Prehospital providers face death on a regular basis. With time and without a proper outlet, stress builds. It’s important to recognize the emotional and psychological effects of continued exposure to human suffering and death when healthy outlets are neglected or unavailable. When ignored, stress can lead to grief, anxiety, withdrawal, depression, sleeplessness, personality and mood changes, and failed relationships.1–4 Grief often mirrors major depression and unheeded can lead to thoughts of suicide and worse.5 Between the year 2000 and early 2013, over 200 firefighters in the United States committed suicide. Although not all of these can conclusively be traced back to on-the-job stresses, it’s instructive to note two of the top risk factors: 1) acute and chronic stress, and 2) the impact of trauma.6
With the implementation of adult termination of resuscitation protocols, providers have the additional stress of providing death notification to the family.7 Sure, they’ve always done that; but now, in plain sight of the family, they often start and stop resuscitation efforts. Multiple studies have demonstrated the futility of continued resuscitation efforts under the following conditions: 1) EMS providers haven’t witnessed the arrest; 2) There’s no shockable rhythm; and 3) There’s no return of spontaneous circulation after about four rounds of CPR.8–12
Unlike the past, EMS no longer transports these patients. This respects the dignity of the patient and family, reduces ambulance accidents, frees up medical resources and reduces cost.13–17 Left alone with the family, a provider’s job is to explain the reasons for their actions and offer them support and comfort. This is difficult under the best of conditions, and when the incident involves the death of a child, stress levels rise even further.7
Defending Against Death
A 2003 survey showed that EMS providers will initiate rescue efforts under conditions where they themselves would not want to be resuscitated 40% of the time.18 First responders see themselves as “lifesavers” and “defender[s] against death.”19 Rescue workers recognize the immense responsibility they bear and have admitted to initiating CPR to avoid criticism and continuing CPR simply because family members were present.14,20
Providers are more willing to initiate rescue efforts on children even when they see their efforts as futile. They’ll continue their efforts longer, and are much less comfortable terminating resuscitation on children.13,20 Even after being educated on the dismal survival rates of pediatric patients, EMTs and paramedics admit it doesn’t make them any more comfortable with ceasing rescue efforts. They attribute their uneasiness on personal discomfort, fear of family confrontation, being uncomfortable with their training in pediatric patients, fear of legal liability and fear of missed non-
accidental trauma.13 Confidence in one’s skill level didn’t make field pronouncement any easier;3 however, lack of experience in working pediatric codes did cause discomfort by the thought of stopping CPR.13
EMTs and paramedics report being unfamiliar and uncomfortable with providing death notification, most likely because they’re being called upon to recognize death before the obvious signs appear—lividity, rigor mortis, etc.7,19 Additionally, the majority of their training concerning death originated from their own personal reading.19 One study reported less than 20% of prehospital EMS providers have received death notification training.14 Nevertheless, most acknowledge their actions have an effect on how the surviving family members deal with grief over the loss of a loved one.19,21
Death Notification Training
EMS personnel overwhelmingly agree their training in death and death notifications is inadequate.7,19,21 Moreover, after a reasonable amount of training (16 hours or less), they reported an increase in confidence and comfort in providing death notification.7,14,21
The need for training in death notification has been acknowledged since the mid-90s, when training curricula and methodologies to address this issue were first developed.22,23 However, EMS providers continue to confess discomfort and a lack of training in the delivery of death notifications. Responders must recognize their professional duties on the scene of a patient’s death and have the skills to interact with bereaved families.21
Training methods vary, but include the use of instructor-led presentations, multimedia technologies, discussion and small group exercises, role-playing, pre- and post-reading assignments, question-and-answer sessions, and evaluation and feedback.5,14,21–23 This diversity allows for a variety of training scenarios, which can be adapted to fit the size and budget of any agency.
Three general areas should be addressed in training curricula that teaches providers to deliver death notifications: 1) background information, 2) delivery techniques, and 3) next steps.
Background information focuses on issues and topics important to understand before responding to an incident where a death notification may be necessary. Familiarity with topics such as understanding causes of death (including suicide, homicide, etc.), the many issues surrounding grief (e.g., phases of, recognition of, etc.), legal issues, and cultural and religious beliefs are essential in our diverse and multicultural society. It’s also crucial to understand the legality of termination of resuscitation protocols, your agency’s specific guidelines, and the justification for their use.
Communication techniques need to be discussed, illustrated and practiced—such as asking open-ended questions, displaying concern, knowing when to be silent and what to say.1,2,24 The pneumonic GRIEV_ING can help providers deliver the notification. (See Table 1.)
It’s important to gather all family members together and not exclude anyone. Clearly identify yourself and explain your role in the incident. When doing so, be prepared to explain why you either stopped or didn’t initiate resuscitation efforts.
Use the patient’s name; don’t refer to the patient as “grandpa” or “grandma.” Be clear that a family member has died by avoiding euphemisms such as “has fallen asleep,” “has gone on a trip,” etc.24 Allow questions from the family. If they ask you something you can’t answer, try to direct them to an appropriate resource.
Be prepared to provide contact numbers for outside agencies, mortuary services, etc. Contact the police department, as law enforcement is often required to file a report. Unless aggravating circumstances exist (e.g., certain types of suicide, disfiguring trauma, a possible crime scene, etc.), allow the family to view the body. Some family members may want to be alone with the deceased—allow them their privacy. In some cases it’s important to discuss matters such as organ donation.
Death and delivering death notifications is stressful. In the past, it was common practice to suppress feelings of grief and stress, to internalize it, and simply deal with it, but this is no longer the case.25,26 Responders have critical incident stress management teams to help work through issues arising from stressful events.
The involved crew should be taken out of service, returned to their station to meet with a supervisor, and talk about the incident among themselves. No one should be forced to participate; however, everyone should be encouraged to take part in the discussion. For those who choose not to join, give them their space—but keep a watchful eye on them. Emergency service personnel, because of continued exposure to stressful incidents, typically handle stress differently and, overall, better than the general public.26
Throughout these encounters, supervisors can apply the simple methods of psychological first aid.1,2,26 (See Table 2, below.) Use good communication skills, be nice, meet and anticipate needs, and plan follow-up. In time, crews will become more comfortable with providing death notification even in the case of pediatric patients.27 Consequently, some crews will not desire an informal process after every death notification. Be prepared and ready as an organization to assist your members in their continued well-being.
The privilege and satisfaction associated with helping those in need isn’t without its emotional toll. There are moments of joy as well as times of confusion, hurt and distress.
Training in death and death notification is woefully lacking among first responders; yet, as little as two hours of training on the topic increases comfort levels and reduces anxiety. Leaders must better prepare their members for delivering death notifications to a grieving family.
Finally, support systems need to be in place to assist crew members in appropriately handling stress, pain, and grief so as to maintain emotional wellbeing throughout their careers. By having these components in place, this industry can relieve much of the emotional toil of continued encounters with death.
1. Woodall SJ, Thomas JA: Case studies for the emergency responder: Psychosocial, ethical, and leadership dimensions. Delmar Cengage Learning: Clifton Park, N.Y., 2010.
2. Thomas JA, Woodall SJ: Responding to psychological emergencies: A field guide. Thomson Delmar Learning: Clifton Park, N.Y., 2006.
3. Morrison LJ, Cheung MC, Redelmeier DA. Evaluating paramedic comfort with field pronouncement: Development and validation of an outcome measure. Acad Emerg Med. 2003;10(6):633–637.
4. Cowen AR. Death, dying and grieving: Dealing with personal and work-related tragedies. Emerg Med Serv. 1998;27(1):109–110.
5. Friedman RA. Grief, depression, and the DSM-5. N Engl J Med. 2012;366(20):1855–1857.
6. Antonellis P, Thompson D. (2012). A firefighter’s silent killer: Suicide. Fire Engineering. Retrieved April 5, 2015, from www.fireengineering.com/articles/print/volume-165/issue-12/features/firefighters-silent-killer-suicide.html.
7. Hobgood C, Mathew D, Woodyard DJ, et al. Death in the field: Teaching paramedics to deliver effective death notifications using the educational intervention ‘GRIEV_ING.’ Prehosp Emerg Care. 2013;17(4):501–510.
8. Verbeek PR, Vermeulen MJ, Ali FH, et al. Derivation of a termination-of-resuscitation guideline for emergency medical technicians using automated external defibrillators. Acad Emerg Med. 2002;9(7):671–678.
9. Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2006;355(5):478–487.
10. Sasson C, Hegg AJ, Macy M, et al. Prehospital termination of resuscitation in cases of refractory out-of-hospital cardiac arrest. JAMA. 2008;300(12):1432–1438.
11. Chiang WC, Ko PC-I, Chang AM, et al. Predictive performance of universal termination of resuscitation rules in an Asian community: Are they accurate enough? Emerg Med J. 2015;32(4):318–323.
12. Goto Y, Maeda T, Goto YN. Termination-of-resuscitation rule for emergency department physicians treating out-of-hospital cardiac arrest patients: An observational cohort study. Crit Care. 2013;17(5):R235.
13. Hall WL, Myers JH, Pepe PE, et al. The perspective of paramedics about on-scene termination of resuscitation efforts for pediatric patients. Resuscitation. 2004;60(2):175–187.
14. Ponce A, Swor R, Quest TE, et al. Death notification training for prehospital providers: A pilot study. Prehosp Emerg Care. 2010;14(4):537–542.
15. Hazinski MF. (2010). Highlights of the 2010 American Heart Association guidelines for CPR and ECC. American Heart Association. Retrieved Nov. 29, 2014, from www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf.
16. Millin MG, Khandker SR, Malki A. Termination of resuscitation of nontraumatic cardiopulmonary arrest: Resource document for the national association of ems physicians position statement. Prehosp Emerg Care. 2011;15(4):547–554.
17. Ong ME, Jaffey J, Stiell I, et al. Comparison of termination-of-resuscitation guidelines for basic life support: Defibrillator providers in out-of-hospital cardiac arrest. Ann Emerg Med. 2006;47(4):337–343.
18. Marco CA, Schears RM. Prehospital resuscitation practices: A survey of prehospital providers. J Emerg Med. 2003;24(1):101–106.
19. Smith-Cumberland TL, Feldman RH. Survey of EMTs’ attitudes towards death. Prehosp Disaster Med. 2005;3(20):184–188.
20. Naess AC, Steen E, Steen PA. Ethics in treatment decisions during out-of-hospital resuscitation. Resuscitation. 1997;33(3):245–256.
21. Smith-Cumberland TL, Feldman RH. EMTs’ attitudes toward death before and after a death education program. Prehosp Emerg Care. 2006;10(1):89–95.
22. Leash MR. Death notification: Practical guidelines for health care professionals. Crit Care Nurs Q. 1996;19(1):21–34.
23. Smith TL, Walz BJ, Smith RL. A death education curriculum for emergency physicians, paramedics, and other emergency personnel. Prehosp Emerg Care. 1999;3(1):37–41.
24. Goldberg G, Boustead R. Compassion. JEMS. 1998;23(2):34-35, 37–40.
25. Coleman J. (Dec. 1, 2004). Critical incident stress management. Fire Engineering. Retrieved April 6, 2015, from www.fireengineering.com/articles/print/volume-157/issue-12/departments/roundtable/critical-incident-stress-management.html.
26. McEvoy M. (Dec 1, 2005.) Psychological first aid: Replacement for critical incident stress debriefing? Fire Engineering. Retrieved April 6, 2015, from www.fireengineering.com/articles/print/volume-158/issue-12/features/psychological-first-aid-replacement-for-critical-incident-stress-debriefing.html.
27. O’Brien RJ. The grief support program for the Fremont (CA) Fire Department. Emerg Med Serv. 2002;31(10):124.