Every year,30000 cardiac arrests occur outside the hospital in the UK (Nolan et al, 2010). Paramedics are required to pronounce patients in the field in 53–61 % of out-of-hospital cardiac arrests (Roth et al, 1984; Aprahamian et al, 1986). As such, paramedics are frequently required to communicate death notifications to the bereaved in a pre-hospital setting (Norton et al, 1992; Regehr et al, 2002;Smith-Cumberland and Feldman, 2006). In a pilot study, paramedics perceived death notification to be even more challenging when communicating notifications for deaths that were traumatic, unexpected, preventable, involved children, within a situation they identified with, or when it was their first experience (Douglas et al, 2011). Paramedics may be the only source of support for survivors after a death occurs in the field and balancing patient care with delivering calm, compassionate support can be challenging (Schmidt and Tolle, 1990; Smith et al, 1999).
The addition of termination of resuscitation (TOR) rules to the paramedic skill set will increase the frequency of death notifications communicated by paramedics in the field (Morrison et al, 2010). Previous studies suggest that many health professionals feel unprepared to communicate a death notification and emergency care professionals such as paramedics would not be an exception (Barnett et al, 2007; Iserson, 2009). There is a paucity of literature describing paramedics’ perspectives on communicating death notifications and on how they manage the professional and personal aspects of this task. This study explores the lived experiences of paramedics and communication of death notifications, their coping strategies, and their support needs.
Methods
Paramedics in urban and urban/rural areas of Ontario were recruited to participate in focus group sessions after ethics approval was obtained from the University of Toronto. A qualitative study of a homogeneous population composed of all levels of land-based paramedics (Primary Care Paramedics and Advanced Care Paramedics) was used to collect data on their experiences of communicating death notifications (Schensul et al, 1999; Parahoo, 2006). Recruitment messages were distributed through departmental e-mail, flyers, and by word-of-mouth. Paramedics replied to these messages by e-mail and were scheduled to attend a session based on their availability.
Four focus group sessions were run by a trained facilitator from 14 June 2011 to 21 November 2011 with the lead author (LD) in attendance after written informed consent was obtained— characteristics of the sample are provided in Table 1. The groups ranged from four to 12 participants. Using a semi-structured question guide, paramedics were asked to describe an experience with death notification, how this experience affected them, how they managed their emotions, what type of support they received, and what type of support they would like.
| Gender | Paramedic level | Mean years of experience | ||||||
| Focus Group | n | Male | Female | Primary care | Advanced care | Primary care | Advanced care | Location |
| 1 | 5 | 4 | 1 | 2 | 3 | 7.0 | 6.3 | Sunnybrook Center for Pre-hospital Medicine Toronto, Ontario |
| 2 | 7 | 5 | 2 | 4 | 3 | 10.5 | 16.3 | Sunnybrook Center for Pre-hospital Medicine Toronto, Ontario |
| 3 | 12 | 9 | 3 | 11 | 1 | 8.4 | 27.0 | The Hospital for Sick Children Toronto, Ontario |
| 4 | 4 | 4 | 0 | 3 | 1 | 7.0 | 5.0 | Hastings-Quinte EMS Headquarters Belleville, Ontario |
| Total | 28 | 22 | 6 | 20 | 8 | |||
The question guide was adapted as required by the author and the facilitator after each session toclarify some questions based on the paramedics’ responses. Focus group sessions were audiotaped and transcribed. The transcripts and field notes were analysed by two authors (LD and SR), and datawere analysed using an inductive approach, in which themes were generated from the focus group data.The themes were discussed with the other two authors (SC and MF) until consensus was reached. Member checking was accomplished by distributing a summary of the results to participants and eliciting feedback.
Results
Twenty primary care paramedics and eight advanced care paramedics with mean experiences of 8.5 and 21.5 years respectively (range: 5 months to 31 years) attended sessions held in an urban hospital, an urban/rural paramedic service headquarters and an urban base hospital office. Overall 22 males and six females participated. Participants were recruited until no new information was obtained.
Four themes arose inductively from the analysis of transcripts and field notes: the practical aspects of death notification, how paramedics acknowledge the emotional toll, how they manage the emotional toll, and the support mechanisms they used.
Practical aspects of death notification
Paramedics acknowledge the importance of communicating with the family, especially when death occurs in the field. This was expressed by one urban paramedic:
‘… it’s kind of a normal part of life and we’re there to kind of help and to be clear and to be direct and offer help.’ Participant 1 from focus group 3.
Many paramedics reported that they receive minimal training in communication skills, including how to communicate a death notification. This view was pervasive throughout the focus groups:
‘…it was just hard because she started breaking out crying and what do you tell, what do you say? We just don’t have enough training, and I’m just trying to be as nice as I can and try and break it…But…we don’t have enough training in it which is very awkward.’ Participant 4 from focus group 4.
Death notification training was perceived by paramedics to be an essential yet challenging aspect of their jobs.
Acknowledging the emotional toll
Paramedics report varied attitudes towards communicating death notifications. One urban paramedic expressed that her personal attitudes to death may affect the way that she communicates with someone who is close to death:
‘I don’t know, I don’t know if I’d tell a person they’re going to die. Like I don’t know…if they only had a couple minutes left I don’t know if I’d want to know if it was my last couple minutes.’ Participant 4 from focus group 4.
Some paramedics were unsure of their roles with respect to communicating death notifications. Comments such as ‘I didn’t know whether it was my place to tell him or not’ illustrate this point and were expressed by paramedics in most groups.
Paramedics expressed feelings of helplessness, discomfort, and awkwardness when communicating death notifications.
‘So I have to break the news to the family that we’re leaving the body there, and that’s very hard. There’s no easy way of saying that, and I’ve found… it’s just very uncomfortable, cause they don’t understand the nature of the situation. They don’t know why we’re not taking them with [us], and like they call you for help, and you’re supposed to help them and… they don’t understand…why you’re not taking them. So that’s very hard at times.’ Participant 5 from focus group 1.
Despite the challenges of communicating death notifications, paramedics have many positive experiences as well:
‘…when we left an entire group of people… had arrived and they made sort of an assembly line as we went by and they hugged both my partner and I as we were leaving the apartment…it was exhausting dealing with this family on such a close connected emotionally charged level, but at the end of the day I think we did right by them.’ Participant 1 from focus group 1.
An urban paramedic discussed the importance he placed on communicating with the family during and after a resuscitation:
‘It was gratifying and what it also helped me with was attaching…dignity to the concept of death, which is something that gets so depersonalised. We intentionally, I think potentially for all of us, I think a lot of us depersonalise what’s going on.’ Participant 3 from focus group 2.
The pre-hospital environment is unique and can present challenges to effectively communicating a death notification in the field:
‘So all of a sudden I’m thinking, I’ve never done this before, I’venever communicated in this kind of way before…So this was totally, totally new. And you’re trying to drive the vehicle as well….it’s not an easy task when you’re not distracted by a…crying family member who’s praying to god, and looking at her husband “Is he going to be okay?”‘ Participant 2 from focus group 4.
Urban/rural paramedics face unique challenges, especially when managing a case of obvious death:
‘Sometimes you could be on scene for an extended period…we’re there, we’re waiting for police for a while with the relatives who…haven’t comprehended thatthis person’s dead…it was very uncomfortable.’ Participant 5 from focus group 4.
Paramedics also communicate death notifications in the hospital setting, even though they are not required to do this:
‘…I think I’ve delivered more bad news to people in hospitals long after my responsibility to the patient has ended than I’ve ever had to deliver it acutely, you know on scene, somebody’s house, somebody’s office, or backyard.’ Participant 2 from focus group 1.
Paramedics find it difficult to switch from a clinical to support role after the patient is pronounced dead:
‘…there’s always this moment where I’m leaving the patient’s side, and I’ve been so incredibly focused on dealing with this patient, and doing all the things that need to get done, and there’s that moment where you need to gather your thoughts, and really you need to steel yourself against what you’re coming up against… And you’re shifting gears, you’re shifting gears from being patient-centered and focused and task-oriented to switching back to the emotional side and…display[ing] the right level of empathy and trying to achieve the right level of connectedness so when you go and talk to these people.’ Participant 1 from focus group 1.
Deaths that were traumatic, unexpected, preventable, involving children, the paramedics’ first experience, or a situation they identified with added further stress when communicating a death notification:
‘And it would have been a lot less stressful for me, but when you walk into a room and you’re like “oh she’s been dead for however long” and then now you have to stay there and you have to inform the family… …you have to be the first ones to talk to the family and tell them that their 21-year-old daughter is dead, and you see all these pictures of her and her friends on the wall, and I was only twenty-one at the time.’ Participant 2 from focus group 1.
In addition to the dual roles that paramedics have when communicating a death notification, their focus of care changes after the notification to supporting the bereaved very quickly:
‘Once you’re finished with…the patient that you just pronounced at the home, it’s the family and friends that become your patients.’ Participant 4 from focus group 2.
The bereaved may pose further challenges to managing a scene based on their reactions to the death notification:
‘I had a mom pound on my chest. Basically, she started to pound on me and scream at me and tell me that I killed [her] child. “You killed him, get in there and save him, get in there and save him.”‘ Participant 2 from focus group 2.
Managing the emotional toll
Dealing with the emotional aspects of a resuscitation and potential death notification begins before the paramedics even reach the call. This can be especially stressful when paramedics experience multiple stressful calls in a short period of time:
‘Once I heard the details of an eleven month old VSA, vital signs absent…I told my partner “hey you’re driving. I’ve got math to do…” But…the call was literally a minute from the base and I didn’t have time to get myself in that situation, prepare myself….And I was very nervous and very sick because I was like, if I have to deal with another dead kid in like…I’m just going to lose it.’ Participant 4 from focus group 4.
During the call, paramedics use avoidance to help them focus on decision-making and communicating with the paramedic team and the family (Halpern et al, 2009b).
‘I’ve personally become very good at taking everything and just, I don’t know how I do it, but it just gets pushed aside. I don’t, I don’t have a box, I don’t have a towel, I don’t have a touch stone or anything it’s just, okay game on, this has to go over here for a minute.’ Participant 6 from focus group 3.
Paramedics’ past experiences can influence how they manage their emotions during stressful situations. They also reported using informal and formal support systems.
Informal support for paramedics
After the call, paramedics use their peers as their primary support system:
‘by… going through the emotions of the surrounding stuff, the gallows humor, the running though calls’. Participant 3 from focus group 1.
They also use distraction to cope with their emotions:
‘We get sitting on the back of the truck and either tears or just, you know got to take a deep breath, could do a lap of the hospital, you could go get a coffee, you can go out with friends after work and have a couple beers and talk about anything but work.’ Participant 3 from focus group 1.
Outside of work, some paramedics avoid talking to their friends and family about their emotions, in order to keep them ‘innocent.’ If they do talk with them, they prefer to talk with someone who is an emergency care professional or was in the past. Paramedics learn about this culture of support from their peers:
‘…in four years nobody ever came up to me to ask me how I was feeling after a call. “Really?!”[Other participant’s comment]’ Participant 5 from focus group 2. ‘At first I was “why are you asking me that?”…It made a difference. It changed my personality because, now when I see someone having a tough call, I make that extra step. Peer support.’ [Agreement from participants]
It is evident that paramedics rely on informal support at work and at home to manage their emotions.
Formal support for paramedics
Paramedics reported that the emergency care professional culture may influence their willingness to seek out formal support following a stressful incident:
‘…in emergency services in general, where it’s that boys club you’re untouchable, you’re too strong, this shouldn’t affect you, when really it does and affects us far more I think than anybody else, because we’re immersed in it so deeply.’ Participant 4 from focus group 1.
New paramedics are more reluctant to ask for support because of this stigma and fear of punishment:
‘I like didn’t want to be like I need to take a couple of hours off because I did not want to look bad in front of the supervisor.’Participant 2 from focus group 2.
Use of formal support programs such as peers support teams, staff psychologists, or employee assistance programs (EAP) is varied. Paramedics’ perception of support from their management is also a significant stressor.
‘…a number of paramedics…have lost their careers because their stress issue wasnot able to be managed, because it wasn’t supported…Like go to work and go crazy, or doI quit and run?’ Participant 3 from focus group 4.
They report varying experiences with their management after a stressful call, from supportive, to being urged to get back to work:
‘My supervisor…he called us on the way back from the call…and was like “I booked you guys off for the day. So you guys are done.”…it was good… because if he would have asked, “you know what, would you like to talk to someone?” I would have most likely said no.…He set it up and he said, “you know what, you really don’t have to, but I’m bringing her here.” So she came up to the base and you know what, that was totally fne… Because otherwise I wouldn’t have done it. I wouldn’t have said, you know what, I want to talk to someone. I would have gone home…’ Participant 4 from focus group 4.
Paramedics have varying perspectives on receiving mandatory or voluntary support after a stressful call. One urban paramedic’s attitude to mandatory support is described:
‘My emotions are none of your business and if I wanted to share my emotions with you, I’m going to share [them] with someone I trust…’ Participant 1 from focus group 1.
Paramedics want formal support from trained peers, or professionals who share common experiences:
‘…someone I think understands what’s going on, and has been through what I’ve done.’ Participant 3 from focus group 4.
They prefer support to be offered immediately after the call and find that downtime after a stressful call allows them to decompress and prepare for the rest of their shift:
‘…we knew we weren’t going to get a call right, so we knew we had the two hours, so we watched a funny show and had a nap…But…like for me personally… that’s exactly…what I needed.’ Participant 4 from focus group 4.
Paramedics’ confidence in their management team to support them varies. They prefer support immediately after the event from trained people who share their experiences.
Discussion
Communicating a death notification is a challenging task that paramedics perform frequently (Morrison et al, 2010). Their personal attitudes to death and uncertainty about their role may influence their abilities to communicate death notifications. This is consistent with interview and focus group research and reinforces the lack of communication-based competencies for Canadian and UK paramedics alike (Joint Royal Colleges Ambulance Liaison Committee, 2006; Halpern et al, 2009b; Paramedic Association of Canada, 2011).
Our study found that paramedics find switching from a clinical to support role challenging, which is consistent with the literature (Schmidt and Tolle, 1990). They adopt these dual roles on scene, often without additional resources (Norton et al, 1990; Schmidt and Tolle, 1990). Role confusion is further complicated when paramedics communicate death notifications at the hospital. Clarification of paramedics’ roles by governing organisations may reduce the stress of managing these multiple roles.
During a resuscitation, paramedics value the act of communicating with the family, and previous research indicates that developing this relationship is the most important part of the call (Steen et al, 1997;Holzhauser and Finucane, 2008). Families report increased anxiety when they do not know whatis happening (McGahey-Oakland et al, 2007), and paramedics’ actions can affect the family grief process (Smith-Cumberland and Feldman, 2006). As such, it is important that paramedics are trained to communicate death notifications in order to reduce the stress on the bereaved.
Paramedics identified their peers as the most important source of informal support and the effectiveness of this support is evident (Timmermans, 1999). They have varying opinions on the effectivenessof formal support networks. Mandatory support sessions remove the stigma of asking for help and beingperceived as weak;on the other hand, paramedics are reluctant to talk with their peers and their management team. New paramedics especially are reluctant to seek support.
After a stressful call, paramedics want formal support from trained peers or a health professionalwith similar experiences. Having downtime would help them to finish their shift. This timeout periodis important to prevent the consequences of critical incident stress (Timmermans, 1999). The management style described by some of the urban/rural paramedics may be something that other paramedic organisations could emulate, as the stigma of vulnerability is a barrier to accessing support after a critical incident (Timmermans, 1999). It is evident that organised formal support and the provision of downtime may reduce the stress of communicating a death notification for paramedics.
Limitations
The focus group participants were self-selected which is an accepted method for qualitative studies. As a result of this, they may have been more (or less) traumatised or more willing to discuss their experiences.
The focus groups were held at a base hospital administration building, a hospital, and an urban/ rural paramedic service headquarters. One paramedic supervisor attended a focus group session in urban/rural Ontario. Although the investigators attempted to create a safe and neutral space for the participants, the office locations and the supervisor’s presence may have influenced the data. Overall 21 % of participants were females. This is consistent with the gender demographics (24 % female) in an urban paramedic service (Halpern et al, 2009b).
Conclusions
Communicating a death notification can be a stressful, yet rewarding task for paramedics. Deaths that are poignant increase the stress of the death notification. Our study suggests that clarification of roles, formal training, and management support may increase paramedics’ comfort with and management of the effects of communicating death notifications in the field.