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Crisis Intervention
Week Five
Death & Dying
Concept of Hope / Comfort / Power
Hopelessness / Powerlessness / Compassion
The Health Care Industry has not always been willing to recognize that there are people in their care who are dying. But we do. One of the things that I have learned while working in Home Care / EMS Care and Hospice Care, is that you can do something for everyone, even the person who you cannot keep alive.
Providing appropriate care for the person who is dying and their family can be challenging and even difficult at times. To meet this challenge, the Health Care Provider must be there for the patient and the patient's family and for each other.
As students in this class, you will have a varied background when it comes to dealing with the issues surrounding death and dying. Some of you have never been with a person who is dying or one who dies in your presence. Some of you have been involved in situations where someone died before you arrived or during your care.
First of all one must learn to maintain compassion through the history taking, the questions about DNR, and the total assessment of the patient and the situation. The 'how do I know when someone is dead' will not be discussed in this class but in the other EMT classes or health care provider classes.
Those with more experience have you developed the skills to feel comfortable working with the family, or the bystanders and the crew? What helped you develop this confidence? and skills?
Many EMS providers find that their closeness to issues of life and death sets them apart. Sometimes friends and relatives cannot understand your feelings. Those who do not work in close proximity to death can feel uncomfortable around those who do. For example, I have been with a person at that moment of life leaving and death taking over. It is usually an amazing time, that doesn't mean it's always a moment that is positive or one that I would have chosen. But you see, we aren't in control. More about that topic later.
Guilt is the emotion we feel when we think we have done something we are not supposed to, or have not done something we should have. It is an emotion we have experienced since early in our lives. If you have ever seen the look on a child's face when he or she feels guilty, you can understand what a basic and natural emotion it is. The child feels bad. There is guilt that helps to guide actions in a good way and there is guilt that can be felt when you absolutely could not avoid the situation or when a poor choice was made.
In the text, the scenario has the patient dying in the back of the ambulance. Then at the Emergency Department, the Doctor told the family about the death of their loved one. What if the ending were changed and as the family arrived at the hospital they encountered you and your partner by the outside door. What would you say to them? What would help you gain the confidence and comfort to talk with them instead of sending them off to someone else? If you aren't already familiar with Kubler-Ross's 5 Stages of Dying, please review the following resources.
Kubler-Ross 1
Kubler-Ross 2
What Do You Say?
Note: Some of the following ideas come from "Death and Dying: Dealing with the Stress," a paper developed by Bella Streiner, John Janson, Steve Tyukodi, and Tom Bedford.
The following advice was compiled during an ambulance staff skills exchange session. EMS providers answered the question, "What suggestions do you have for staff members who need to tell people that a loved one has died?"
- Personalize the delivers as much as possible using the deceased's name and/or relationship
- Physically situate yourself on their level when telling someone that a loved one has died
- Look in the person's eyes
- Speak directly with a firm but compassionate voice
- Get close enough for a gentle, appropriate touch. Don't crowd or be distant.
- Allow the person to grieve. Don't try to distract them with Pollyannaisms.
- Answer questions directly, sincerely.
- Assure them they did all they could. Even when there is clearly nothing they could have done, survivors still feel they should have done something to prevent the loss. Certain words and phrases may arouse feelings of guilt (e.g. "When did your husband last talk to you?" The latter may indirectly imply that they should have checked the spouse earlier.)
- Sometime it helps to allow relatives to see the procedures used to try to save their loved one. It helps them accept that all that could have been done has been.
- Describe in understandable language the problem, what was done and what outcomes led to the loss. Explaining the situation makes it easier for them to accept.
- Explain to them what is likely to happen so they can know what to expect.
- They may attack the messenger of the bad news. Remember, they are not angry at you but need to be angry.
- If they do not look like they will be able to handle the grief (faint, appear suicidal, etc.), take them to a hospital.
- Allow the family to view the body but prepare them for what they will see, such as tubes in the mouth, skin color, etc.
When informing children:
- Talk to the child in familiar surroundings (i.e. within their home).
- Don't compare death to sleep. The child may develop a fear of sleeping.
- Don't tell the child that the deceased has gone away on a long journey. this may heighten the child's fear of the surviving parent or friend leaving.
- Don't use the word "sick." The child may then believe all sickness leads to death.
- Do not force the child to see or touch the body.
- It is appropriate to use the word "die."
Caring for you, the messenger:
- Helping others cope with death can help emergency responders avoid burnout. Engage in a variety of stress-management techniques after providing such assistance.
- If you find yourself engaging in black humor after dealing with the family, don't think negatively of yourself or others. It is an understandable means of releasing shared tension. Obviously, caution should be used so that such behavior does not cause embarrassment or offense.
- Informing a child about a death can be as frightening for you as it will be for him or her. Requesting departmental support, such as a debriefing, may be beneficial.
Activities for Week Five
- Reading:
- Chapters 14 from the text
- Participation:
- Discuss the scenario put in the Discussion Group Wk#5 utilizing your background and the information from your articles and reading. On the Web Board it works better if each of you post your own response (with your name in the title) and then others respond to your conference in sequence.
- When responding to each other share some of your perspective about how various words / actions might work or not work. It is important to actively dialogue to help each other think more broadly at times.
- In the Discussion of Pain most of your teams got very creative listing a great variety of pain. Keep that kind of thing in mind when you work with these various scenarios. Keep your vision open. I will pool the types of pain together and share that with you later.
- Article:
- Read Article #3 from your article list. You will read your article and then post in the Web Board Tree Article Conference Article #3 Reviews. Respond to the scenario with information from your article first, relating its contents to the situation. Remember you are sharing information from different articles so it is the responsibility of each person to share information from your article with the others. Later you can discuss from your own opinion and background as well.
- Worksheets:
- Respond to the questions below the scenario on the Web Board
Week #5 Activity 1, in your tree Discussion Group - Due by Thurs - I also expect each of you to respond some to each other.
This is a 66 year-old-female who has experience neurological degeneration from multiple sclerosis for the past 12 years. She has been bedridden for 4 years and for the past 6 months has been developing left-sided paralysis. The patient stopped eating about the same time and a feeding tube was placed to provide basic nutrition.
For the past 2 months there has been decreased feeling and movement of the right side as well. Respiratory support was started approximately 2 weeks ago with a home ventilator.
911 was called by the respite caregiver after the patient appeared to have a seizure. By the time the medics arrived the husband had arrived home and was able to present the signed DNR document.
The patient evaluation showed an EKG with asystole, absence of respiration after the ventilator was stopped and all extremities were cold with positional lividity.
What are some of the issues present here?
How can you provide support to both the respite caregiver and the husband? And avoid implications of guilt for either person.
From the text, discuss how families might respond differently to the death of the chronically ill loved one.
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- Respond to the questions below the scenario on the Web Board
Week #5 Activity 2, in your tree discussion group - due Saturday.
You are called to your neighbor's house where you find your friend, Sam lying on the floor. He is about 80 yrs old and has been in fairly good health for his age. Mary, his wife, states that he was eating supper, complained of a severe abdominal pain and shortly thereafter fell to the floor. He has not responded to her since.
Mary has physical disabilities and is in a wheelchair. Sam has taken very good care of Mary and especially since she has been wheelchair bound.
It took her about 4 - 5 minutes to get to the phone and call you (of course it took you 2 - 3 minutes to respond from your house). You find Sam on the floor, no sign of life, the skin is cold and a gray/blue color.
Mary is very distraught, feels guilty about not being able to help Sam herself and is very worried about how she will manage at home while Sam is in the hospital. You realize (and this is confirmed by EMS on arrival) that Sam is dead and he will not be going to the hospital as Mary is thinking.
What are some of the issues present here?
How can you provide support to Mary, your neighbor?
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