Grief Support Following In-Hospital Deaths

Function

Death Notification

Having a structured approach to unforeseen circumstances in the emergency department or hospital is useful for both the family of the deceased and the healthcare professional involved. The GRIEV_ING mnemonic provides a systematic method for delivering concise and compassionate death notifications, ensuring that all essential information is conveyed while being easy for clinicians to remember.

• Gather (G): Gather the family members and bring them to a quiet, private environment. Assist the family and provide information to everyone at once, allowing for optimal support within the family.[6]
• Resources (R): Arrange for additional support resources to assist the family, such as chaplain services, family ministers, family members, and friends.
• Identify (I): Introduce yourself and identify the deceased by name. Identify the family's state of knowledge of the situation. Is the news of the death unexpected? Foster an environment of open communication by inviting family members to sit with you.
• Educate (E): Briefly update the family about the events in the emergency department or hospital unit. Explain the current state of their loved one. Use thoughtful language and avoid technical terms.
• Verify (V): Verify the death of the family member. Use clear and direct language such as "death," "died," or "dead" to avoid ambiguity. 
• _ (Space): Pause and allow the family some personal space and time to process the information you have shared.
• Inquire (I): Ask whether they have any questions or how you can assist them further.
• Nuts and bolts (N): Inquire about organ donation, funeral services, and personal belongings. Offer the family the opportunity to view the body.
• Give (G): Give the family your card and contact information. Offer to answer any questions they may have later and ensure you return their calls.

Issues of Concern

Reactions to Expect

Grieving family members often exhibit a wide range of emotional reactions. Common emotional responses include numbness, sadness, anger, hopelessness, irritability, denial, guilt, fear, and anxiety. Some common cognitive reactions include difficulty concentrating, confusion, difficulty making decisions, and disbelief. Some common behavioral reactions are blaming others, avoidance of the situation, and acting out. Calmness should be maintained, and respect should be shown to the deceased's family as individuals express their emotions. Employ good judgment regarding touch as a comfort measure; the shoulders may be considered the most appropriate location.[7]

Clinical Significance

When notifying the family members of a patient's sudden death, it is necessary to provide complete, accurate information about the death. An accurate death notification may diminish the tendency for survivors of the deceased to develop complicated health conditions, such as prolonged grief disorder or posttraumatic stress disorder.[8][9]

Proper death notification protocols are not only vital for family members but may also reduce adverse physiological and psychological responses experienced by clinicians in such stressful situations. When tasked with delivering the difficult news of a patient's death, clinicians may experience heightened anxiety, palpitations, sadness, and disappointment, which can lead to insomnia. These emotional responses can hinder attention and concentration, potentially impacting the high quality of care expected from healthcare providers.

Other Issues

Special Situations

Long-distance notifications: The aforementioned GRIEV_ING mnemonic should be followed when notifying a family about the death of a loved one. If the family of the deceased wishes to come to the hospital, someone should be available 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 or coroner. Some examples are unexplained or unusual deaths, homicides or suicides, medical procedure deaths, pediatric deaths, accidents, or unnatural deaths. If the death qualifies as a medical examiner or coroner case, resuscitative lines and tubes must not be removed from the deceased. If the death does not fall under medical examiner or coroner jurisdiction, the physician is still obligated to offer the family the option of an autopsy.

Organ donations: The emergency medicine physician is not responsible for discussing organ procurement with the deceased's family. The Joint Commission standards on organ procurement require specific hospital procedures and protocols and entail collaboration with organ and tissue procurement organizations. A representative from these organizations should provide the family with all necessary organ and tissue donation information.

Witnessed resuscitation: Clinicians should develop procedures that facilitate safe family-witnessed resuscitation efforts. Offering family members the opportunity to observe the resuscitation in real-time can provide closure and may result in less complicated grief responses. If family members pose any risk to the safety of the healthcare team, they should be escorted out of the area.[10]

Pediatric deaths: Pediatric deaths are one of the most challenging situations for healthcare teams. The 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 the child during resuscitation efforts. The family should also be provided with appropriate resources and family planning. Clinicians should contact the child's primary care practitioner and disclose the circumstances of their death so that the clinician can further support the deceased child's family. Pediatric deaths must be reported to the medical examiner or coroner.[11]

Enhancing Healthcare Team Outcomes

Complications with the grief and bereavement of family members of the deceased can be minimized with team-oriented care efforts. A team of healthcare professionals, including clinicians, social workers, chaplains, and other healthcare providers, collaborates to deliver a comprehensive death notification. This interprofessional collaboration provides family members the support and resources to ensure clear communication and enhance grief support outcomes.[12]

Interprofessional collaboration also facilitates the sharing of resources and support for the family. Social workers and chaplains, for example, can provide additional emotional support and guidance, whereas nurses offer compassionate care during the complex process. By combining the expertise of various healthcare providers, the family receives a more comprehensive and empathetic response, improving communication and promoting better grief support outcomes.

Nursing, Allied Health, and Interprofessional Team Interventions

Nurses play a crucial role in supporting a grieving family by providing compassionate and personalized care that helps the family navigate their difficult emotions. This process involves:

• Acknowledging their feelings. Nurses should avoid pretending to fully understand the family's pain. Expressing honest acknowledgment of their loss can be more meaningful to the family than forced reassurances.
• Engaging in conversation about the deceased: Asking about or encouraging the family to share memories of their loved one can help nurses validate the family's grief, creating a supportive space for their emotional expression.
• Offering assistance and support: Asking how nurses can help, even if the family is uncertain, opens the door for dialogue and lets the family know they are not alone.
• Facilitating connections with support resources: Nurses can help families access chaplains, social workers, or other healthcare providers to offer support as needed.
• Coordinating clinician interactions: When requested, nurses arrange for the family to speak with clinicians involved in the deceased's care, providing them with crucial information and closure.
• Providing opportunities for cultural or religious practices: Offering the chance to connect with clergy ensures that their needs and beliefs are respected.
• Comforting the family during goodbyes: Allowing private time to say goodbye to the deceased while making efforts to create a peaceful and comfortable environment offers a meaningful moment for the grieving process.
• Preserving memories: Nurses can offer the option to create keepsakes such as thumbprints, handprints, or locks of hair for the family.
• Guiding practical arrangements: Nurses can help families with questions about funeral homes and other arrangements, easing some logistical burdens during emotional distress.
• Being available for questions: Grief can be overwhelming, and questions may arise later. Nurses make sure that families know they have support, even beyond their initial encounter.

Nurses should acknowledge that they may not know what to say. Families understand that the situation cannot be fixed. The family should be given as much attention as needed, but private time should also be provided. Additional contact information should be given after the family has left the hospital, as they may be overwhelmed and have questions that arise hours or days later. Cultural awareness should be maintained, recognizing that families from different religions and cultures may have differing views on death.[13][14][15][16]

Nursing, Allied Health, and Interprofessional Team Monitoring

Supporting grieving families requires continuous, coordinated monitoring by the healthcare team. Nurses and allied health professionals play a crucial role in assessing family needs and supporting team well-being.

Assessment of Family Needs

• Monitoring reactions: Signs of complex grief, such as intense anger or prolonged denial, should be monitored. Early intervention through mental health or social work referrals can help mitigate these reactions.
• Clear communication: Families should be informed about autopsy procedures, medical examiner involvement, and any necessary next steps, helping reduce confusion and frustration.
• Resource access: Families should have regular access to chaplains, social workers, and bereavement counseling.

Supporting Healthcare Providers

• Debriefing sessions: Regular debriefs should be conducted to allow team members to process difficult cases and support each other.
• Wellness support: The use of wellness programs and mental health support should be encouraged, especially after traumatic cases.
• Ongoing training: Periodic training on grief communication helps healthcare providers manage their responses while supporting families.

Evaluating Grief Support Protocols

• Feedback collection: Feedback should be regularly gathered from staff on the effectiveness of grief support protocols and areas for improvement.
• Data-driven adjustments: Family and staff feedback should be used to make data-informed adjustments that enhance grief support practices.[17][18][19][20][21][22][23][24][25][26][27][28][29]