One summer afternoon, as a light rain coats a winding two-lane road, a father with his three children in an SUV overcompensates on a turn. In the subsequent accident, they are broadsided by a minivan traveling in the opposite direction. As the vehicles come to rest, the aftermath involves two adults and four children — three noncritical, two critical…and one fatality.
Arriving with the second-due advanced life support (ALS) unit, the first thing that strikes me is that some of the EMTs and firefighters on scene are crying. Everyone is moving around in that tightly contained chaos of a major accident scene, with tears freely streaming down their faces. The cause of their dismay is in the SUV: the macerated remains of a little girl entangled in the remnants of her seat, a grim-faced firefighter attempting to cover the sight from bystanders and responders alike. Where is her family?
We check in with the ALS unit already on scene. One medic is already enroute to the landing zone with one of children from the SUV, a little girl with a traumatic brain injury. The weather is starting to turn; we have enough time to fly just one before the skies close up on us. The other medic is in the ambulance with the passengers from the minivan: a father and his son, both secured to backboards. The medic directs us to a third ambulance, indicating that the remaining passengers from the SUV, the father and his young son, are in it. Before walking away I ask him, "What does the father know?" The response is, "Nobody's told him yet."
My partner and I enter the ambulance. A young boy is secured to a long board on the stretcher, crying hysterically. His father sits on the bench seat, trying to console him with litany of soothing phrases that do not wholly disguise the panic and fear in his voice. The volunteer EMT who had been left to care for them is overwhelmed and glad to see us.
The father is obviously injured, but absolutely refuses any attempt at intervention or care — he is focused solely on his son and, ultimately, all his children. He begins asking about his daughters — what is happening with his girls? My partner and I look at each other in dismay. What should we tell him? "I'm sorry, sir, but one of your girls is on a helicopter, and I have no idea how badly her brain is injured. Your other daughter is practically cleaved in two in what's left of your vehicle. Oh, and because you and I have never met, I have no idea which daughter is who."
We know what this information will do, how it will devastate him and undermine any chance we have at an appropriate level of care for him. But how do we not tell him what he wants to know? Do we lie? Do we ignore it? What if you were the parent? All these things jumble together in a Gordian knot that tongue-ties you and leaves you flailing for answers.
"What About My Girls?"
As a personal rule, I do not lie to my patients. I may omit, I may reword, but ultimately, if you ask me a direct question, I will answer you with the truth as best I know it. I think there needs to be an inherent trust between patient and care provider. Once violated, that is never recovered. And not just on a personal level, but with all providers to come after you. They won't remember your name, they won't be able to pick your face out of a line-up, but they will absolutely remember what you said to them and how it made them feel.
"How medics relate to survivors is vital, since at this pivotal moment, memories are seared into their minds and their behavior patterns may be radically altered. Even years after the event, many survivors recall not only the tone of voice and manner of speaking, but also the exact words medics said to them…Sometimes, EMS personnel don't have to say anything. Their attitude and non-verbal behavior say it all. This is especially true during rescues or body recoveries."
—Kenneth V. Iserson, MD
Grave Words: Notifying Survivors About Sudden, Unexpected Deaths
Cradling an injured arm, the man clasps one of his son's hands tightly, rocking slightly on the bench seat. Any attempts to care for him are rebuffed. He asks again: "What about my girls?" I look up, over the boy, to my partner sitting at the head. We exchange a horrified glance that says we're both at an utter loss as to how to answer him. I can't lie, but how do I tell him the extent of the tragedy that's struck his family? He was ambulatory on the scene; even if it hasn't registered yet, he knows. Now I'm going to lie to him? The dead girl's brother is sobbing on the stretcher. If I lie, he'll know I did as well. He'll remember that. I would.
If we tell him, he'll want to go to her. We can't have that happen either. Damn, where is the driver? Maybe if we get some distance from the scene, we'll be in a better position. He's beginning to insist, the platitudes aren't working and he wants to know what's going on. I think about what I would want as a parent, and even I cannot answer it. Would I want to know right then and there, or later? He's not going to let us proceed without some answer he can process. So I take a breath and roll the dice. I tell him his son is with us and one of his daughters is being flown to the hospital via helicopter, and I let him process it, hoping it will buy us time. But eventually he does the math.
"I have three children, not two." He says that a few times, like a mantra. "What happened to my other daughter?" I meet his eyes, and he knows. All I can say is I'm sorry, there was nothing that could be done. He immediately tries to rise — he wants to see her. There is no way we can allow the remains outside to be the last sight he remembers of his little girl. My partner and I frantically try to convince him that he needs to remain in the truck. His son is injured and needs him there. Everything that can be done is being done. The little boy begins sobbing again, drawing his focus.
Between his son, his injuries and the sheer magnitude of what is happening, he finally gives in — to shock, to grief, to exhaustion. He grows quiet, passive. We speak to him quietly, calmly, guiding him onto a backboard and allowing him as much contact with his son as possible. He stops interacting, offering no resistance to our attempts to care for him. The EMT occasionally tries to draw him back out, goading him to speak. We tell her to let him be, it's a long ride and we're monitoring him. There's nothing any of us can say at this point that will help.
On arrival at the trauma center, I am pleasantly surprised to see not only the trauma team waiting, but grief counselors as well. They want to know specifically what we've said, what he knows, what was confirmed from the scene. I freely admit that we had no idea what to say, or how to answer his simple question.
Would I do it differently if presented with the same situation? I do not know. Ultimately we are the first-line patient advocates, and he was my patient. Telling him could have significantly complicated his care. Not telling him could have done the same thing, as he was growing progressively more insistent. It would have been so much easier just to say, "I don't know, sir; they're still working out there." But I did know, and if it were my child, would I forgive someone who did not tell me what I needed to know?
In EMS, death is our dance partner. We push it away, move it closer, move around it. Sometimes it leads, and other times it does not, depending on the skill of the dancer and the music being played. Do this job long enough, and guess what — you will see dead people. As a result, many of us are no longer taken aback at the sight of a lifeless body. This is both a blessing and a curse. It allows us to continue to function as medical professionals, but it also causes us to forget that most people will not process the site of that body in the same way — especially if it's a loved one.
Despite the fact that death is a basic truth of our profession, we are usually woefully unprepared to explain it to those left behind. Regardless of how peaceful or traumatic the circumstance, I do not know of anyone who likes to do a death notification. Assess, pronounce and get the heck outta Dodge—that's the deeply rooted sense of emotional self-preservation that wants us to avoid being snarled in whatever the grief-laden aftermath is going to be.
While awareness of the necessity of death notification education has increased, it has yet to be translated into a readily available curriculum. That does not mean we should remain ignorant of the impact we can have upon the survivors of loss. With a little education and some insight, there are definitive steps you can take in your approach that can help at least mitigate some of the emotional devastation and shock you are otherwise taking part in delivering. Remember that the deceased is not your only patient; in fact, he or she is no longer the priority — the loved ones on scene are also your responsibility, and your choice of words and actions will leave an irrevocable mark on their memory.
• Have a plan. It's awkward to be in a position of authority on a scene and not be able to answer questions. Know what your department protocols are for out-of-hospital death, and have a general idea of what your regional policies are for what comes next. Do the police come? Is there an investigation? Who moves the body? Where is the morgue or funeral home?
• Introduce yourself. This rehumanizes the uniform, serving as a small buffer to the information you're about to deliver. It also validates your information as coming from someone in authority, as well as giving the recipient a focal point for questions.
• Identify who's who. Figure out the relationship of those present to the deceased. If possible, try to give the same information to all the adults present at the same time; it will simplify things for them later. Consider segregating small children before speaking — their needs are different and are usually better met through adult family members. When asking, always use the present tense: "Are you the parents/husband/wife of…?" Referring to the deceased in the past tense can incite confusion and even anger; the information is just too new and has not been processed yet.
• Fire the warning shot. This is called the "preparation statement." It gives the person time to prepare, even on a subconscious level, for the bad news they know is coming. In many instances, they already know on some level what you are about to tell them, but they have not acknowledged it as reality yet. Giving them a brief review of events gives their psyche a moment or two in which to take that proverbial deep breath and prepare itself to process what you're about to say. If you are doing a field pronouncement post care, an example might be, "We arrived to find your father unconscious. He was not breathing, and there was no pulse, so we immediately began CPR…" Do not include large amounts of detail; they simply will not process it.
• Get to the point. This is called the "core statement." Make the information simple, keep it direct and try to deliver it with compassion. Using the word died or dead is important; there is a certainty to the terminology that helps survivors recognize what's going on. You may have to repeat things a few times. Their psyche will filter out what the person can't handle; it may take several attempts to get through.
• Express empathy. Avoid the use of euphemisms or platitudes. They can confuse and even anger stressed family members. Don't say "He's in a better place" — you don't know that. Don't say "I know how you feel" — you don't. Remember that sometimes, less is more: "I'm sorry for your loss."
• Be prepared for the aftermath. You have no way of knowing what somebody's grief response might be, and there is no hard or fast rule saying what it should be. You may find they accept the information tearfully, but rationally, or they may begin rending their shirts, pulling their hair and keening in ululations of grief. Some may need their hands held; some may need to be pulled away from the deceased. Remember that we are an increasingly diverse society, and while some of this reaction is certainly emotional, there may be a cultural component as well.
In some instances, there may be a significant physiologic reaction — you may be suddenly faced with a person suffering a clinical expression of stress, such as chest pain or respiratory distress. Just because the cause is emotional does not mean it cannot cause the body to go into shock — that is something to keep in the back of your mind as you're tending to the family on scene.
• Answer honestly. Don't assume or surmise on facts surrounding the death unless you are certain of the answer and will not be contradicted later on. A dishonest answer on scene may be revealed in other venues — for example, via autopsy, investigations or future court proceedings. It not only damages your credibility, but can cause irreparable harm to the family and shake their faith in the entire institution you represent.
• Give practical information. Know, or at least have an idea of, what happens next in the process. After survivors weather the first emotional barrage, there are plenty more to come, and often they frankly just don't know what to do next. This is where you can be of enormous help. Just by outlining what the next few steps typically are, you will give them some sort of structure within which to function while trying to sort everything out. If your department supports it, give out supplemental information on support groups or hotlines for grief counseling. Someone may pick up that slip of paper a week later and be grateful for somewhere to turn.
• Turn care over to someone else in authority. We are just the first in a long line of authority figures survivors will have to deal with. Very often, we are the only anchors they can rely on while they try to find some immediate footing. But we are not designed to be there long-term. When you've finished with your role and it's time to leave, make sure you do not leave them without a next contact point. This may be the police officers on scene or a hospice worker or staff nurse at an extended-care facility, but give them a source for additional questions. Do not leave them without someone to turn to.
Do No Harm
The dead, while unfortunate, are beyond our reach. Our focus is the patients in front of us, and above all we should do no harm. Telling a survivor on scene has the potential to go horribly awry, and the grief reaction could cause anything from exacerbation of an injury or condition to realistic safety concerns and scene compromise. Yet not telling them, especially if they're lucid, could pose exactly the same problems. Just like anything else in EMS, there is no blanket answer for every situation. You need to balance the needs of the patient alongside the resources and abilities of the providers and the patient's ability to process such devastating information at an already traumatic time.
If the above situation were to happen today, I do not know if I would do anything differently. I might stall more, waiting until we had some physical distance from the scene before addressing the father's questions. I might have just deferred the whole question until we got to the hospital, allowing the staff there to do it instead. That may have meant deferring any additional care for him for the better part of an hour. All I can say is that when he asked us the question, I felt like I was spinning — I had no answer I wanted to give.
Whatever the circumstance, it's clear that as a profession, we need more training on this. Death notification is stressful on providers. If providers have poor stress-management skills, then situations like these can trigger or worsen their own personal stress. Increasing their awareness and giving them better tools can do nothing but improve their ability to cope with the burden of truth.
When my grandmother passed away at home in rural Virginia, the crew that responded to my parents was not only professional, but compassionate. They treated her with respect, did the pronouncement and then remained behind. One medic sat with my mother and helped her make the necessary phone calls, speaking when she couldn't. His partner took the ambulance out to the main road in order to guide funeral home personnel to the house. My parents cannot tell me their names or what they looked like. But they can tell me everything they said, as well as every step of what was done for them in that difficult hour. Perhaps I'm just looking to return the favor.
Kenneth V. Iserson, MD. Grave Words: Notifying Survivors About Sudden, Unexpected Deaths. Tucson, AZ: Galen Press, 2001.
Janice Harris Lord and Alan E. Stewart. I'll Never Forget Those Words: A Practical Guide to Death Notification. Burnsville, NC: Compassion Books, 2008.
TRACEY A. LOSCAR, MICP, is a training supervisor at University Hospital EMS in Newark, NJ. A practicing paramedic for 20 years, she is active in multiple facets of pre-hospital education. Loscar can be found in ambulances and classrooms throughout northern New Jersey or via e-mail at email@example.com.