076 - help me talk to physicians about death notifications.

Welcome back (or welcome).

On Friday, I'm part of a group of chaplains talking with some of our medical residents about chaplaincy and grief and death notification. We have a total of an hour. I'm focusing on death notification because I think that all of us who do it can think about being more helpful. 

I'm sharing here a portion of what I'll be saying. I'd love to know if any of the 500 of you have had positive experiences in the awful moments of being told that your loved one died. 

Or negative, too. But I would love to help physicians, in particular, know whether there is anything they can do that will be helpful. 

Thanks for taking the time to read about this hard time. 

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I never get to do this. You are the doctors. I’m the chaplain.

But it turns out that I’m the kind of doctor who looks at words. And so, for this moment, I have the opportunity to talk about talking.

I want to talk first, about what you could rethink about these conversations at the end of life.

I listen to your colleagues, your peers. Some of you are a little defensive when talking about the death of a patient.

I understand. It’s an acknowledgement that your profession couldn’t do enough. And you want to be sure you explain that you did.

Let’s think about this as a communication moment. As a treatment moment. As a hard moment.

One script I read says that you start by asking the family what they know about what happened.

And then you talk about what you did.

And then you tell them what has happened.

Really? That’s how you build suspense in a movie.

But in this moment, there is one question these people, this audience, cares about: “Is dad alive?”

Making sure that you get to that information in a timely manner will help everyone in the room. Think audience, not script.

Sometimes, your colleagues talk about all the things that were done.

“We tried everything. We coded them for this long.”

Sometimes, your colleagues talk about all the things that were wrong.

You want to be technically accurate about what happened. (at some point)

There was this bleeding, this trauma, these complications.

I understand the desire to explain, to cover all the bases, to assure yourself and your conscience that you did what you could.

You want to answer the questions that you think they are asking you: “What happened? Are you sure? Did you try everything?”

But they have to ask those questions, not in a quest for long answers, but in what we do as humans. We are so used to people being alive, that when they aren’t, we don’t know exactly what to say.

And most of that explaining, that justifying, in this moment isn’t helpful at all. You keep using words that people outside medicine mostly don’t know. You keep giving explanations that may make things worse, that may suggest to people that if they had done more, if they had spoken up, their loved own wouldn’t have died.

And for the bereavement process of the people you are telling, that may be harmful.

So what do people need to hear?

• That their loved one died. With the word “died”.

• That you honor that death with space and silence and respect and your presence.

• That you acknowledge that this is hard.

• That you will make sure they have time to see their loved one.

If you want it more simply:

1. Show up.

2. Speak up.

3. Shut up.

4. Step out.

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That’s not complicated. And, it’s excruciatingly hard.

Let me suggest some other practical notes:

• Focus on the next of kin.

• Make as much eye contact as you can. (To look away, to seem distracted, will feel like you are being evasive.

• If they fall to the floor weeping or if they punch the wall or if they run out of the room screaming, let them. Seriously. Their life just changed. And they get a minute. Or an hour of initial shock.

• And different people and different situations and different cultures respond to a death differently and on different timelines. I remember the woman who said yes, when we asked if she understood. And then I understood that with her stroke and other cognitive issues she could only say, “yes.”

• Stay close to the door, not in the back corner or between people and the door.

• Understand that though they were expecting this, it still is hard. It still changes everything. And this is, of course, partially our fault. For example, I’m a fine print person. I hear commercials for medications, including cancer meds. They talk about “more life”. For the person with cancer, more life means decades. For the FDA, more life means 6-8 weeks, on average. For the physician, more life may mean “until someone else picks up this case” which sounds pretty cynical. Or it means, “I don’t want to give up and so we’ll try anything.“

• Wait for the questions they have rather than answering the ones they don't. You don't need to answer the questions where the answer is best, "God only knows." We often try. Right? Why did this happen? I can give you the medical explanation, but I can't tell you why. 

• And you don’t have to speak for God’s plans or purposes. Not here, in the very first seconds of this news.

• Practice. Right? You practice all the rest of your work. That's why it's call the practice of medicine. 

• If you know that compressions started at home, tell them they did good. 

• Remember that grief will shape the rest of their life. So don’t wish it away now.

I spend a lot of time thinking and writing and worrying about the support people get in the days and weeks and months after a death.

But I want to worry less about what you all and we do in the seconds and minutes after a death. Which is why we’re here now.

• Show up.

• Speak up

• Shut up

• Step out.

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Dear reader. Anything to add?

I’ll share with the physicians and with my chaplain colleagues and with you.

Thanks.

By the way, we’re also giving them copies of This is Hard: What I say when loved ones die.

See you next week.

Jon