolt out if things go nuts. Remember: emotionally trying times + emotional immaturity do not make for a great mix.

I usually use a similar pattern as described:

"What have you been told so far?"
"When he came in, he was not breathing.."
"His heart was not beating..."
"We did XXX" (quick)
"And I'm sorry to tell you, he died."
I don't put a lot of effort into giving gigantic explanations after that, because almost nothing is processed.
I offer social work and usually a "I don't think he suffered" if it's a reasonable assumption (SAH, trauma)

mike

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I agree with all of the above, including that it does get easier with time. The only tough ones for me are telling parents that their kid died. Or when a younger adult dies, and you have his wife and kids there....As far as the gomes, no biggie....You figure the family has to have some idea that their hundred year old great grandma was going to kick the bucket sooner or later....

The key to being a good "notifier" is that you have to be genuine, and make the family believe that you care and feel bad..... Make sure to sit down if there is a seat available. Don't be afraid to put your hand on the shoulder of one of the family members. Lastly, ask them if they have any questions and tell them that if they do have any questions, that you will be available to answer them...

Offer the family the opportunity to view the body. Tell them what to expect (ETT tube, lines, etc). Make sure the body is ready to be viewed, and that a hand is exposed for them to touch. I will sit the bed up a little, put a sheet over up to the neck, and put the hand out and rest it on the abdomen/chest. Make sure there are tissues and a couple of chairs in the room. Don't rush the family out. Let them take their time to say goodbye.

I suggest that when you are in an ER, or whatever rotation that involves notifying family members, you ask the doc if you can tag along. I did this many times as an ER tech, and it was VERY useful. Also, during your rotations, ask to go with the person and watch them one or two times before you do it. This will help you at least get familiar with the environment and the reactions.
 

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When I was an undergrad I worked as a unit clerk in an ICU at a regional referral center. We had a pregnant female with a CVA airlifted from a rural area that died shortly after she arrived. When her father arrived several hours later he came in through the waiting area where a large family was grieving, so I figured he knew already and brought him back to the room. As he looked down at her peaceful body he asked me "Is she sleeping ok?" and I ended up explaining to him that she was dead. I was so not ready to do this.
Normally I would have had the RN bring the family back, but of course she was in a code at the time.
 

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southerndoc said:
I've done it several times, and unfortunately it doesn't get easier. I hate telling people that their loved ones have died. I learned a 4-step process in medical school that seems to work the best:

1. Ask them what they know of the situation (get them to tell you what's they think is going on, what they witnessed, etc.);

2. Summarize things that you did and what you think happened;

3. Inform them that their loved one has died (using the word "die" to eliminate any confusion);

4. Console and leave room for questions (specifically ask if they have any questions).

Then I allow them to see their loved one.
This is an excellent protocol.

Asking them what they know is really important because it tips you off to how they will react. They may say "Well I saw EMS doing CPR so I know that's bad." which means they have a general idea and your job is easier or they may say "I saw EMS doing CPR so I'm sure they woke right up just like on TV." which means you have a tougher job.

I will sometime use "passed away" if the family was expecting the death. Otherwise I use "died."

Once I had a dying pt in the ICU and I told the family (Mexican, spoke some English) that the pt was going to die. I told them this very bluntly in English and in Spanish and with an interpreter. They just didn't get it. I left for rounds and the nurse called me about 30 min later and said they finally got it and they wanted to talk to me. What finally got through? The nurse asked them if they wanted a priest. Died, muerte, toast, all nothing. Priest? Whoh! You mean she's gonna DIE? Weird.

When you let the family come to be with the pt after make sure that if you did any invasive procedures like chest tubes, central lines, cut downs, etc. that you cover the pt with more than a sheet. Otherwise these big blood stains will slowly appear while they grieve. Also make sure that the vent and the monitor are off or someone will misinterpret signs of life.
 

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As a paramedic, I told quite a few people that their loved ones were dead/dying. Soemthing that I started doing to make it a bit easier for myself, as well as the staff at the emergency department, was to have a discussion with the family prior to leaving the scene. After I had done all I could do, and if it looked as if the patient probably would not make it, I would take a moment to speak with the family as the patient was being loaded into the ambulance, or while my partner was still working on the patient (if we were calling it on scene). I would explain what we found when we got there, what we had done, and how the patient responded. Sometimes I would explain the prolonged lack of oxygen to the patients brain or whatever else the reason for their impending death was. I would add something like "We are doing everything that we can do, and we will keep trying, but it does not look very good. His chances of living are very slim." I used variants of this depending on the reaction and education of the family. It really seemed to soften the blow later, as they expected bad news. I feel it was even more important when the family saw a positive response and started to get really hopeful (ie you get a pulse back on a cardiac arrest). When they were finally told the patient died, they knew that everything was done that could be done. If they lived (rarely), you were a miracle worker.

I also think it helps the family when they get to see the resuscitation. Many physicians I worked with also did this. It takes the mystery out of everything and seems to bring them some closure when they saw that people were working very hard on their loved one.

As far as telling people that were not at the scene, I like the 4 step process that southerndoc provided, as I have seen some very adverse reactions from the family. And yes, some people do not grasp "passed away", "In a better place", "Pushin' up daisies", or any other phrases often used to soften the blow. Dead is a unambiguous word...
 

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An EM doc I shadowed during my pre-med days told me he had been physically assaulted on several instances after notifying a family member of the death of a loved one...so much so that security had to be close by to deal with it. I just found that so hard to grasp. Is that really common? Does that seem to happen to everyone?
 

blaze1306

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I can't believe physical confrontations are happening!! I guess I never really considered the fact that some uneducated family members, in the throws of extreme grief can blame the messenger to this extent. I cannot fathom having to consider weather or not to have security accompany me to a notification! If this is a common problem I certainly agree with the above post about only notifying 2 family members at a time. Do assaults happen often?
 

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We had a case where we were called for a "person down" call, and we arrive and find the patient dead- in fact VERY dead, full rigor. We checked her, and realized we couldn't do anything for her. So we told the family she was dead and the son comes un-F--KING-glued. He grabs my partner by the throat and orders us to do something- that he had just talked to her a couple of hours ago, blah, blah, blah. Well, we decided to "transport" her. We loaded her on the cot and get her in the ambulance (and then into a body bag as we rolled down the road) and call for sheriff's backup. The guy got a year and a half in jail for assault. So yeah, it does happen.
 

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Physical confrontations do happen and not just with "uneducated people". Anger is a natural part of the grieving process...however, some people jump past all the other steps and plunge into rage. The messenger or the first person they see often is the focus of the rage. Some people are not equipped to deal with such raw emotion in any way other than lashing out. They may throw stuff, punch the wall, or lunge at you. Certainly most people don't do this, but it does happen.

I agree with ditchdoc's post completely. If I have the opportunity to give the family the head's up on what is happening, I do. It gives them some concrete info during a confusing time and they understand what we are doing to try to save their loved one. This is particularly helpful on codes worked on scene. We often don't know much on scene and if I don't have answers I let the family know this as well.
 

blaze1306

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I agree the more informed the family is about the situation, i would expect the easier it would be to break bad news to them. another question I haver is I would like to work in Illinois or St. Louis hospital. I am concerned about being a EM doctor working with Trauma surgeons. A recent episode of a reality show on TLC channel(I can't remember which one, Life in the Er or something)showed a busy ER in Oakland, Califonia I believe. The Trauma surgeon was working the interesting cases and the EM doc was relegated to the fast track beds as nothing more than a glorified resident. Is this common? I would like to work on the interesting cases also and not be looked down upon by surgeons. I know every hospital is different. But one of the main draws for me to EM is the excitment of not knowing what will come in next, I'd like to be in the thick of saving a criticaly ill pt not in the back writing scripts for antibiotics all day.
 

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Not every interesting case is a trauma. There are WAY more interesting medical cases that don't have anything to do with surgeons. The traumas are the hollywood cases. The stuff TV shows are made of. But when people ask me if I've seen anything cool lately, the traumas never come to mind, it's always the cool medical cases. Traumas are so cookie cutter anyway, ATLS, primary and secondary survey, etc.
 

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How much formal training have you guys gotten in giving bad news/code status discussions in medical school and in residency?

My program seems to rely exclusively on peer education, with rare exceptions when a senior resident has the attending address the processes, which is so hit-or-miss. I even arranged two evening lectures on my own because it seemed such a shame that short-shrift was given to something so important in our careers. I know most of the residents are not comfortable with code discussions because I've been called on consults for what would seem to be simple code status discussions. I wonder if the attendings are not so comfortable with this stuff either.
 

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Annette said:
How much formal training have you guys gotten in giving bad news/code status discussions in medical school and in residency?

My program seems to rely exclusively on peer education, with rare exceptions when a senior resident has the attending address the processes, which is so hit-or-miss. I even arranged two evening lectures on my own because it seemed such a shame that short-shrift was given to something so important in our careers. I know most of the residents are not comfortable with code discussions because I've been called on consults for what would seem to be simple code status discussions. I wonder if the attendings are not so comfortable with this stuff either.
There's a woman at UNC (who is very likely going to be the first female president of ACEP) that does a program that is in depth on death notification (it's a similar model to the one southerndoc mentioned, but much more comprehensive and in depth and structured), and we had to "play act" various roles. Of course, being the histrionic actor PRN, I did a good job of being that person that just flips out when told granny has been taken to Jesus.
 

mikecwru

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blaze1306 said:
I can't believe physical confrontations are happening!! I guess I never really considered the fact that some uneducated family members, in the throws of extreme grief can blame the messenger to this extent. I cannot fathom having to consider weather or not to have security accompany me to a notification! If this is a common problem I certainly agree with the above post about only notifying 2 family members at a time. Do assaults happen often?
It happens not uncommonly. Like I said, when I do trauma notifications, I kneel in the doorway (my version of "sitting down" with the family). I do not let anything get in the way of the door. I've had a few family members start swinging at me. Usually, it's just people bouncing off the walls or rolling on the floor. I also don't address crowds. I usually notify two people in the family. It's just not safe (for me).


mike
 

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people get very emotional- collapse, hug you, wail, stoicism.

Sadly, I had to notify someone over the phone last night. 48. Core body temp: 81.1

Couldn't get his temp to budge above 82 degrees.
 

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Don't believe everything you see on television. And trust me...all traumas are not interesting.

blaze1306 said:
A recent episode of a reality show on TLC channel...
As far as the primary thread goes about notification of family members, some family members will in fact lash out. It can be hard to predict. But in addition to the other good advice in this thread about being blunt, etc., you should:

1) NEVER walk into a room of family members to do a notification by yourself. If you have to wait an extra couple of minutes to get a clergy member, social worker, or RN to go with you, then wait. You need somebody there to stay behind to help with the details (funereal/transport arrangements), call for help if things don't go well, and to help you get out of there in a reasonable amount of time so you can get back to the 8 living patients you're taking care of.

2) Keep the door open at least a bit (so any racket will attract outside attention) and by all means sit down, but keep your back to the door. Do not allow a patient or family member to come between your body and the nearest exit. This is a good general rule for any patient care situation, but especially important if you are going to be in a situation in which you might need to beat a hasty retreat.

I don't bring this up because every third family tries to wring my neck...that's quite a rarity. But you need to cultivate some safe habits "just in case".
 

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roja said:
Couldn't get his temp to budge above 82 degrees.

What did you try?

Reminds me of a biophone call a few years back for a guy found in a pond in the middle of winter. The paramedics wanted a pronouncement. The attending gave the usual winter time you're not dead until you're warm and dead lecture to which the paramedic said." No, No you don't understand he's frozen solid into ice more than a foot thick. It would take a jack hammer just to get him out"

In terms of the main thread. I do everything people mentioned above including sitting by the door and having clergy or someone with me to take over when I need to get back to the living but I have never been assaulted.
 

blaze1306

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I learn something cool about EM everyday.I'ts good to know I won't have to fight my way out of situations by myself.
 
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