The GRIEV_ING© mnemonic is a method for delivering concise and accurate death notification. This mnemonic provides physicians with an organized, sequenced approach to deliver the news of death (Table 300-1).19 The structured organization of communication elements provides a coherent sequence of information to the family that is easy for providers to remember and ensures complete information transfer to the family.
TABLE 300-1The GRIEV_ING Mnemonic ||Download (.pdf) TABLE 300-1 The GRIEV_ING Mnemonic
|G ||Gather ||Assemble the family in a calm, considerate place for the discussion. Gather as many family members as time allows. This mitigates the need for multiple episodes of information delivery. This step may be done by ED support staff. |
|R ||Resources ||Ask for any additional support available to aid the family (e.g., hospital chaplain services, family ministers, additional family and friends [especially if the survivor is alone], and, if needed, an interpreter). |
|I ||Identify || |
Upon entering the room with the family:
Identify the deceased patient by name
Identify the family's state of knowledge. Are they aware of the situation, or will news of the death be unexpected?
|E ||Educate || |
In a concise manner, educate the family about the events that have transpired since the patient entered care. EMS should be included in this description.
Fire a "warning shot" by stating that you bring "very bad news."
Tell them the current state of their loved one.
|V ||Verify ||Confirm the news of death. State emphatically that their family member is dead. Be clear! Use the words dead or died. Express your sincere condolences. |
|_ ||Space ||Stop talking. Allow the news to settle and give them time to process the information. |
|I ||Inquire ||After a brief interval, ask if they have any questions. Then take the time to answer all of them. |
|N ||Nuts and bolts || |
Provide additional information on:
Funeral service that will collect the body.
The deceased's personal belongings.
Be sure to offer the family the opportunity to view the body.
|G ||Give || |
Give the family your card and contact information.
Offer to answer any questions that they may have later. Return their call if contacted.
As early as possible during the resuscitation, instruct ED staff, nursing, social work, or chaplain services to "gather" the family. Place the group in a quiet, private environment with few distractions. Assist the family with outreach to other family members or friends. Gathering allows the physician to deliver the information a single time, ensuring that everyone hears the same information. This also allows the family to support each other during this most difficult time.
Ask if there are any needs, and work to collect any needed items. Ask about desires for a chaplain, minister, or priest who may provide support for the family. Obtain interpreter services if needed.
Confirm that the deceased individual is properly identified. As the physician and staff join the family, they must clearly identify themselves and their role in the resuscitation. They must then clarify and confirm that the family is associated with the deceased individual. This can be done by saying the patient's full name, for example, "Are you the family of Ellen Smith?" Ask the family members to state their relation to the patient. Identify the next of kin. All discussion moving forward is between you and the next of kin. Face that person directly and ask permission to discuss the events of the day in the presence of the extended family and those gathered in the room.
Ask for a brief statement of the state of knowledge of the family regarding the patient's status. This final step is important because it allows you to begin your story of the day's events at the point their knowledge ends. This assists you in providing complete and essential information. Depending on the prior state of knowledge, the family will process information differently and at different rates. Your story will be very different for family members who witnessed a complete arrest versus those who last saw their family member healthy. The following is an example of an introductory narrative:
"Good Afternoon, my name is Dr. Hobgood. I am the attending physician taking care of Mrs. Ellen Smith. Are you the family of Mrs. Smith? Thank you for coming. Would you mind introducing yourselves and your relationship to Mrs. Smith? Thank you. Mr. Smith, do I have your permission to discuss Mrs. Smith's case in the presence of your family? Thank you.
Before I begin, it would be helpful to understand what you already know about what is going on. Can you tell me what you know about what happened to Mrs. Smith today?"
If possible, before you begin your discussion, ask the family to take a seat. You and your team should sit as well. Having the family sit reduces the risk of falling and sustaining injury during the notification. Position yourself across from the next of kin, preferably at eye level, and address the majority of the dialogue to that person. This posture creates open communication and allows you to assess understanding as you deliver the information. As a physician, a seated posture indicates that you are open to discussion and are willing to remain as long as needed.
From this point forward, your role is to educate. Your description of the event should begin at the conclusion of the family's knowledge of events. The narrative should be a focused summary of the scene, including any EMS response and the events in the ED. Communicate with nontechnical, nonmedical words; be thoughtful with your language and listen and watch for incomprehension. Throughout your summary, on multiple occasions, provide the family with "warning shots," such as "this is difficult news," "the information that I am relating is bad news," or "the news that I am bringing may be difficult for you to hear." These "warning shots" are a communication strategy intended to adjust the family toward the idea that they are about to learn something difficult and portend the disclosure of death. Carefully observe the family's reactions and those of the next of kin. If it appears that they do not understand the severity of events, reemphasize the finality of the news. Once the family appears to be following your story with clarity then you must disclose the death.
Continuing your dialogue seamlessly, you will "verify" the death. You should unequivocally state that their family member has died. You must decisively affirm this fact clearly and say the words death, died, or dead. Provide your condolences on their loss. This may include language such as "I am sorry for your loss" or "I can see how difficult it is for you to learn of the death of your [mother, brother, sister, friend, etc.]." Without knowing the religious convictions of the patient and everyone present, it is inappropriate to say "they are in a better place" or that the events "were God's will."
Now stop talking. Give the family some room to comprehend what you have just said. Even families who were anticipating the death will need a moment to register the information and compose themselves. Once you have allowed an adequate period of time to pass, you may move into the last three steps of notification.
The next phase, "inquire," is a very natural progression of the dialogue. Ask the family, "Are there any questions for me?" or "How can I help you?" In most cases, if the preceding steps have gone well and there has been complete information transfer, then there will be no major questions. The family may ask if there was pain or suffering. This is a difficult question to answer. Maintaining your credibility is important and you can never state with full certainty that the patient did not suffer. If you did everything possible to mitigate pain and suffering while the patient was in the ED, you can reassure the family with this fact.
The "nuts and bolts" are the necessary practical things that require attention. The physician has several key tasks at this stage. Inform the family that they will need to complete documents before they leave the hospital. You should also ask the family's wishes regarding autopsy and organ donation (see sections below). You should also offer the family the chance to view the body after it is appropriately prepped. This preparation includes removal of blood and secretions, closing the eyes, and covering the body except for the hands and face. It is fine to remove tubes and catheters as long as it is not a medical examiner's case. If the patient is disfigured, cover the wound as best as possible with towels or bandages. Sometimes it is impossible to completely cover wounds, particularly if they are on the face. You should warn the family that there is trauma or if tubes must be left in place and that these sights may result in a lasting memory of their loved one. Let them know that you are willing to take them to the bedside but that these wounds will be difficult for them to see. In all situations, it is best to have the family members seated.
The concluding step in the notification process is "give." During this period, you give the family your name and, if possible, your business card. Inform them that if they call you may not be immediately available but that you will contact them after you receive the message. If they reach out to you, be sure to return the call. Typically, calls are made to provide additional clarity or to thank you. Express your condolences and then close the encounter.
Responses to loss vary greatly. Families often describe themselves as numb immediately after learning of the loss. They have difficulty processing information and making decisions. Following the initial shock, the family may experience denial, anger, and/or guilt.20 Denial is most typically expressed as incredulity and is thought to be a defensive mechanism, because it permits additional time to comprehend the new situation. Your role is to understand this condition and allow time and, if needed, provide additional information to confirm death. Seeing the body of the deceased may help the family to accept the truth. Anger is not unusual. Be prepared to react in a supportive manner rather than responding with anger or becoming defensive. If the family or individuals react with charges of negligence or malfeasance on the part of the care team, keep calm and provide support in a nonjudgmental way. These are typically expressions of grief and misplaced guilt.
The survivors' culture is an important predictor of the types of emotional responses that may be exhibited. These may range from no expression of emotion to wailing and hysterical collapse. Allow these expressions and remain calm and respectful. If you want to touch the grieving individual, the shoulder is the most suiTable location.