Death notification is perhaps the most difficult, emotionally
laden communication that physicians must perform. In 2006 alone,
there were >119.2 million ED visits, and, of these, 249,000 resulted
in patients who were dead on arrival or died in the ED.1 Fear
of being blamed, difficulty dealing with families’ emotional
reactions, and personal fears of death contribute to physician stress
when performing a death notification.2 Delivering
difficult news in the ED adds a unique set of challenges because
the emergency physician has no prior relationship with the deceased
individual’s family. A prolonged and difficult resuscitation
may leave the emergency physician emotionally and physically drained,
making the task of communication even more difficult.
When an ED patient dies, the emergency physician acquires a new
role and relationship with the family. Management of that relationship
appropriately is particularly important for the surviving family.
For survivors, the death notification is a life-altering event.
Although death notification is stressful for the emergency physician,
for the family, the words and phrases used in communication, the
physical setting, and the characteristics of the individual delivering
the news constitute memories for the family that are never forgotten.3 Skillful
death notification is particularly important in the ED, where many
of the deaths are sudden, untimely, premature, or violent. All of
these characteristics are qualities that have been linked to complicated
bereavement or post-traumatic stress disorder (PTSD) in survivors.4 As
many as 21% of persons exposed to the news of sudden death
met the Diagnostic and Statistical Manual of Mental Disorders, revised
3rd edition, criteria for lifetime prevalence of PTSD.5 There
are data which demonstrate that properly performed death notifications
may mitigate the impact of substantial negative effects on the surviving
family members.6 For example, well-delivered death
notification may reduce the incidence of PTSD in sudden death, particularly
those involving the loss of a spouse or the death of a child.7 As
emergency physicians, we must begin to think of death notification not
as a difficult conclusion to an already difficult case but as an
opportunity for prevention: reducing the incidence of secondary
trauma to the family by the way in which they learn of a death.
Well-delivered death notifications may also have a substantial
effect on our own well-being as clinicians. Most ED physicians find
death notification to be emotionally draining.8 Although
the number of studies specifically focused on emergency physicians
is limited, there is compelling evidence from the bereavement literature
that is directly applicable to the practice of emergency medicine.
Emergency physicians charged with informing families often have
little knowledge of the family’s social or cultural value
system, and lack an awareness of the family’s expectations about
the death, or about their relationship to the deceased. Compounding
the difficulty of this situation for the physician is the need to
transition rapidly from the emotionally detached leader of a resuscitation
team charged with saving a life to that of an empathic informant ...