Physicians frequently deal with the loss of a patient in the emergency department and in intensive care units. These deaths are often due to unforeseen violent circumstances, such as gunshot wounds, motor vehicle accidents, suicides, and homicides. Only after extensive, failed resuscitation attempts will the emergency department team end their efforts. This harrowing experience takes not only a physical but emotional toll on the providers, as they are the last hope of survival for the patient. The loss of a patient’s life reflects immense personal and professional stress and anxiety on the emergency physician. However, they must put aside their grief to disclose the bad news to family members of a patient who has died unexpectedly. The physician likely lacks a prior intimate relationship with the family. This lack of familiarity makes it important the emergency physician be aware of and ready for various emotional reactions from the family so that he or she can alleviate extended grief and bereavement.
Having a planned approach to the unforeseen circumstances in the ED is useful for both the family of the deceased and emergency physician in charge. The GRIEV_ING mnemonic provides an organized method for concise and accurate death notification; it delivers all the necessary information to the family and is simple to remember for clinicians.
Reactions to Expect
Reactions of grieving family members often differ. Some common emotional reactions observed during times of grief are feelings of numbness, sadness, anger, hopelessness, irritability, denial, guilt, fear, and anxiety. Some common cognitive reactions are difficulty concentrating, confusion, difficulty making decisions, and disbelief. Some common behavioral reactions are blaming others, avoidance of the situation, and acting out. Stay calm and be respectful of the family of the deceased as individuals express their emotions. If you choose to touch a grieving family member, the shoulders are the most appropriate location.
Effects on Survivors and Physicians
When notifying the family members of patients who died suddenly, it is necessary to provide complete, correct information about the death. An accurate death notification may diminish the tendencies for survivors of the deceased to develop complicated health conditions, such as prolonged grief disorder (PGD) or posttraumatic stress disorder (PTSD).
Proper death notification protocols are not only vital for family members but may also reduce adverse physiological and psychological responses experienced by emergency physicians in such stressful situations. Faced with delivering the difficult news of a patient’s death under their care, clinicians and nurses commonly experience the following: excess cortisol upset and irregular heart rate, combined with feelings of sadness and disappointment resulting in insomnia. This hindrance to attention and concentration will negatively affect the high quality of care expected.
Long Distance Notifications
Proceed with the aforementioned GRIEV_ING mnemonic. If the family of the deceased feel inclined to come to the hospital, request that they are accompanied and make certain someone is accessible to answer any of their questions.
Autopsy and Medical Examiner Cases
Depending on state laws, deaths meeting established criteria must be promptly reported to the medical examiner and coroner. Some examples are unexplained or unusual deaths, homicides or suicides, medical procedure deaths, pediatric deaths, accidents or unnatural deaths. If a medical examiner and coroner case, resuscitative lines, and tubes must not be removed from the deceased. If the death is not a medical examiner and coroner case, the physician is still obligated to present the family with the opportunity for an autopsy.
It is not the responsibility of the emergency physician to discuss organ procurement with the family of the deceased. The Joint Commission standards on organ procurement require specific hospital procedures and protocol. This entails the collaboration with organ and tissue procurement organizations. Allow a member of the organization to discuss all information relating to organ and tissue donations with the family of the deceased.
Clinicians should develop procedures that facilitate safe family-witnessed resuscitation efforts. Allowing family members comprehensive, real-time observation on the patient’s situation may provide families with closure, leading to less complicated grief responses. Family members should be escorted out if concerns emerge of them posing a risk to the safety of the healthcare team. 
Pediatric deaths are one of the most taxing situations faced by the team. Protocol for pediatric deaths is different from other deaths, in which clinicians and nurses are to provide a family-centered and team-oriented approach. The family should be allowed to be with child during resuscitation efforts. The family should also be provided with appropriate resources and family planning. Clinicians should get in contact with the child’s pediatrician and disclose the circumstances of their death so the pediatrician can further support the deceased child’s family. Pediatric deaths meet the criteria to be reported to the Medical Examiner and Coroner. 
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