Author: Sarah Sanders, MD (EM Resident Physician, PGY-2, NUEM) // Edited by: Kory Gebhardt, MD // Expert Commentary: Kathy Neely, MD
Citation: [Peer-Reviewed, Web Publication] Sanders S, Gebhardt K (2016, August 2). The GRIEV_ING MNEMONIC: A Simple Approach To Death Notification In The ED [NUEM Blog. Expert Commentary by Neely K]. Retrieved from http://www.nuemblog.com/blog/death-notification/
Introduction
Death notification is an action that no emergency physician should take lightly. Fueled with emotion, it is an event that is a common albeit unfortunate occurrence in the emergency department and an area that rising providers must have proper teaching and instruction. Dr. Cherri Hobgood (previously at UNC, current Indiana University Chair of Emergency Medicine) developed an educational intervention, using the GRIEV_ING mnemonic, which demonstrated a significant increase in residents’ confidence with and competence in delivering a death notification. The intervention and teaching instructions are currently available through the American College of Emergency Physicians (ACEP) website and available for use by any individual or institution. We will review the points of the GRIEV_ING mnemonic in this post and touch on pearls and pitfalls.
The GRIEV_ING Mnemonic
G-GATHER
Gather all the necessary individuals. This includes the patient’s family, friends, and any other important individuals who desire to be present. This task is often best delegated to a charge nurse or other staff who can organize the family into a private location for the notification prior to your arrival.
Additionally, gather the necessary staff in the ED (See Resources below). Make sure to tie up loose ends and inform your team that this death notification will be occurring and you will be unavailable for a length of time. You do not want to be interrupted unless it’s an absolute emergency.
PITFALLS
- Not having important family members present who are on the way. You want to only do this once, if possible, and if it means waiting 10 minutes for a few other important family to arrive, this would be preferable.
- Having too many family/friends present. Sometimes there might be a large gathering of family, friends, coworkers, etc. for a patient. The optimum number present for a notification will vary depending on many factors including the circumstances of the patient and their death, space, and staff factors. Doing your best to keep the initial notification to close family and friends will often be of benefit, but will be a judgement call.
- Unresolved, active ED issues. This is difficult to control, but making an effort to complete any time-sensitive tasks prior to leaving for the notification will maximize your ability to focus on the task and avoid interruptions. If possible, quickly discuss any active/sick patients with other providers so they might help with any issues that arise.
R-RESOURCES
Utilize resources that are available to you. This includes social work, chaplain, ministers, nurses, and security. Determine who needs to be present in the room, both from the family’s perspective and from your perspective. An important step in the process at this point will be to quickly review with the staff accompanying you as to your approach to the notification and to who and how you will hand the discussion off to at the conclusion (see "nuts and bolts" below). Knowing who will address which logistical items before starting the notification is important.
PITFALLS
- Not having security present or aware of the notification. Families respond to unexpected news of death of a loved one in unpredictable ways. Unfortunately this can sometimes manifest as violence towards the care provider. It is not always necessary to have security in the room, but having them close by and aware of the impending discussion is important for you and staff safety. Similar to interviewing patients with acute psychiatric emergencies, it is important to always have an available exit and not find yourself trapped in a room if things turn violent.
- Too many staff present in the room. It can be overwhelming to family to have a large staff presence for the notification, so minimizing who is present initially can be helpful, but it is important to know what resources are available to you and the family. Consider having staff not critical to the initial notification wait nearby until they are needed.
I-IDENTIFY
Identify yourself as the medical provider of the deceased patient. Identify the deceased patient by name. Have family/friends present identify their relation to the deceased (Ask "Just for my knowledge, how is everyone related to _"). Identify the current state of knowledge by the loved ones regarding how much information they know about the situation ("What do you know so far about what has happened?").
PITFALLS
- Assuming who certain people are. This sounds obvious but we’ve all had to put our foot in our mouth and assumed someone is a husband/wife, son/daughter, sister/brother, etc when it wasn’t the case. Knowing who you are talking to is especially important with death notifications.
- Too much time on "what do you know?” While it is important to have a sense of where everyone's understanding is, it can sometimes evolve into a long presentation of unimportant details. Avoiding spending significant time here will allow you to spend more time on more critical upcoming items.
E-EDUCATE
Educate the room on the events leading up to the patient’s death. This includes events that happened with EMS and events which occurred in the emergency department. Remember to avoid medical jargon and use simple language.
PITFALLS
- Too detailed of a lead-in. "Forecasting" the news of death is important, but think of what details are a necessary part of this. It is easy to overload those present with information so providing a brief but complete idea of the events leading to death will be appreciated by all those involved.
- Medical jargon. It is incredibly hard to provide a detailed series of events leading to death without using unexplained medical jargon. Even more commonly understood words like intubate, defibrillate, rhythm, etc. can add to confusion in an already stressful situation. Keep it simple and explain any medical terms used. Erring on the side of simplifying is better. Detailed clarification can be provided later if the family wishes.
V-VERIFY
Verify that the family member has died. Use the words “dead” or “died.” Avoid euphemisms like “passed away” or “no longer with us.” There needs to be no uncertainty about the state of the deceased patient.
PITFALLS
- Continuing to talk after saying "dead/died.” Plan in advance how you will deliver this final piece of information with the intent to have this be the last thing you say before the next step. Nobody will remember anything you say afterwards and it is important that this critical piece of information is received and understood by all present.
_ GIVE SPACE
Allow the loved ones time and space to absorb the information. There will be a lot of silence and it may be uncomfortable, however there needs to be time for the family to process the information.
PITFALLS
- Allowing your discomfort to show. This often is the most difficult time for providers in the process of delivering a death notification, but it is so important. Continue to remind yourself not to fidget, talk/provide more information, or lose focus on what you are doing while those present take in the news you have just delivered.
I-INQUIRE
Inquire if there are any questions. Answer them to the best of your knowledge. If you do not know, be honest and open.
PITFALLS
- Speculation. We, as providers, want to give families information as much as they want to have it. Unfortunately, in the majority of death notifications, this just isn't possible. Be transparent and avoid speculating to what you don't know.
N-NUTS AND BOLTS
Start planting the seeds about logistical tasks. This includes autopsy, organ donation, funeral arrangements, and personal belongings. This all does not have to be discussed immediately and is variable depending on patient situation. Offer to have the family see the patient if they desire. Remember to have the body in a presentable manner (non-bloody, non-exposed, etc).
This is the time where it is most appropriate to begin to excuse yourself. Passing off the discussion to a staff member (often the charge nurse) is appropriate, as it is often this staff member who will review the logistical items in detail.
PITFALLS
- Not having a transition plan. As discussed earlier, knowing who will address which logistical items before the discussion starts will be important. Often times, a nurse or social worker will discuss details such as the funeral home, belongings, and when to bring the family to view the body. Knowing these details ahead of time is important and will allow for a comfortable transition.
G-GIVE
Give the family your contact information and phone number. Offer to answer any questions that arise at a later time. Be available. Always return any calls in a timely fashion.
Give your sympathies.
PITFALLS
- Giving your contact information if you don't want it to be used. It is provider dependent if you will give your personal or business contact information. Do not give out your contact information if you aren't prepared to respond to any further questions through those means.
Summary
Death notification is a situation that no emergency medicine providers enjoys however it is inevitably an important scenario to be well-trained and well-versed. It is our hope that by summarizing Dr. Hobgood’s intervention, providers will gain an increased sense of confidence and comfort with this essential action.
Expert Commentary
Hello, Dr. Sanders -
I so appreciate the seriousness you bring to difficult bad news conversation. Difficult conversations in medicine are interventions. Interventions can be taught and learned. The expert-based step-by-step “protocol” you describe promotes the best outcome possible for the survivors.
In the complex intervention of sharing catastrophic bad news, getting at the right thing to say, in the right way, at the right time is a lifelong professional aspiration. I appreciate the nuanced balancing this piece prescribes, which reflects the psychological savvy of the author. As humans, we MDs bring our own inner turmoil and reluctance to sharing bad news. Rather forthrightly sharing it, we as humansare known to dither and dodge. ED doctors might linger needlessly in the “what do you know?” phase, obfuscate the tragedy with medical jargon, or fill up a needed silence with anxious chatter, rather than allow loved ones to take in the tragic news. This piece highlights each of these pitfalls. Bravo! I have two recommendations to consider:
Attending to survivor emotions
I recommend considering explicitly extending sympathy earlier in the protocol, right after the bad news delivery that the patient has died. In that moment, couple the cognitive “education” with “I am so sorry for your loss” – a small but powerful token of emotional support.
Attending to team and self
Bad outcomes in the ED and the follow-up delivery of bad news takes a toll on everyone. As an example of team-care, I have heard of some ED teams holding a brief moment of silence after a code fails. Everyone catches their breath, acknowledges the profundity of human death, and thus re-equilibrated, they are more able to move on to do what needs to be done next. As an example of self–care, I recommend debriefing with a trusted colleague. This colleague might well be a chaplain; many EDs have designated chaplains whose roles include support for staff.
Thank you and congratulation on a great piece!
Kathy Johnson Neely, MD
Northwestern Memorial Hospital Ethics Committee Chair
Northwestern Memorial Hospital Ethics Consultant
Attending Physician, Palliative Medicine
Associate Professor of Medicine, Northwestern University Feinberg School of Medicine
References
Hobgood, C. (2005). Delivering The News With Compassion: The GRIEV_ING Death Notification Protocol [PDF]. URL http://www.acep.org/workarea/DownloadAsset.aspx?id=29088.
Hobgood, C. The educational intervention "GRIEV_ING" improves the death notification skills of residents. Acad Emerg Med. 2005 Apr;12(4):296-301.