Death and Dying - MD Ambulance

Death and Dying - MD Ambulance

Helping those that remain(That includes You!!)

The Issue of Dying Across the Life SpanChildhood– Until around 5-7 don’t understand thepermanence, universality, and lack of functioningin death– Age 12 accurately perceive• Parent euphemisms (just went to sleep)• attending funerals, etc?

The Issue of Dying Across the Life SpanAdolescence- More experienced with death and grief- Loss of sibling, friend or parent (survivor’s guilt)- Positive outcome includes greater appreciationfor life

The Issue of Dying Across the Life SpanAdulthoodMiddle-aged• understand next in line to die• change in perception of time(lived vs amount left)* death of a parent* death of a child - violates the natural order• Transition to being the oldest generation

Late Adulthood- Older adults• Least concerned with dyingLoss of a partnerLoss of child or grandchild**although think about death more

Fantasy Death Exercise• What are your criteria for a ‘good’ death?• The only hitch, as in life, is that you have todie.• Imagine you are there right now• Notice where you are, what your are doing,who is with you, what it is like, perhapssounds, smells, other sensory specifics…

Common Ideal Death Scenarios• Sudden death in sleep (Older Adults too)• Dying at home• Dying engaged in meaningful activity

Themes for a ‘Good’ Death• Home• Comfort• Sense of completion (tasks accomplished)• Saying goodbye• Life-review• Love

Scenario• You are called to a rural home for anunresponsive male.– First Responders have been doing CPR for about20 minutes prior to your arrival– When you arrive you find an elderly male on thebedroom floor with CPR ongoing– His wife is waiting in the living room wanting toknow how he is doing

EMS Death Notification• Family members accept stopping CPR in thefield• The express satisfaction with the emotionalsupport they receive from EMS• Many state they knew the patient was deadwhen they called• More comfortable grieving at home withfamily and loved ones

EMS Death Notification• They felt closer to the deceased• Felt more informed• Some expressed that patient would havewanted to die at home• Less rushed, more personal communication

Delivering Death Notification• Softening – switch from responder tosupporter (from clinical to empathic)• Direct yourself to spouse, parent, familymember or friend• Put yourself on the same level (sitting orstanding)• Make eye contact but don’t stare

Delivering Death Notification• Deliver the death notification by using the‘D’ word: dead, died, death. (helps avoiddenial)• Deliver quickly – don’t drag it out.• Reassure about resuscitation efforts (ifstarted): “We did every medical procedurepossible, but were unable to revivehim/her”.• Allow a pause for survivor response.

Supporting SurvivorsUsing Touch:• Generally touching key survivor’s hand,shoulder or arm is sign of closeness.• Take survivor’s lead from there.• Hugging the survivor works for someparamedics – especially women. Gauge thesituation appropriately.

Supporting Survivors• Describe what you did and why.• Listen to how the survivor feels and what theyneed.Stay calm and compassionate at all timesdespite any hostility that might arise - it’snot about you, it’s about the reaction to adeath

Supporting Survivors• Answer with honesty (not brutal) & in anonjudgment way. Omit clichés.• Do not reinforce denial of death• Restrain violent survivors only enough toprotect them and you. (involve police)

Supporting Survivors• Offer to make tea, coffee, get drinks.• Offer to call relatives if needed.• Don’t feel you have to keep talking – justbeing there is usually sufficient.• Offer the family the chance to say goodbye,including touching deceased (consult withpolice).

Helpful phrases• I can’t imagine how difficult this is for you• I know this is very painful for you• I’m so sorry for your loss• It must be hard to accept• It’s harder than most people think• You must have been very close to him/her• How can I help?• Most people who go through this react just as youare

Hurtful phrasesComments to avoid:• God clichés such as “It was actually a blessingbecause…”Unhealthy expectations such as:• You shouldn’t feel/act that way.• Aren’t you lucky that at least…• You must get a hold of yourself.• You must focus on your precious moments.

Hurtful phrasesDisempowering statements:• You don’t need to know that.• I can’t tell you that.Ignorance:• Let’s not talk about that.• S/he died because of…• His/her death was for the best.• Things always work out for the best.

Hurtful phrasesBasic Insensitivity:• I know how you feel. My ___ died last year.• We all have to deal with loss.• At least s/he died in their sleep.• S/he had a very full life.• Everything is going to be OK.• I’m sorry. (in isolation = pity)

PLEASE LET ME DIE• Advance Directives• Living Wills• DNR

Cultural Diversity and Grief• It is not essential to study and know allcultural and religious practices and theirimplications following a death in the field.• It is important to ask questions and listen tosurvivors and family members of decedents.• It is important to make every effort to respectthe wishes of family members where possibleand practical to do so.

Cultural Diversity and Grief• Judaism: the body is to be buried (not cremated)within 24-48 hrs of death.• Islam: the body is to buried without coffin, notcremated, as soon as possible.• Hinduism: the deceased should be placed as closeto the ground as possible.(Source: Religious beliefs and death)

Symptoms of Acute Stress and PostTraumatic Stress Disorder• The signs of acute stress and post traumaticstress fall into these categories:– Physical– Emotional– Cognitive– Behavioural"a normal reaction to abnormal events."

Physical Reactions• Increased muscle tension• Increased breathing rate• Increased heart rate and blood pressure• Unneeded systems close down (stomach,digestion, kidneys, liver, immune system)• Hormones are released (cortisone, adrenaline)• Pupils dilate to admit more light, increasedperceptions.• Blood flow diverted

Emotional Reactions• Fear• Anger• Fatigue• Fluctuating moods• Sorrow and depression• Guilt- “Why wasn’t it me?” “Why can’t I do more tostop it?”• Anxiety and nervousness- “It could have been me”• Low self esteem• Futility• Avoidance and denial

Cognitive Reactions• Loss of control• Preoccupation with incident• Lack of interest• Difficulty concentrating• Lack of creativity• Difficulty making decisions• Poor memory, distracted

Behavioural Reactions• Apathy• More easily startled• Loss of sense of humour• Aggressive or anti-social behaviour

ASD PTSD• Requires fewer avoidancesystems• Initial symptom & response• Occours within the firstmonth• Lasts for min-2 days• Sense of numbingdetached.• Normal things seem unreal• Avoidance and denial• Long term-”delayed onset”• One month toseveralmonths before onset• ASD can become PTSD• Survival mode- unable toreturn to normal

ASD & PTSDDon’t wait until it is broken to fix it!When the thoughts and feelings begin tointerfere with a persons life, professionally orpersonally, or when they become distressing anddo not subside over a period of time ,professional assistance should be sought out.

Supporting Yourself• Acknowledge right now that this can be astressful event for you• Stress increases when a death notificationhas to be given• Confide in your partner and colleagues• Confide in your partner at home• Consider professional support if a case “justwon’t leave you” in a few days