Notifying Family Members After Unexpected Deaths

Death is not a rare event in healthcare settings. Yet, healthcare providers receive little training on how to inform family members when a loved one has died. How a family is informed and the information given can affect the health and well-being of the bereaved family for months and years.

Unexpected death results from a variety of causes, including accidents, suicides, homicides, as well as medical mishaps, disasters, and terrorism. Such deaths are shocking to the family and are likely to be more stressful if the deceased is a child, the death was violent or disfiguring, or the deceased suffered before death.

“Healthcare providers cannot lessen the loss of a loved one, but they can provide family members with clear, concise, and accurate information about the death, and access to helpful resources, in a way that is professionally responsible, empathic, and culturally sensitive. The scope of responsibilities for healthcare providers regarding death notification varies depending upon the situation, the institution in which they work, and the involvement of ancillary services that share in the death notification process.

The following guidelines review the range of the tasks of healthcare providers in notifying a family of a death.

• Review the circumstances of death (what is known, as well as not known) with staff.
• Identify the next of kin and their contact information.
• Identify age, gender, names, and special needs of family members.
• Be aware of relationships within the family (either healthy or problematic) that might affect communication.
• Anticipate questions that may be asked, prepare, and rehearse answers.
  • What was the cause of death?
  • Did my loved one suffer?
  • Could there be a mistake?
  • Where can I see my loved one?
• Dress professionally (e.g., remove or cover any soiled clothing, such as a surgical gown).
• Shift from clinical objectivity to empathic sensitivity.

• Chaplains can be a resource for spiritual support.
• Social Workers can identify resources (e.g., therapeutic) and assist with planning (e.g., funeral services).
• Interpreters can overcome language barriers.
• Support organizations (e.g., Compassion Friends, the Dougy Center, Tragedy Assistance Program for Survivors) are available for family members who have suffered similar losses.

• Hospital leadership will likely be involved in cases of medical error, suicide, emergency room deaths.
• Hospital public relations personnel should be engaged if the media is involved in reporting of the death.
• Law enforcement or fire department may be present if death was part of a crime, fire, accident or mass fatality event.

• Respect the privacy of the family.
• Death notifications are best conducted in person when possible. Ask family members to come to the hospital: “It is important that you come to the hospital regarding your brother. Is there a friend or family member who can drive you?”
• Meet in a private room, not in a hallway or waiting room.
• Ensure everyone is seated, including the notifier.
• Certain factors such as distance to the hospital, time of day, weather, or age/functional status of the next of kin may necessitate a notification be done over the phone. If so:
  • Advise they may want to find a quiet place, without children or distractions to take this call.
  • Ask if there is a support person available.
  • Ensure they are seated.
  • Warn that they are about to receive bad news.

• Introduce yourself, especially if you did not have a prior relationship with the family.
• Ask and confirm who is the next of kin and their relationship to the deceased.
• Set the tone: “I am sorry, but I have bad news.”
• Use, non-technical, easy to understand language because cognition declines under stress, for example:
  • “Mr. S’s heart stopped beating this morning. We attempted to restart it but were not successful. I am so sorry, he has died.”
  • “Your brother was brought to the emergency room after a serious accident. Despite attempts to save him, he died.”
• Next of kin may remember little of what you initially say. Aim for three brief points and be prepared to repeat information. As appropriate, put information in writing for the family.
• Be clear about what is known, as well as what is not known.

• If appropriate, offer the opportunity to view the deceased.
  • Clean and prepare the body prior to viewing (e.g., remove blood, medical equipment).
  • Prepare the family for what they will see, especially if the body is disfigured. Remove medical appliances (e.g., intubation tubes).
• Discuss deceased’s wishes for organ donation when appropriate.
• Discuss autopsy (if family requests or if required by law enforcement).
• Assist the family in working with hospital personnel that assist with decedent affairs.
• Advise the family how and when to discuss the death with vulnerable family members (e.g., children, special needs family members).

• Next of kin’s initial responses may include numbness, shock, or disbelief:
• Other common reactions include:
  
  • denial
  • anger or bitterness
  • blame
  • sadness
  • guilt
• Avoid interpreting or being critical of family members’ emotional reactions.
• Don’t become defensive about what they might say.
• It may be appropriate to touch (e.g., a shoulder or hand) or hug the next of kin, but be alert to their comfort or discomfort, and respectful of culture, age, and gender.
• Allow the next of kin time to consider the information in the safe setting of the private room.

• Consider a family’s background (for example, culture, race, and ethnicity) when speaking about the death.
• Deliver information in a way that all families can understand.
• Be prepared for questions that indicate unique cultural perspectives, for example, “Does the way he died mean he is not going to heaven?”
• Respect displays of emotion that may be culturally unique.

• Answer questions. If you do not know the answer, provide a timeframe in which you will get back to them. Don’t be afraid to say, “I don’t know.”
• Provide contact and important information in writing. Details given are likely to be forgotten if not written down.
• Identify another professional as a point of contact for the family when you go off shift and before the family leaves the hospital.
• To aid others: review the notification, correct mistakes and share what you learned about the process.

• Death notification is especially challenging during mass fatality events due to limited resources. Careful planning is required.
• Since suicide may be determined after autopsy or investigation, it is best to describe the event based on cause of death (e.g., gunshot wound) rather than intention (e.g., suicide vs. accident).
• Developing competence in death notification requires that it be formally taught. Allow medical students to observe death notifications, but never expect untrained individuals to conduct notifications independently.

• …discount the magnitude of the loss if the patient is old, terminally ill, or if the death was medically expected.
• …assume ANY death is “expected” by family members.
• …use euphemisms for death (e.g., passed away, no longer with us) that can cause confusion.
• …postpone the notification.
• …speculate about information if you are uncertain.
• …place blame on the deceased, other people or organizations or become defensive.
• …refer to the deceased as “the body” or “it” (use their name instead).
• …offer false reassurances.
• …rush the family to leave their loved one; most will view the body for about 15 minutes.
• …bring patient’s personal belongings with you to the initial notification.
• …discuss death-related administrative matters at the initial notification.