Oct. 05, 2019
In the trauma field, sometimes patients' injuries are unsurvivable: They suffer multisystem trauma, irretrievable damage to an organ system, head injury due to penetrating or blunt force trauma, or oxygen supply to the brain is cut off. In these cases, trauma centers need to feel equipped to provide bereavement services to families who lose a loved one and also to staff who've cared for the patient.
Brenda M. Schiltz, M.D., M.A., pediatric critical care specialist who leads the Pediatric Palliative Care Consulting Service at Mayo Clinic's campus in Rochester, Minnesota, offers perspective on assisting both families and staff impacted by a patient's death.
How to help grieving families
It's crucial to work closely with the family to make decisions about a patient whose survival is uncertain. Often, the family and patient care team may decide together to change the goals of care away from pursuing further treatment, says Dr. Schiltz.
If the family wants to pursue aggressive medical interventions despite a low chance of survival, it's important to continue to support them, says Dr. Schiltz. She encourages digging down to the bottom of what the family's goals are and what's important to them. In some cases, families have strict religious beliefs compelling them to continue lifesaving efforts, she says.
To communicate effectively with family whose loved one has unsurvivable injuries or has just died, Dr. Schiltz suggests the following:
- Be simple: They can't process complicated medical information at this time.
- Be honest and transparent: Tell the truth and help them to understand the situation for themselves.
- Be compassionate: Death of a loved one may be one of the worst days of the family members' lives.
- Give them space: The family needs space to process, as they can't hear anything beyond the patient's injuries being unsurvivable. They will come to you with their next questions when ready.
- Offer follow-through: Assure the family that even if the patient is transferred, you are there for them in the future.
These suggestions are especially significant as family members may be injured themselves, or full of adrenaline, upset or scared due to the trauma and resulting injuries. Families are devastated when learning a family member will die or has died, says Dr. Schiltz, and reactions vary: They may be quiet and withdrawn, demonstrate outward emotion with tears, or be angry and in disbelief.
Dr. Schiltz recommends offering the following services for patients with unsurvivable injuries and their families at a local hospital:
Determine goals of care
Address questions together with families such as whether medical care needs to move toward comfort measures versus continued attempts toward life-sustaining care.
Work with the patient unlikely to survive and the family on care goals such as preserving the patient's dignity and creating meaningful moments.
Manage symptoms
Provide medication and other therapies for symptoms such as pain, nausea, agitation and anxiety.
Present integrative medicine options
Offer therapies such as acupuncture, massage or music therapy, if available.
Suggest a bereavement program
If the patient dies, point the family to a bereavement program at your hospital or in the community.
How to help grieving staff
Several factors are significant for staff working with patients near death or whose patient has died, says Dr. Schiltz:
Joint responsibility and decision-making
For staff caring for patients near death, it's crucial to use a team approach: One person is not responsible for decisions to stop treatment and allowing a patient to die. Rather, a multidisciplinary group comes to consensus that injuries are unsurvivable and further treatment is futile. Every voice of the team is important to be heard and respected.
Recognize loss
It's important to recognize that experiencing the loss of a patient can be difficult. Staff may have cared for a patient long term or gone to extraordinary measures to help the patient. The Pediatric Palliative Care Consulting Service at Mayo works with personnel in these situations, including a debrief a couple of days after the patient's death to hear what staff members experienced and discuss coping with loss.
Dr. Schiltz recommends other centers hold similar sessions — perhaps led by chaplains or social workers — so staff can talk about emotions in a nonjudgmental place. In addition, it is important to discuss concerns about deceased patients and their care with performance improvement teams, and suggest future care improvements.
Encourage self-checks
After losing a patient, encourage staff to check with themselves to assess how they're doing and if they're ready to move to other patients. Each member should ask, "How do I need to take care of myself to help the next patient and safely care for them?"
At times a patient death may hit staff members especially hard, and they may need to go home for the day.
"Hopefully staff can be gracious to one another if someone needs to step away," she says. "It can be really hard."
Connect with the family
Contacting bereaved families to express condolences from the local trauma center and share in the family's grief can be a good thing, says Dr. Schiltz.
"When a patient dies in a trauma situation, we all feel it," she says. "The family needs to know you recognize their family member as a person and not just a number who passed through."
Reach out to the receiving hospital
Often patients undergoing severe trauma will be transferred to a Level I Trauma Center, leaving local staff unable to talk to the family and grieving when they learn their patient has died.
Dr. Schiltz encourages contacting the receiving hospital where the patient was transferred for information and help with grieving staff or the community.
"Our doors, phones and emails are always wide open," she says. "If you're struggling about a patient you took care of, you can contact us anytime. We want to partner with our referring providers every step of the way, and that includes carrying the load of grief together."