GRIEVING A Tool to Improve Death Notification Copyright

GRIEV_ING A Tool to Improve Death Notification

Copyright 2005 Cherri Hobgood, MD Associate Dean Curriculum and Educational Development Department of Emergency Medicine University of North Carolina

GRIEV_ING Objectives Learners will be able to: n Communicate using empathic skills n Organize death notification using the GRIEV_ING mnemonic n Perform an effective death notification using “GRIEV_ING”

US Deaths n Common occurrence ~ 1 Million in-hospital deaths/yr u In 2002 there were > 272, 000 ED deaths u n High Risk Significant source of family dissatisfaction u Management of the death a major determinant in malpractice litigation u

Why do we care? n All of us will care for dying patients & their families n At the end of life there is no second chance to get it right

Ideal World n Ongoing Relationship with the patient & family n Death expected with time to Emotionally Prepare n Physician has Education and Expertise in the delivery of death notification

The Intern’s World n Often no significant relationship with the patient or family n Sudden and unexpected death n Death after an emotionally exhausting failed resuscitation n Little education to prepare us to deliver this devastating news

Our World n Variables are often out of our control n Create significant stress for the MDs Emotionally draining u Dealing with Death a major cause of MD and staff disillusionment u

Their World n Stressful for family members Limited psychological preparation u Don’t know you u Have little or no contact with you afterwards u Increased rate of pathologic grief reactions t Intense grief t Prolonged mourning t Increased morbidity and mortality u

See one, Do one, Teach one. Should not apply here

Empathic Communication Empathic Characterized by or based on empathy Empathy 1. 2. Projection of a subjective state onto an object Capacity for participation in another's feelings or ideas Webster’s New Collegiate Dictionary

Empathic Communication 2 Components n Cognitive t Accurate understanding of the patient’s feelings n Behavioral t Effective communication of that understanding to the patient

Empathic Communication n Empathic u Directly expressed emotion by a patient n Empathic u Response Expressed recognition of the patient’s emotion n Empathic u Opportunity Terminator Directing the patient away from the

Empathy Identify how emotions are expressed Goal Understand our response to these expressions of emotion Recognizing and Acknowledging a Patient’s Emotion Outcome

Identify how emotions Understanding are expressed emotional expression Empathy Therapeutic Dialogue Understanding our responses to emotional expression Recognizing and Acknowledging a Patient’s Emotion

Emotional Expression n Crying n Anger n Numb, just blank n Incomprehension n Blame n Denial n Guilt n Antagonism n Hostility n Complete collapse n Hysteria n Wailing n Fear n Prayer

The Range of Emotional Responses is Wide so Expect Anything and Everything

Physician Responses n Withdrawn n Clinical n Distant n Fear n Sorrow n Antagonism n Hostility n Understanding n Empathy n Concern n Curt n Unflappable n Brave n Indifferent

How would you act if…. . n Your next door neighbor came over to tell you he had cancer? Pull up a chair and sit down u Listen u Express our sympathy and concern u Offer to help in any way we could u

Why should we act differently at work ? Misconceptions of the Professional Role Know what to do & say in every situation u Consistently unflappable and brave u Basic human resources and vocabulary unavailable u Unable to express human sympathy u

“I’m sorry” n Two types Sympathy u Apology & acceptance of responsibility u n Use phrases that express Your feelings t “ I am sorry for your loss” u Your acknowledgement of their feelings u

Listen

3 Rules of Listening 1. 2. 3. Assume an attentive posture Let people speak Then show them you heard

1. Assume an attentive posture n Introduce yourself n Shake hands n Sit down at matching eye levels n Lean forward, hands on the knees

2. Let people speak n Factoid u Average time patient is allowed to speak uninterrupted by a physician is 18 sec. n Use open questions and verbal cues to encourage their expression n Tolerate brief periods of silence

3. Then show them you heard n Repetition u Use one or two of their key words n Reiteration u Paraphrase what they have said n Reflection u Interpret & Listen for the hidden ? n Respond

Small Group Session I

What is “GRIEV_ING” n Tool to assist you An information and organizational prompt u Allows you to insure accurate and complete information transfer u Frees you to attend to the empathic portions of the communication u

n. G n. R n. I n. E n. V n_ n. I n. N n. G gather resources identify educate verify space inquire nuts and bolts give

GRIEV_ING G-Gather n The family or survivors Insure that all members are present u Offer to call others or wait if other family members will be arriving soon u

GRIEV_ING R-Resources n Call for support resources available to assist the family with their grief hospital chaplain services u family minister u family u friends u interpreter u

GRIEV_ING I-Identify n yourself and your role n the deceased patient by name n the family’s state of knowledge about the events n that you are bringing BAD NEWS u Fire the Warning Shot

GRIEV_ING E-Educate n The family Start from where they ended their story u If possible, use their terms u Avoid Jargon u Use slow and steady steps u If needed, fire another warning shot u Check their comprehension u

GRIEV_ING V-Verify n Their family member has died n Be clear! Do not use euphemisms “Passed away” u “No longer with us” u n Use the words “dead” or “died”

GRIEV_ING _Space n Give the family personal space n Emotional moment n Registration of information n Tolerate silence n Touching is ok n Give them permission to cry

GRIEV_ING I-Inquire n Ask if there any questions n Answer them all n Assess understanding Elicit summary statements from them u Listen for the hidden question u

GRIEV_ING N-Nuts and Bolts n Inquire about organ donation n Funeral services n Personal belongings n Offer the family the opportunity to view the body

GRIEV_ING G-Give n Give them your card & contact information n Offer to answer any questions that may arise later n Always return or take their call

Policies n Hospital specific n Know your hospital’s policies for Reporting deaths to the ME u Discussing organ donation with family u Calling your state’s organ procurement association u

n. G n. R n. I n. E n. V n_ n. I n. N n. G gather resources identify educate verify space inquire nuts and bolts give

“ Life is short, the art long, experience treacherous, judgment difficult” Hippocrates

Small Group Session II

Small Group Session II Structured Role Play n Three cases n Everyone will play each role n MD u Family member u Observer u n Feedback given to MD in every cycle Be accurate and specific u Scoring guides provided u