I.Ya. HORBACHEVSKY TERNOPIL STATE MEDICAL I.Ya. HORBACHEVSKY TERNOPIL STATE MEDICAL UNIVERSITYUNIVERSITY

Disaster medicine and military medicine department Disaster medicine and military medicine department

• Lecture 1Lecture 1

Organization of medicare Organization of medicare

at pre-hospital stage. at pre-hospital stage.

Primary inspection of a Primary inspection of a casualtycasualty

•DEATH AND DYING IN DEATH AND DYING IN THE EMERGENCY THE EMERGENCY DEPARTMENTDEPARTMENT

Who should notify the family Who should notify the family that someone has diedthat someone has died??

Many families have stated that they Many families have stated that they want a physician to inform them want a physician to inform them about the death. However, family about the death. However, family members prefer that a nurse stay with members prefer that a nurse stay with them to answer questions and provide them to answer questions and provide comfort. Nurses are perceived as comfort. Nurses are perceived as more compassionate, acknowledging more compassionate, acknowledging the significance of the death for the the significance of the death for the family.family.

Can anyone else help with Can anyone else help with death notification?death notification?

Yes. You may want to explore Yes. You may want to explore developing a collaborative group who developing a collaborative group who can be called upon to assist families in can be called upon to assist families in the ED when death occurs. Team the ED when death occurs. Team members may include social workers, members may include social workers, clergy, psychiatric staff, and trained clergy, psychiatric staff, and trained volunteers.volunteers.

WWhat's the first thing I should say hat's the first thing I should say to the family when I have to tell to the family when I have to tell

them someone has died?them someone has died?You should You should not not start with "I'm sorry" or start with "I'm sorry" or "I have bad news for you." Statements "I have bad news for you." Statements like these do not give families enough like these do not give families enough

time to assimilate and process time to assimilate and process information. Sit close to the family and information. Sit close to the family and

speak directly to them. Use the speak directly to them. Use the sequential notification processsequential notification process

to tell families about the death or any to tell families about the death or any other critical situation. This notification other critical situation. This notification

process provides guidelines to help process provides guidelines to help inform family members of deaths and inform family members of deaths and critical situations in a short period of critical situations in a short period of

time. The staff member should:time. The staff member should:

• • Find out what the family already Find out what the family already knows.knows.

• • Give them a brief description of what Give them a brief description of what has has happened during the time the happened during the time the patient was receiving care, bridging patient was receiving care, bridging

their knowledge of events. Begin with their knowledge of events. Begin with simple information and then provide simple information and then provide

more complex details.more complex details.• • Explain what resuscitation efforts Explain what resuscitation efforts

were made.were made.• • Conclude your description with a Conclude your description with a

statement that describes the patient's statement that describes the patient's response to treatment and explain the response to treatment and explain the

cause of death.cause of death.

How do I tell someone How do I tell someone about a death over the about a death over the

telephone?telephone?Try any way possible to have the Try any way possible to have the

person come to the ED. If you must person come to the ED. If you must notify someone of a death over the notify someone of a death over the

telephone, you may find that using the telephone, you may find that using the sequential notification process works sequential notification process works well. Eachwell. Each case is different and you case is different and you

may have to rely on your "sixth sense." may have to rely on your "sixth sense." In some situations you may want to In some situations you may want to call with very basic information such call with very basic information such as, "There has been an accident and as, "There has been an accident and

the staff is working with Mrs. X. I'll call the staff is working with Mrs. X. I'll call you back in 5 to 10 minutes to tell you you back in 5 to 10 minutes to tell you

how things are going; can you call how things are going; can you call someone to stay with you?"someone to stay with you?"

When you handle the notification using When you handle the notification using this two-step process, the person whom this two-step process, the person whom

you have called may then have you have called may then have someone with them when they are told someone with them when they are told

about the death. If you have a list of about the death. If you have a list of resources, such as counselors, support resources, such as counselors, support groups or clergy, who are available to groups or clergy, who are available to go to the survivor's home, contacting go to the survivor's home, contacting

them will provide an additional source of them will provide an additional source of support for the bereaved.support for the bereaved.

Should I call someone during Should I call someone during the middle of the night or wait the middle of the night or wait

until a reasonable hour?until a reasonable hour?

Family members prefer to be called as Family members prefer to be called as soon as possible, no matter what the soon as possible, no matter what the time. Waiting to notify a family of a time. Waiting to notify a family of a critical injury or death may make it critical injury or death may make it

harder for the family to trust the care harder for the family to trust the care givers. Moreover, the family may feel givers. Moreover, the family may feel

that they were cheated out of precious that they were cheated out of precious last moments to spend with the last moments to spend with the

deceased.deceased.

How do I prepare the body if How do I prepare the body if the family wants to see it?the family wants to see it?

The The body should be cleaned of all blood, body should be cleaned of all blood, secretions, and dirt secretions, and dirt if forensic evidence if forensic evidence is not needed. is not needed. Gelfoam can be applied Gelfoam can be applied

to oozing wounds to decrease the to oozing wounds to decrease the amount of drainage, and clean amount of drainage, and clean

dressings applied. Intravenous lines, dressings applied. Intravenous lines, catheters, and endotracheal tubes catheters, and endotracheal tubes

should be removed should be removed if approved by the if approved by the medical examiner. medical examiner. Medical equipment Medical equipment

should be cleaned but left by the should be cleaned but left by the bedside. This helps families to know bedside. This helps families to know that appropriate interventions were that appropriate interventions were

performed.performed.

What should I tell the family What should I tell the family before they go in to see the before they go in to see the

body?body?

Clearly describe everything they will Clearly describe everything they will see, including endotracheal tubes, see, including endotracheal tubes,

obvious wounds, and medical obvious wounds, and medical equipment. You may need to repeat this equipment. You may need to repeat this information several times since people information several times since people need time to understand new material, need time to understand new material, especially during an extremely stressful especially during an extremely stressful

situation such as this.situation such as this.

Is there a "best way" to Is there a "best way" to position the body?position the body?

Yes. The body should be positioned with Yes. The body should be positioned with the head elevated. Placing a small the head elevated. Placing a small

towel under the head will bring the chin towel under the head will bring the chin closer to the chest; this helps to keep closer to the chest; this helps to keep the mouth closed. Place the body near the mouth closed. Place the body near the door, feet first. This prevents the the door, feet first. This prevents the family from having to walk across a family from having to walk across a

large open area to approach the body.large open area to approach the body.

How should I prepare the room How should I prepare the room and adjust the lighting when a and adjust the lighting when a

family wants to spend some family wants to spend some time with the body, especially time with the body, especially if it is a child who has died?if it is a child who has died?

Although a child's death is tragic, every Although a child's death is tragic, every death may be thought of as a death may be thought of as a significant loss and all people, significant loss and all people,

regardless of age, can experience regardless of age, can experience death in a supportive way with the help death in a supportive way with the help

of health care personnel. If time and of health care personnel. If time and space in the ED permit, the family space in the ED permit, the family

should be allowed to stay as long as should be allowed to stay as long as possible. possible.

ShouldShould I stay with the family I stay with the family when they see the body?when they see the body?

Every case is different. You need to Every case is different. You need to assess the situation; the best way assess the situation; the best way

to do that is to ask. Most often, to do that is to ask. Most often, staff will stay the first few minutes staff will stay the first few minutes to answer questions, and then ask to answer questions, and then ask the family if they want to be alone the family if they want to be alone

for a while.for a while.

What should you tell children What should you tell children when someone they care about when someone they care about

dies?dies?Children should be told the truth. It is Children should be told the truth. It is

important that the adults who are with important that the adults who are with the child hearthe child hear what you say so they can what you say so they can repeat the explanation later to the child. repeat the explanation later to the child. Use simple terms andUse simple terms and speakspeak directly to directly to the child. Be careful to avoid common the child. Be careful to avoid common

phrases, such as "Gone to sleep," since phrases, such as "Gone to sleep," since the child may become afraid to sleep, or the child may become afraid to sleep, or "You're the man or woman of the house "You're the man or woman of the house now," which places tremendous stress now," which places tremendous stress

on a grieving child.on a grieving child.

Is there anything special we Is there anything special we can do to help parents when a can do to help parents when a

child dies?child dies? Yes. The most important thing you can Yes. The most important thing you can do is provide the family with as much do is provide the family with as much time as they need to say good-bye, time as they need to say good-bye, even if this means the child must be even if this means the child must be

moved out of the ED to a quiet place. It moved out of the ED to a quiet place. It can be very hard for families to leave a can be very hard for families to leave a

loved one's side because they don't loved one's side because they don't want to leave the deceased person want to leave the deceased person

alone in a morgue. Parents sometimes alone in a morgue. Parents sometimes find comfort in leaving a child's favorite find comfort in leaving a child's favorite toy or blanket with him or her. Offer the toy or blanket with him or her. Offer the parents the opportunity to comb their parents the opportunity to comb their child's hair or wash their child's face child's hair or wash their child's face

while they spend time with their child.while they spend time with their child.

How do I know when it is How do I know when it is appropriate to transport the appropriate to transport the

deceased patient to the morgue?deceased patient to the morgue?First, the body must be released by the First, the body must be released by the

medical examiner. Second, you will need to medical examiner. Second, you will need to know if the family is coming in and their know if the family is coming in and their

approximate arrival time. If there is time and approximate arrival time. If there is time and space in the ED, you may want to keep the space in the ED, you may want to keep the

deceased there until the family has visited. If deceased there until the family has visited. If time and space are not available, you may time and space are not available, you may need to move the body to another location need to move the body to another location

for family viewing if the morgue is not for family viewing if the morgue is not designed for family visits.designed for family visits.

Who arranges for the body to Who arranges for the body to be picked up from the morgue?be picked up from the morgue?

This arrangement is made by the This arrangement is made by the family. Because the death of a family. Because the death of a

loved one is a stressful event, the loved one is a stressful event, the family may need to be reminded family may need to be reminded that they need to call the funeral that they need to call the funeral

home so that all final arrangements home so that all final arrangements can be made.can be made.

Who determines whether or not an Who determines whether or not an autopsy will be done?autopsy will be done?

This decision is usually made by the This decision is usually made by the medical examiner's office or the medical examiner's office or the

patient's attending physician. Several patient's attending physician. Several factors determine whether a patient has factors determine whether a patient has an autopsy. First is the cause of death. an autopsy. First is the cause of death. Any death associated with a known or Any death associated with a known or suspected criminal activity is usually suspected criminal activity is usually

cause for an autopsy. Second, autopsies cause for an autopsy. Second, autopsies are done to determine the cause of a are done to determine the cause of a

sudden, traumatic, or unexpected death. sudden, traumatic, or unexpected death. Third, a family member may request an Third, a family member may request an

autopsy in certain situations.autopsy in certain situations.

Regulations regarding autopsies vary Regulations regarding autopsies vary from state to state and among different from state to state and among different

law enforce ment agencies. Medical law enforce ment agencies. Medical examiners and private physicians may examiners and private physicians may

also have individual preferences also have individual preferences regarding autopsy decisions. ED staff regarding autopsy decisions. ED staff should consult with all of the agencies should consult with all of the agencies

and physicians making autopsy and physicians making autopsy decisions in their area to determine decisions in their area to determine local regulations and preferences.local regulations and preferences.