Wellness Wisdom

Louise B. Andrew MD JD FACEP

Howard Spiro, emeritus professor at Yale taught that most physicians fear death more
than ”normal” people, which may be a key reason we choose to spend much of our young
adult lives learning to thwart it. As an intern, my very first clinical rotation was
oncology, and in that era, death was far more common than remission. One of my two
faculty had the habit of disappearing whenever death for one of his patients drew near.
Fortunately, the other attending was comfortable with speaking to patients and their
families about dying, so I owe all of my skills to this early mentor and to the practice
opportunities provided by his avoidant partner. Death-telling is an art, and for most
hands-on specialties, doing it skillfully is an essential clinical and wellness skill.

I sometimes believe that EM appeals to those of us who don’t ever want to feel
responsible for the deaths of patients, because of course, most of our dead patients are
already in that condition when they reach us. If they are successfully revived, we are
heroes, and if not, we are not responsible since they arrived in extremis. Still, it may be
this nagging feeling which makes telling family members about death so difficult for
many of us. Additionally, we know the news we are about to deliver, of an unplanned,
untimely, and sometimes gruesome death of a loved one, is something we ourselves
would never want to hear from anyone.

So I thoroughly understood the reluctance of some of my very best house staff to initiate
these conversations. But every one of them became a better, more caring clinician
through learning to master this art.

What is most important in imparting the fact of death to a family? It is the fact of the
death itself. Yet this key fact is sometimes euphemized or glossed over in our
discomfiture. Occasionally the death news is delivered so obliquely that families ask,
after the conversation, “so, how is he, doctor?”. It is essential that the fact of the death be
delivered fairly promptly, quite directly, and in unambiguous terms: “Mrs. ___ “(or
“your mother”) unfortunately did not survive. She died quietly at 10:00. I’m very sorry.”

Often it is necessary to elicit a few vital facts first, for example, to determine whether this
death is a medical examiner case. But questions should be brief and narrowly tailored, so
as not to raise the anxiety level (or hope) of the family unduly before imparting the actual
outcome. Next, a little information should be provided about what happened to the
patient since coming to medical attention, followed promptly by the fact of the death.

These discussions should always occur in privacy, ideally in a soundproof and

comforting space designated for this function. If there are language issues, it is essential
to have a translator (ideally other than a family member) from the start of the
conversation. Phone and tissues should be nearby. If circumstances allow, wait until the
entire family has gathered, and take a nurse with you after conferring about any details.
Immediately introduce yourself and the nurse to everyone, and then quickly identify the
“next of kin” by asking who among the group is the “closest relative”. Sit, or if
necessary, kneal near this person’s face, and if appropriate, hold his or her hand.
Sometimes you can introduce yourself with a handshake and continue to hold the hand
gently. Look the person directly in the eyes with all the empathy and concern you can
muster, and some of your work will already be done.

After the news is imparted, be very careful to specifically indicate your openness to
questions and concerns. Unexpected death is difficult to absorb at one sitting, and more
questions will invariably crop up the moment you leave the room. If the nurse does not
remain behind, everyone must understand that you will be available in the department for
a while to address any other issues you can. Some hospitals encourage physicians to
provide a business card at this point, or a brochure specifically prepared to deal with
hospital death issues. Some have chaplains on site or on call, or even staff offices to
assist in the process. If private visitation with the deceased patient is a possibility, gently
inquire about the interest of the family. Visitation is considered almost essential in SIDS
deaths, and there should be protocols and support staff to assist in this special case. If
visitation is contemplated, it is of course necessary to prepare families for any appliances
or disturbing effects they may encounter.

If you can, say something which might ease any potential guilt felt by the family. The
easiest technique is usually to reassure them that they did everything they could under the
circumstances, even if you are not sure it is the case. If at all feasible, share that you do
not believe there was much suffering involved in the death. Never hesitate to express
sympathy, which will be greatly appreciated even if not acknowledged. It may be the
only part of the interaction which is remembered later, because the public, sadly, does not
generally expect displays of human emotion from doctors with no established connection
to them.

We in Emergency Medicine rarely have the opportunity to have lasting effects on

individual patients or the community. It is one of the reasons the specialty is not
satisfying to some who wish to have a greater impact. But compassionate and effective
death telling provides us with the opportunity to help whole families to begin to absorb
and heal the pain of death, and thus can have both immediate and far-reaching effects.
These effects are not limited to the patient family or community. We ourselves feel more
effective and competent as well as caring and compassionate as physicians when we
master this essential clinical responsibility. Death telling is not one of the more
pleasurable aspects of our specialty, but it is inevitable. Becoming skilled at delivering
bad news confers many benefits upon us, not the least of which is helping us to overcome
our own most existential fears.

A superb and practical resource on the art of death telling, Grave Words, by Kenneth
Iserson, is available from Galen Press, Ltd. http://www.galenpress.com/018.html. A
companion Pocket Protocoland video ares also available.