Jeffrey Covitz details how EMS providers can help distraught families find peace at the time of a loved one’s death.
Imagine the worst day of your entire life. If one lives long enough, we eventually face a tragedy of one kind or another. It may begin with the phone call informing us of the death of a father, brother or sister. Perhaps it is a solemn-faced friend, relative or stranger softly saying, “I’m so sorry, your Mom passed away.” Maybe it was a wife, husband or a child. For many, the memory of that day can be excruciating to recall decades later. The initial shock, denial, and numbness as your inner defense mechanisms shield you from the waves of raw emotion rolling toward you, building strength until it smothers like a landslide burying a town.
Now try to recall the thirty to forty minutes that followed the initial shock if you can. Who was there? To whom did you speak? What was their tone of voice? Their expression? Did they hug you or keep a distance? Did you help comfort someone else in the room? What did the room smell like? Was someone annoying, insensitive, or just plain stupid? Now ask yourself, did anyone or anything make the worst day of your life better? Even a little?
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From the outside looking in, many think we in EMS spend our days performing lifesaving procedures, rushing the critically ill to the hospital, and saving injured puppies. If you have been in EMS for more than twenty minutes, you know that many of our patients die no matter what we do, and many others live despite what we do. Incidents where we prehospital providers tip the see-saw between life and death and “save a life” certainly occur, but they are few and far between. Most of our calls do not involve life-threatening emergencies but rather gaps in our broken healthcare system for which we are the catch-all filter. After so many low-acuity “social work” calls, coupled with a national epidemic of underfunded dysfunctional EMS agencies, many paramedics find the path to burnout when they become convinced they make no difference. I often hear a crispy medic say something to the effect, “We don’t change anything; what’s the point? We’re a taxi service; we’re UBER.” Early in my career, I had similar episodes of burnout; it almost drove me out of the profession.
Despite my griping, like many reading this article, I have also had my fair share of cardiac arrest saves, babies delivered, STEMIs rushed to cath-labs, and critical trauma patients delivered to the Emergency Department intubated, oxygenated, ventilated, and warm. After all these years, however, I genuinely believe the most significant impact I have made in this job is something altogether different.
These days I am an EMS supervisor, and in my system, I am dispatched only to high-acuity calls in my district: cardiac arrests, multiple patients, critical pediatrics, penetrating trauma, etc. In my role, I am often the liaison to the family, keeping them informed of what our paramedics and EMTs are doing as they attempt to resuscitate their relative. When we are unsuccessful, more often than not, it is my role to deliver the sobering news that their mother, father, sister, husband (sometimes child) did not survive. I am the harbinger of bad news almost every day I go to work. Some who have been working in the business for a while may not find it surprising that I have no formal training to perform this duty whatsoever.1 I vaguely recall a one-hour lecture covering death notifications in paramedic school a hundred years ago. Perhaps there was a video on some online continuing education class I took once that I barely paid attention to? I never took a formal class or had a psychologist explain evidence-based methods of delivering the worst news. Early in my career, like many of us, I winged it; I learned by watching experienced paramedics, took away what I liked, left what I didn’t, and fashioned my own approach over the years.
Part of my approach is informed by personal experience. The events surrounding the death of a loved one, coupled with the loss of a relationship, are burned into my head forever. Looking back at that time, I remember every subtle detail from the moment I received the news; every person I spoke to, what I said, what they said, where I stood, how they acted, their tone of voice, everything. The memory of the worst day of my life burned a permanent etching into my psyche; became part of my DNA and changed how I existed from that moment onward. Recognizing that in myself made me realize how careful I must be when interacting with distraught family members. What I say, do, how I look them in the eyes, the tone of my voice, my body language, no matter how subtle, will be recalled in detail for the rest of their lives. As is the case for me, they will replay events repeatedly in their head, remembering it as the moment life turned upside-down and transitioned into something unrecognizable. What a sacred responsibility it becomes when understood in this context.
It begins while we are still working on the patient. I’ll break away and approach slowly to give them an update. Respect their personal space. My job is to acknowledge their feelings, provide them with facts in plain English, and prepare them for the worst. Speak gently yet directly:
“My name is Jeff. I’m the paramedic supervisor for this area. I want to keep you updated on what’s happening with your dad. Your dad’s heart stopped beating on its own. I know it seems confusing, a lot is going on in there, but everything we’re doing — all the machines, medications, breathing tubes — are trying to get his heart to start beating again. It’s all the same procedures, equipment, medicines, they would be doing in the hospital; we brought the ER to you. So far, unfortunately, we have not been able to get his heart to beat on its own again, but we aren’t giving up yet. We’re still trying. I just want to make sure you understand what is happening and what we are doing. Do you have any questions?”
They rarely do.
“I will check back with you in a couple minutes to update you. If you think of a question, I’m right here, my name is Jeff.”
I establish myself as their lifeline of hope. Don’t give them false slack, but also don’t eliminate the possibility; there’s always the potential we can get a return of spontaneous circulation and the patient survives.
A few more rounds of meds, the LUCAS device is pumping away, perhaps another shock, H’s and T’s are considered. The family has no clue what we are doing. After a few more minutes, break away and prepare them more directly. Speak slowly, breathe:
“I wanted to give you an update. As you can see, we are still trying, but nothing we have done has worked so far; your father’s heart is still not beating on its own; we are doing it for him with that CPR machine. I spoke to a doctor on the phone, she’s the boss of us, and she agreed if there isn’t a change after a few more minutes, there is an endpoint to this.”
Inevitably, a family member will say, “Please do everything.” I assure them we will.
Two more minutes, hold CPR. Asystole on the monitor, no pulse. We are long past the point our protocols allow us to stop. I ask the crew if anyone has any objections to calling it. No one ever does. Time of death, 17:52.
Break away, approach the family slowly, plant your feet. Look them directly in the eyes. If they are seated, sit at their eye level; never stand above. Take a breath:
“As I told you before, we did everything that could be done, but unfortunately, we could not get his heart beating again. I’m so sorry to be the one to tell you this, but your father died.”
Silence. Breathe. I didn’t say stupid ambiguous terms like he “passed” or “didn’t make it.” The correct word is the most direct and truthful, “He died.” My job now is to guide them through the initial phases; explain why the police are called and why information needs to be gathered for the medical examiner. Get them something to drink. Explain what they will see when they enter the room where their dad lays on the floor under a yellow sheet; why the medical examiner wants the “breathing tube” left in place. Hold their hand. Let them embrace their husband, father, brother for the last time. Ask about his life. Assign someone to watch the children upstairs. Speak gently. Allow them space to scream, cry, punch the wall, curse you or hug you if that’s what they need.
Call their brother who lives across the country and deliver the news again if there’s no one else to do it. Don’t lie. Don’t say, “everything will be alright.” Nothing is alright. Instead, say we are here to do whatever we possibly can to help get you through this. Answer all questions honestly; it’s okay to say you don’t know. Coach them to slow their breathing. Speak gently. Consider they woke up this morning with plans to go out to dinner, see the kids, go to a wedding or a game; now they must choose a funeral home. Give them the list. Call the funeral home they choose yourself if the logistics of sudden death are too overwhelming. Make sure they are supported and not alone. Eventually, the police arrive for the standby. Know when it’s time to leave. Tell them again how sorry you are that you met under these circumstances. On your way out. Say one last thing:
“Your dad sounded like an amazing person. He obviously has a beautiful family who loves him very much. He’s lucky he was surrounded by you. Again, I’m so very sorry for your loss.”
Slowly exit. Get on the radio and go back in service. Run the next call.
More likely than not, we will never see these individuals again. But the memory of everything we said and did, how kind our voice sounded, how we looked them in the eye and gently told the horrible truth, everything will be branded into their memory. Perhaps it is one of the last things recalled before a stranger announces their time of death.
In twenty-two-plus years in EMS, I have encountered countless loved ones of the recently deceased. I take pride in my responsibility to make the most unbearable day slightly less terrible. That is our job, after all. It is my hope that how I cared for all those people accelerated their healing process far down the road. There is research available that supports my hope.[1] It is not something we receive accolades for or makes the evening news; if you work in my world, you may catch grief for taking too long on-scene. However, I believe how we provide grief support to loved ones amidst the worst tragedy of their lives is one of the most impactful things we do in EMS, and I consider it an honor.
If you’ve been watching the news lately, multiple tragedies are occurring every day. The worst days of many lives happened in Buffalo, Texas, Tulsa, Philadelphia, and scores of other places around the country. As the horrific details are splashed across my television, I think how awful it must be for the individual who has the equivalent of my job. I hope that person has the empathy, experience, and strength to guide those broken families through the first unbearable hours of the present, so they may find peace one day, far in the future.
References
1. Cheryl Cameron et al., “Dealing with Dying – Progressing Paramedics’ Role in Grief Support,” Progress in Palliative Care 29, no. 2 (March 4, 2021): 91–97, accessed June 4, 2022, https://www.tandfonline.com/doi/full/10.1080/09699260.2020.1856634.
2. Anders Bremer, Karin Dahlberg, and Lars Sandman, “Balancing Between Closeness and Distance : Emergency Medical Services Personnel’s Experiences of Caring for Families at out-of-Hospital Cardiac Arrests and Deaths,” Prehospital and Disaster Medicine 27, no. 1 (2012): 42–52, accessed June 4, 2022, http://urn.kb.se/resolve?urn=urn:nbn:se:lnu:diva-16284.
