Care of the suddenly bereaved in cardiac care units: a review of the literature

Care of the suddenly bereaved in cardiac care u n its: a rev iew of the l i terature

Linda Edwards and David G. Shaw

Linda Edwards BSc (Hons), SRN, Sister, Cardiac Care Unit, Battle Hospital, Reading, West Berks RG30 lAG, UK

David G. Shaw MA MSc RN, Research Fellow in Health Psychology, Buckinghamshire Chilterns University College, Newland Park, Gorelands Lane, Chalfont St Giles, Bucks HP8 4AD, UK

(Requests for offprints to LE) Manuscript accepted 29 May 1998

This paper considers the experiences emerging from relatives whose loved ones die suddenly in a Cardiac Care Unit (CCU). It examines how best to address their needs and how to facilitate the normal grieving process during their brief yet traumatic hospital encounter. There appears to be no primary research relating specifically to sudden bereavement in a CCU. Several authors assume that findings can be applied between specialities but there is no empirical evidence to support this assumption. The research which does exist is predominantly in the areas of bereavement generally and in Accident and Emergency (A&E) in particular. This paper contains a critical examination of this literature and consideration of the extent to which findings from these fields can be relied upon to lead practice in the CCUs. It is concluded that recommendations for practice arising from such literature, e.g. those supporting the allocation of an advocate nurse to accompany relatives and allowing observation of resuscitation, may not be readily applicable to CCUs. The paper concludes with a consideration of future cardio-specific research needs.

INTRODUCTION

Improved technology and invasive treatments have considerably increased the demands made on CCUs, many of which were designed to cater for the original approach of 'watchful waiting', as described by Jowett & Thompson (1989). Since the advent o f thrombolysis,

maximum benefit has been demonstrated from early initiation of treatment, reducing both myocardial damage and mortality (TIMI 1 Study 1985). This has resulted in rapid admission to hospital being advocated, with direct access to CCUs being seen as optimal (Burns et al 1989). Maynard et al (1989), found that earlier arrivers tended to be those who were younger and those who were more likely to be hypotensive and in cardiogenic shock, many of whom would not previously have survived for long enough to reach hospital.

With direct access now operating exten- sively around the country, there is an increased likelihood of critical incidents, which previously occurred in the home and A&E departments now occurring in a CCU. It would seem reasonable to suppose that this has consequences for the frequency of sudden deaths in CCU.

The aim in this paper is to consider how best to address the needs of people who are suddenly bereaved in a C C U environment. As sudden death is known to be more difficult for relatives to cope with than expected death, and to carry a high risk of abnormal grief reactions (Parkes 1972, Lundin 1984), it would seem important that relatives' care is optimized during their brief yet traumatic time in the CCU.

DEATH, BEREAVEMENT A N D THE PROCESS OF GRIEVING

The term 'bereavement' means the state of having lost through death a dear relative or friend (Macdonald 1979) or, as Freud (1917) put it, bereavement is '...the price paid for love.' Most authorities on the subject of bereavement, though not all, define grieving as the universal psychological reaction to bereavement, whereas mourning is a term used to describe public displays o f grief which are cul- turally prescribed (Parkes et al 1997).

In the Western world, death is still treated as a taboo subject, and the social stigma and denial associated with bereavement results in a paucity of interpersonal support (Lendrum & Syme 1992, Parkes 1996). Social norms within the many western cultures may be such that the expression of grief is seen as weakness and a cause of embarrassment, while suppression of feelings and the maintenance of emotional control may be socially valued (Lendrum & Syme 1992, Parkes et al 1997).

Parkes (1996) makes the point that voluntary organizations, such as Cruse - Bereavement Care, are the main source of bereavement counselling in the UK, a fact which speaks volumes about the lack of formal provision

Intensive and Critical Care Nursing (1998) 14, 144-152 © 1998 Harcourt Brace & Co. Ltd

Care of the suddenly bereaved in cardiac care units 145

within the health and welfare system. Another indication of the lack of support for the bereaved in the UK comes from the work of Ferguson (1993) who found that compassionate leave from work averages only 5 days, with many who return too early struggling in isola- tion to come to terms with their loss.

There have now been several decades of research into the grieving process. One of the earliest and most influential theories is that which arose from the original studies of Colin Murray Parkes. Both the Bethlem Study (Parkes 1965) and the London Study (Parkes 1970) were small longitudinal studies in which data were collected by means of qualitative interviews. Parkes concluded that there are four phases to the grieving process: numbness (including shock, alarm, emotional blunting and denial); pining (including emotional pain, intrusive thoughts, agitation, guilt and anger); disorganization and despair (including apathy, inability to cope with daily tasks and self neglect); and recovery (developing a new iden- tity and role structure etc).

Particularly in his later writing, Parkes (1996) is at pains to acknowledge that these stages are not universal and that the bereaved can move unpredictably backwards and for- wards between stages. However, such stage theories are criticized by those who believe they encourage people to think of grief in a simplistic way (Germain 1980, Wortman & Silver 1989) and because they may also lead to the conclusion that deviation from predicted stages may be viewed as abnormal (Wortman & Silver 1989, Costello 1995).

SUDDEN BEREAVEMENT

Numerous writers including Worden (1991) have demonstrated that a number of variables have the potential to influence the grieving process substantially. One such variable is suddenness of death, defined by Raphael as death which occurs, '...with little or no warning...' Thus, most cardiac deaths could be described as sudden.

As long ago as 1944, Lindemann investigated the phenomenon of acute grief reactions in a large qualitative study. A sample of 101 recently bereaved participants were studied using psychiatric interviews. The study showed that increased grief reactions were commonly experienced by the suddenly bereaved. In what is now viewed as seminal work, Lindemann created a vivid picture o f the effects o f sudden bereavement, describing normal as well as delayed and distorted reactions. Despite the weakness of age, sampling and incomplete

reporting of methodology, the results of the Lindemann study have been supported by sub- sequent research.

A more recent study by Parkes (1975) compared the length o f preparatory time prior to death with longer-term grief outcomes. He found that those who had least time to prepare for bereavement were more anxious, depressed and inclined to tearfulness after 1 year. It is unclear how his sample of widows and widow- ers was selected, or indeed how the spouses died, thus making it difficult to judge the va]id- ity or reliability of the study. However, his findings are supported by those of Lundin (1984) who reported similar findings with a group of 130 relatives, whom he found to be more self-reproachful, tearful and numb 8 years after a sudden bereavement. In a complex, longitudinal study of losses sustained through disaster, Murphy (1988) supported these early findings, but identified the availability of social support as another key predictor o f long term outcome. However, as is often the case in longitudinal studies, the attrition rate of 29% was significant. In such circumstances, those drop- ping out may differ in important respects from those continuing to participate, thus creating the potential for bias (Polit & Hungler 1995).

However, additional studies support the view that sudden deaths cause greater difficulties for the bereaved, particularly in respect of their health, acceptance and adjustment to loss, and time taken to return to some kind o£ nor- mality (Parkes 1975, Raphael 1984, Wright 1988). Throughout all the studies reviewed, no conflicting evidence was found. In addition to this, there are several studies which although not methodologically unflawed, demonstrate a diversity of methods, settings and subjects, all yielding similar results. This fact, according to Polit and Hungler (1995), permits greater con- fidence in the findings. It therefore seems reasonable to suggest that these findings should be considered when planning care for people suddenly bereaved in CCUs.

Commenting on the general literature on bereavement, Worden (1991) reasons that the extra parameter which suddenness adds to the grieving process is understandable in terms of the lack of opportunity for anticipation and preparation, the circumstances o f the death, which may be dramatic, medico-legal compli- cations etc. This leads to a greater degree of shock, feelings of unreality and helplessness (Worden 1991). Parkes' first stage o f grieving is likely to be more pronounced and prolonged (Parkes & Weiss 1983).

In addition to this, and in apparent contra- diction to the evidence that sudden bereavement causes increased numbness as stated by Parkes & Weiss (1983), several other investiga-

146 Intensive and Critical Care Nursing

tors have identified that the events surrounding death can subsequently be recalled with remarkable clarity (Lindemann 1944, Fraser & Atkins 1990, Wright 1996), with many hours spent retracing the events of the fateful day.

Lindemann (1944) found that the time immediately surrounding the death of a loved one is crucial in determining the ability to accept death and deal with the crisis. This view is supported by Raphael (1984), who found that events surrounding a sudden death, particularly in relation to the circumstances under which news of the death was broken, often caused traumatic memories, which tended to preoccupy and repeatedly intrude upon the bereaved relative. This finding is supported by Ashdown (1985), Fraser & Atkins (1990) and Wright (1996), who further suggest that early interventions can impact on the experience. Fraser & Atkins (1990) conducted telephone interviews to ascertain the views of the bereaved as to interventions found useful during the crisis of sudden death. However, 21% of their sample had changed address since the loss and were therefore excluded from the study. Since moving house may have resulted from difficulties experienced following the death, this exclusion calls into question the rep- resentativeness of the sample investigated, as identified by Talbot (1994). The studies previously referred to span a variety o f circumstances and a variety of causes of death. Taken together, these studies can be seen to add weight to the argument for optimizing the experience of this crisis situation and, since findings resulted from multiple specialities and various causes of death, they would appear relevant to Cardiac Care environments.

SUDDEN BEREAVEMENT IN THE CCU

In view of the prognostic importance of the time immediately surrounding the event, and in view of the apparent lack o f ongoing support, it would seem logical to assume that C C U care which is both appropriate and client centred will maximize the likelihood of normal grieving.

Clinical experience indicates that many aspects of sudden bereavement may have particular salience in a CCU. For example, bereaved relatives may have been involved in interpreting and decision-making in respect of the onset of symptoms, calling for help, desperate attempts at revival etc. Culpability issues loom large, with an increased risk of guilt and displaced anger. Surprise and shock are likely to be pronounced, particularly in the case of a first

heart attack or where the victim was not viewed as being in a high risk group, e.g. young, female, non-smoker, and so on. It would seem likely that events both before and after admission to the C C U might influence the grieving process.

In search for an evidence base to guide practice, an extensive literature search was carried out involving all the major data bases. This revealed no primary research appertain- ing specifically to sudden death in CCUs. This point was made by Eastham in 1990, who went on to suggest that available research from related clinical specialisms is 'likely' to be relevant to critical care. This paper will now consider the extent to which this assumption is justified.

A study by Dassen et al (1990), supported by Hudson (1993), found that CCUs are predominantly 'cure oriented'. It was therefore considered appropriate that in addition to general bereavement literature, other specialities with the same 'cure' ethos should be considered in order to find the closest fit when assess- ing the transferability and generalizability of research findings. The next section will exam- ine how, in view of the available evidence, this can best be achieved in CCUs. The cure ethos previously referred to, whereby C C U nurses feel that they have failed if a patient dies, is a limited view of the nurses' role which ignores the fact that, as Parkes (1981) put it, °although nurses cannot take away the pain o f grief, they are in a position to help people begin the grieving process'.

RESEARCH AVAILABLE TO LEAD PRACTICE

Within the specialism of A&E nursing, there have been several surveys seeking to ascertain current provision of good practice for the suddenly bereaved, and thereby define good practice. Other approaches to the definition of good practice have involved asking A&E nurses to prioritize given interventions, whilst yet other studies have questioned relatives about the care received around the time of bereavement. Naturally, each of these approaches has its strengths and weaknesses.

A national survey by Cooke et al (1992) involved sending questionnaires to A&E departments in order to establish what facilities were available for bereaved relatives, what care was provided, and the extent to which this var- ied across the country. The study followed recommendations from the Department of Health and Social Security (1992) suggesting the need to review events occurring when a patient dies.


However, although this survey enabled widespread analysis, this type of approach does run the risk of response bias and a consequent tendency towards a distorted favourable image (Polit & Hungler 1995).

In a similar study by the British Association for A&E Medicine and the Royal College of Nursing (1995), two questionnaires were sent to each department, one to the consultant and another to the senior nurse. The main outcome of this study was the development of a check list of good practice. A&E departments were advised to use this check list in the formulation of their own local guidelines and policies. Whilst providing a potential framework, such national guidelines run the risk of leading to a standardized system which ignores individual and local needs.

Other studies have attempted to establish nurses' perceptions of the needs of the suddenly bereaved. McGuiness (1986) and Tye (1993) asked nurses to rank nursing actions in order of priority. When compared with the findings o f studies which had collected the opinions of the bereaved (Fraser & Atkins 1990, Mian 1990), it was found that some initiatives were ranked much lower by the nurses than by the bereaved. This was particularly significant in relation to 'allowing viewing of dead body', and 'providing comfort measures'. This chal- lenges a paternalistic approach in which health professionals assume they know best. Tye (1993) claims that his results have some degree of validity since the questionnaire was derived from an extensive search of literature, which he suggests provides a range of corroborative sources. McGuiness (1986) does not adequately describe her methodology, making further comparison or evaluation impossible.

Ashdown (1985), compared nurses' views, recorded immediately after a sudden death, with those of the bereaved 10 months later. She found remarkable congruence between the nurses' views and the relatives' recall of events. Many relatives, however, refused to participate because they were anxious to avoid emotional breakdown. This raises questions as to the rep- resentativeness o f the sample interviewed and the findings reported. For example, those who did agree to participate may have been those who were coping better with the loss, or those who perceived benefit in having someone credible listen to their stories (Boss 1987).

Five further studies have attempted to ascertain the views of the bereaved, interviewing relatives of sudden death victims between 1 month and 1 year following the event. O f these, one represented deaths throughout a general hospital (Silvey 1990), the remainder considering those occurring in an A&E. Some of these studies utilized telephone interviews

(Fanslow 1983, Mian 1990) and others did not state how the data were collected (Bury Medical Audit i994, Silvey 1990). Thus the methodology of these studies is not always well reported, making generalization difficult. In the Ewins and Bryant (1992) study, representative- ness is threatened due to a decision not to follow up any relatives who displayed aggression whilst m the department. This amounted to 17% of the sample. Furthermore, data from each study are presented as percentages, some- thing which Polk & Hungler (1995) believe risks markedly deviant results from that of a true population in view of the sample sizes involved. Only one study offers any indication of the questions asked (Mian 1990). Nevertheless, there is remarkable congruence between studies in terms of the key issues reported. In some cases these issues were intro- duced by the interviewer, thus raising the pos- sibly of interviewer bias, and in others the relatives offered the information.

It would seem that the main issues arising from these studies relate to: relatives wishing to see the patient on admission, during resuscitation or after death; the provision of comfort measures and facilities; quality of communica- tion; emotions of staff; informational needs after death; and follow up of the bereaved. These issues will now be considered in terms of their app]icability to CCUs.

ISSUES A R I S I N G FROM AVAILABLE RESEARCH

The wish to see the pat ient on admission, during resuscitation or after death

Fanslow (1983) and Silvey (1990), found that spouses had a desperate need to see loved ones during treatment, feeling that by failing to do so they had deserted them in their hour of greatest need. Although relatives understood that they might have been unabIe to tolerate events, they said that they would have appreciated the choice. Hanson & Strawser (1992) report a study they performed in 1985, finding 72% of relatives in their sample wished they had been present during resuscitation. As a result of this they initiated a scheme in their A&E department whereby relatives were allowed to observe resuscitation if they wanted, but were supported through it. They found that 76% of the observer relatives felt they had adjusted to the death better than they otherwise would have, and 64% thought their presence was of benefit to the dying person. Initially, staff had reservations regarding the initiative,


but after nine years Hanson & Strawser (1992) conclude that fears were unjustified and that the scheme was workable.

Further support comes from Adams (1994) a nurse who relates a poignant account of the death of her brother, and how witnessing resuscitation helped her come to terms with the death. She reports being more upset that staff continually tried to remove her from the scene. The doctors involved support Adams' (1994) views, suggesting the paternalistic desire to protect relatives stems from misunderstanding of the human response to possible death.

Since that publication many have replied with opposing views, including Schilling (1994) a Cardiology Registrar, who argues that invasive resuscitation may be unreasonably dis- tressing for relatives. He also points out that in most hospital situations, cramped environments would not allow the presence of spectators, given that difficulty is often experienced fitting essential equipment and staff into the space between beds.

Perhaps this can be seen to highlight the argument against generalizing research findings from A&E to other clinical environments where resuscitation does not take place in a purpose built resuscitation room, but between occupied beds in a C C U or a general ward. Until research o f this type is conducted in a CCU, the question of whether relatives should be allowed to witness resuscitation will remain a highly contentious issue. As Crisci (1994) suggests, perhaps such decision-making needs to take local factors into consideration. There are obvious implications, however, for the design of new CCUs.

Turning to the issue of whether bereaved relatives should be allowed to view the body after death, there would appear to be less dis- pute about the value of this, although there is little research to guide practice. Cathcart (1988) opines that viewing the body helps the grieving process and, in particular, the acceptance of death, but argues that relatives' reluc- tance shoutd always be respected. The findings o f Mian (1990) support this view, portraying viewing the body as an opportunity for the family to say goodbye and to dispel any fears and fantasies surrounding the death. Singh and Raphael (1984) found that 50% of relatives who lost their loved ones in a rail disaster regretted the decision not to see the body, with only 18% satisfied with their decision. More recently the Bury Medical Audit (1994) found 87.5% of bereaved relatives were keen to view the body. However, several relatives expressed dissatisfaction with the length of time they felt welcome to stay, and four were particularly distressed by the fact that they were only allowed to view from behind a glass

screen. A study by Ashdown (1985) found that no relatives regretted seeing the body. However, some relatives resented the presence of staff, which they saw as an intrusion, whereas others were grateful for the support that staff present provided. This finding highlights the need for individuals to be allowed a choice, no matter what the surroundings.

Wright (1996), found that bereaved relatives appreciated discussion about the state o f the body prior to viewing, and appreciated being encouraged to touch their loved one. He found that many relatives preferred to view the body in the place where the death had occurred, but where this is inappropriate a private, quiet room is advocated. This is supported by Ewins & Bryant (1992) who found relatives were very conscious o f the surroundings, particularly where the viewing occurred where there was only a curtain to separate them from other patients. Despite a variety of settings and methods used to obtain data in this area, nowhere in the literature is the view expressed that relatives should not be given the option o f viewing the body. Although based largely on retrospective data, the level of congruence between studies would suggest that allowing relatives the option to view the body in C C U would be appropriate in a quiet, private area, with or without a nurse, depending on the individual's wishes.

The practice of viewing the death or the body is consistent with the literature on bereavement which stresses the importance o f encouraging people to accept the reality of the death, whether this be described as a stage to be passed through (Parkes 1996) or a task to be tackled (Worden 1991). In either case abnormal grief reactions such as protracted denial can be avoided.

The provision of comfort measures and facilities

Many writers offer recommendations in relation to comfort measures and facilities to be made available to relatives. These include the prompt reception on arrival, and the nomina- tion of a nurse to be available for relatives (Fanslow 1983, Ashdown 1985, Cooke et al 1992, Tye 1993, Bury Audit 1994, BAAEM & tKCN 1995). The literature also advocates a private room, appropriately decorated, and equipped with tissues, telephone, refreshments, comfortable seating and adequate light, situated close to the area where admissions are received (BAAEM & R C N 1995, Tye 1993, Cooke et al 1992). As a general principal, where studies agree in relation to details, such as the facilities to be made available, this supports the generalizability of findings from one clinical area to another (Polit & Hungler 1995). However,


several studies found a small percentage of individuals who did not find it helpful to be shown caring and concern from health professionals (Fraser & Atkins 1990, Wright 1988, Fanslow 1983). This view is further supported by Poole (1995) who highlights difficulties arising when a nurse's desire to protect them conflicts with the wishes of the bereaved.

Wright (1988) found nurses had difficulty when relatives did not want help, leading to negative and frustrated feelings. He suggests that nurses should judge the needs of relatives because relatives may not understand their own needs, a view disputed by Fanstow (1983) who found that relatives did appear to identify their own grief needs. Further research would appear essential in this area, as many A&E departments are now routinely allocating a n advocate nurse to remain with relatives during their stay (Wright 1996, Fraser & Atkins 1990, Mian 1990). This paternalistic behaviour perhaps begs the question of whose needs are being met, and at a practical level, many CCUs may not have adequate staffing levels to make this facility viable. It would be difficult for them to argue for higher staffing levels in the absence of a research base which testifies to the value o f this practice.

Informat ional needs of the bereaved

The literature highlights the importance of information, which must be clearly explained in understandable terms, including the cause of death, the treatment given and involvement of the coroner if applicable. A number of sources advocate the distribution of the Department of Social Services (DSS) booklet 'What to do after a death' to all bereaved relatives (Ewins & Bryant 1992, BAAEM & R C N 1995, Wright 1996). They also advocate giving information about the availability of further support such as bereavement counselling.

Given the unanimity of opinion evident in the literature, it is perhaps surprising to find that these informational needs are not always adequately met in practice. For example, Hall & Hall (1994) investigated relatives' needs following Intensive Treatment Unit (ITU) deaths a n d

found that 25% of them would have appreciated more advice. In a similar ITU study, Horton (1995) found 18% of relatives required more information, with 63% given no advice as to how to seek further support if required. Although both studies used only small samples, their findings are supported by many larger studies (Mian 1990, Silvey 1990, Cooke et al i992, Bury Medical Audit 1994). Once again, studies have used different research methods in a variety- o f clinical settings, yet yielded compa- rable results. This supports the argument for

applicability of findings to the CCUs, particularly since the literature contains no opposing views (Polit & Hungler 1995).

Global qual i ty of communicat ion

The Bury Medical Audit (1994) found com- munication to be the key factor in difficulties experienced by relatives during their hospital encounter. Further studies also support this finding (Fanslow 1983, Ashdown 1985, Mian 1990). Mian (1990) discovered that two fami- lies which arrived at the hospital were led into a room without explanation and left waiting for 45 minutes before anyone spoke to them. Raphael (1984) w a r n s of difficulties experienced during this critical phase causing traumatic memories which later return to intrude repeatedly on their bereavement suggesting that careful consideration must be paid to com- munication.

However, when Tye (1993) asked nurses to r a n k helpful nursing actions, giving information about severity of patients' condition ranked only tenth, significantly lower than relatives rated informational needs in the Fraser 8: Atkins study (1990).

Studies consistently show that staff are generally not skilled in breaking bad news (Mian 1990, Fraser & Atkins 1990, Silvey 1990, Ewins & Bryant 1992, Bury Medical Audit 1994). Wright (1988) showed that nurses found breaking bad news particularly stressful, with many nurses almost incapacitated when extreme reactions occurred. Tye (1993) found that 52% of nurses felt unprepared for this role, a n d Buckman (1984) argues that doctors are

also ill-prepared, often fearing being blamed for the death. In a further study Lyons (1988) found that 33% of ward stafffelt uncomfortable with the bereaved, and 39% admitted to igno- rance of the grieving process. Although the size of the sample limits generalizability, Lyons suggests these findings are of particular concern given students' reliance on qualified nurses to gain experience in dealing with the bereaved.

Field & Kitson (1986) found that death education is now receiving more attention in pre- registration education than in previous times. However, as recently as 1993 Tye found that 41% of A&E nurses had received no formal death education either pre- or post-registration. It also appears that length of experience does not necessarily alter the anxiety felt when dealing with the bereaved (Ewins & Bryant 1992). Sherr (1989) suggests this may be due to lack o f feedback from care received, resulting in poor skills as well as good becoming entrenched in practice, which are then difficult to unlearn. There are clear implications here for clinical supervision.


In response to the poor skills exhibited, the BAAEM and R C N (1995), recommend con- tinued education and supervised experience in bereavement care, for both newly qualified doctors and nurses. However, they do not stip- ulate who should provide the supervision. Several prominent authors have addressed these learning needs by designing training programmes, some aiming to combine formal teaching with a facilitative student-centred approach (Maguire & Faulkner 1988, Wright 1996, Tye 1996). All these programmes have been positively evaluated, with participants appreciating validation of existing areas of good practice and reporting reduced personal anxiety when dealing with sudden bereavement (Tye 1996, Wright 1996). However, as Tye (1996) points out, these findings can be criticized as participants may feel reluctant to be critical of the course or the tuition despite guarantees of anonymity. Although not without expense, these initiatives can be seen to be lifting the profile of bereavement education, allowing individual practitioners some opportunity to address anxieties in a multispeciality and multi- disciplinary arena.

Emotions of staff

Thus, a large proportion of staff have difficulties in dealing with sudden death and the suddenly bereaved. Part of this difficulty involves coming to terms with their own grief. This was first pointed up by Menzies in the early 1960s, who suggested that socialization into nursing fosters the expectation that nurses will control their feelings, with emotional outbursts seen as failure to cope (Menzies 1960). Although this view may be seen as dated, in a recent study by Spencer (1994) 29% of nurses were found to 'bottle up' their emotions. However, a study by Finlay and Dallimore (1991) found that relatives gained great support from being aware that the staff member was upset, with colder business-like informants tending to cause offence. This finding is supported by the Bury Medical Audit (1994) and Ashdown (1985) who found relatives who were acutely aware of the difficulties that staff were experiencing interpreted this as showing that they cared.

The United Kingdom Central Council of Nursing, Midwifery and Health Visiting (UKCC) Code O f Conduct (1992) suggests nurses should be aware o f and, where neces- sary, take action to protect colleagues' health and safety. In this highly emotional arena, the need for staff support has been highlighted (Wright 1996, BAAEM & R C N 1995, Spencer 1994), with the advocacy of support groups or critical incident debriefing, depending on the individual situation. Yet in one

study 45.1% of critical care nurses felt inade- quately supported by colleagues (Spencer 1994). The Department of Health in collabora- tion with the U K C C and ENB are actively encouraging the incorporation of clinical supervision throughout nursing. This is seen as a mechanism for protecting standards and public safety, whilst supporting the development of excellence in practice (Tait 1994). The aim is to provide support for professionals working constantly with stress and distress (Proctor 1989). To what extent this will impact on anxieties evoked through sudden death remains to be seen, though it is potentially of use to nurses working in a C C U environment.

Follow up support

Yates et al (1990) identify that, although the suddenly bereaved may require more support and counselling than those who have prepared for death, they usually receive less. They suggest all critical care areas, including the C C U should review arrangements for the bereaved and integrate services with those available in the community. In their A&E department home visits were instigated 72 hours after sudden bereavement for all those relatives regarded by the staff as being at risk of complicated bereavement. Relatives were assessed using the 'Determinants of Grief criteria (Parkes & Weiss 1983). In evaluating the 109 visits included within the study, it was found that 21 people displayed grief reactions such as anger and denial and one person rejected help. This system of making unannounced and uninvited visits may have been seen by some relatives as an unwelcome intrusion, and may have accounted for some of the overt anger encoun- tered. An alternative would have been to offer the visits to all rather than just those judged to be in need of help.

Many other studies advocate similar initiatives (Wright 1996, BAAEM & R C N 1995, Ewins & Bryant 1992, Mian 1990). However, Tye (1993) found that several nurses felt follow-up visits were an intrusion on private grief. In another study Silvey (1990) found that, although 80% of the bereaved relatives perceived a need for some support, none saw hospital staff as being in a position to help them. Yet in a study by Jackson (1992), 32% of ITUs contacted claimed to offer some form of follow up after a sudden bereavement. These initiatives, however, are inherently difficult to eval- uate, with studies concluding they 'appeared to be useful', providing anecdotal evidence to support their statements. They demonstrate inadequate rigour in this respect, and further research is essential before this initiative can truly claim to be research-based.

Care of the suddenly bereaved in cardiac care units I 51

CONCLUSION

O v e r the last 10 years, leading research in to

cardiac care has c o n c e n t r a t e d largely on pos t -

myocard ia l in farc t ion rehabi l i ta t ion, c o u n -

sell ing and medica l studies a t t emp t ing to ascer-

ta in op t imal t r e a t m e n t to reduce fatalities.

H o w e v e r , perhaps this demons t ra tes a ra ther

l imi ted and ove r opt imis t ic approach since no t

all C C U pat ients survive to reap the benefits.

Pat ients do die in the C C U and the needs o f

the i r relatives mus t be adequate ly addressed. As

no research has b e e n f o u n d w h i c h specifically

examines this area, c o m m e n t a t o r s will

u n d o u b t e d l y c o n t i n u e to p re sume that all f ind-

ings f rom o t h e r critical care areas can be applied

to the C C U . H o w e v e r , this has h i the r to

occu r red w i t h o u t any serious cons idera t ion o f

the C C U ' s u n i q u e characterist ics w h i c h , after

all, are the reason for exis tence as a separate

entity.

This paper has offered an assessment o f the

appropr ia teness o f apply ing the f indings o f

studies c o n d u c t e d in o t h e r clinical areas to

C C U s . It is suggested that general f indings

regard ing the gr iev ing process are l ikely to be

transferable since these can be appl ied to the

bereaved , i r respect ive o f l o c a t i o n . T h e sugges-

t ion that sudden b e r e a v e m e n t can cause par t ic -

ular difficulties, and that events in the critical

phase s u r r o u n d i n g dea th can alter the o u t c o m e

o f b e r e a v e m e n t is j u d g e d likely to be useful in

p l a n n i n g care in C C U . It is there fore essential

tha t care o f the suddenly be reaved be g iven

careful cons idera t ion .

A l t h o u g h m a n y o f the o the r issues raised

above are v i e w e d as l ikely to be transferable,

this was no t so in every case. This is o f serious

conce rn , part icular ly as little is k n o w n o f the

b e r e a v e m e n t care b e i n g offered by C C U s

a r o u n d the count ry . C o n c e r n s relate to alloca-

t ion o f an advoca te to be w i t h relatives and

a l lowing obse rva t ion o f resuscitat ion. This is

largely due to practical issues such as staffing,

layout , and concerns for o the r pat ients b e i n g

cared for in the C C U . R e s e a r c h is n e e d e d in

o rder to ascertain cu r ren t pract ice and define

w h a t const i tu tes best practice. I f p resent care

p roves unacceptable , t h e n research in to the

cardio-specif ic efficacy o f facilities such as those

descr ibed above will be needed .

Q u i t e apart f rom invest igat ing the re levance

o f findings f rom studies c o n d u c t e d in o the r d i n -

ical specialisms, C C U specific research is also

indica ted by the possibility o f o the r aspects o f the

C C U e n v i r o n m e n t w h i c h may act as variables in

the gr ieving process, bu t have no t b e e n ident i -

fied by research carried out elsewhere.

In the m e a n t i m e , it is r e c o m m e n d e d that

s t a f f in C C U s cons ider the issues raised in rela-

t ion to the i r o w n local setting. It may be that

clinical standards or protocols will be devel -

oped, bu t these should be sufficiently flexible

and c l i en t - cen t r ed to a c c o m m o d a t e indiv idual

differences.

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Documents

Care of the suddenly bereaved in cardiac care units: a review of the literature