What Others are Saying about
Grave Words:
Notifying Survivors about Sudden, Unexpected Deaths
“This book made the “lights go on.” I never realized how deficient I was in providing comfort and information to the survivors of sudden and unexpected death. I would strongly recommend this book to all emergency personnel.”
–Gary H. Lambert, M.D., LDS Hospital/University of Utah Medical School
“What a terrific resource! Practical, forthright, and sensitive. A critical resource for every healthcare professional!”
--Kyle Nash, Center for clinical Medical Ethics, Pritzker School of Medicine, Chicago
“I will use this book frequently as a reference when teaching physicians and others about giving bad news. I’ve never seen a better source on the subject.”
--Kate Chritensen, M.D., Chief of Bioethics, Kaiser Permanente, Northern California
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Grave Words:
Notifying Survivors about Sudden, Unexpected Deaths
Kenneth V. Iserson, M.D.
Copyright 2012 by Kenneth V. Iserson, M.D., Smashwords Edition
Cover Illustration copyright 1998 by Galen Press, Ltd. All Rights Reserved.
This ebook is licensed for your personal enjoyment only. This ebook may not be re-sold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each recipient. If you’re reading this book and did not purchase it, or it was not purchased for your use only, then please return to Smashwords.com and purchase your own copy. Thank you for respecting the hard work of this author.
This book is also available in a print edition at most online retailers.
This publication is designed to provide comprehensive information in regard to the subject matter covered. It is not intended as a substitute for professional, legal, or medical advice and is sold with the understanding that neither the Author nor the Publisher is engaged in rendering such services through this book. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.
Parts of Chapter 27 of the present work appeared in a slightly different version in Death to Dust: What Happens to Dead Bodies? by Kenneth V. Iserson, M.D. (Galen Press, Ltd.) Copyright 1994 by Kenneth V. Iserson. Used with permission.
Parts of Chapters 12 and 27 of the present work appeared in a slightly different version in Death Investigation: The Basics by Brad Randall, M.D. (Galen Press, Ltd.) Copyright 1997 by Galen Press, Ltd. Used with permission.
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Table of Contents
Table 1-1: Expected versus Sudden, Unexpected Deaths
SECTION 1: Notifications
Chapter 2: Communicating With the Living
Table 2-1: Non-verbal Messages
Table 2-2: Ways Survivors Express Anger
Chapter 3: A Protocol for Sudden-Death Notification
Table 3-1: Protocol for Delivering News of Sudden, Unexpected Death3
Chapter 4: “Helping” Phrases: The Good, the Bad, and the Ugly
Table 4-1: Helpful Phrases
Table 4-2: Comments to Avoid5
Chapter 5: Telephone Notification
Table 5-1: Telephone Notification Protocol5
Chapter 6: Survivor Information Forms
Table 6-1: Survivor Information Sheet
Table 6-2: Hoja De Información Para El Sobreviviente
Chapter 7: Requesting Organ/Tissue Donations and Autopsy Permission
Table 7-1: Discussing Organ and Tissue Procurement with Survivors
Chapter 9: Follow Up With Survivors
Chapter 10: Acute Grief Reactions
Table 10-1: Acute Grief: Actions, Attitudes, and Coping Strategies
Table 10-2: Issues that affect Different Relationships after Death 9
Table 10-3: Signs and Symptoms of Psychological Reactions to Combat
Table 10-4: Aspects of Grief *
Table 10-5: Factors That May Complicate the Grief Reaction
SECTION 2: The Survivors
Table 13-1: Common Reactions Children Have to Death
Table 13-2: Protocol to Notify Children of Sudden, Unexpected Death
Chapter 14: Notifying Friends, Lovers Co-Workers, and Students
Table 14-1: How to Help Friends after a Death14
Table 14-2: Student-Death Protocol15
Chapter 15: Notifying Other Incident Survivors
SECTION 3: The Notifiers
Chapter 17: Emergency Departments, Critical Care, and Trauma
Table 17-1: Potential Barriers to Effective ED Notification
Table 17-2: Protocol for Notification of Death in the Emergency Department17
Table 17-3: Emergency Physician Stress and the Frequency of Topic Discussions during Death Notifications
Table 18-1: Protocol for Obstetric Deaths18
Table 19-1: Responding To Line-of-Duty Police DeathsTable 19
Table 19-2: Police Line-of-Duty Death Policy20
Table 20-1: U.S. Federal Bureau of Prisons’ Death Notification Protocol20
Chapter 21: Medical Examiners and Coroners
Table 22-1: Nurse Interactions that Survivors Find Helpful
Chapter 23: Chaplains and Clergy
Table 23-1: Protocol for Death Notification by Chaplains22
Table 23-2: Religions’ Beliefs about, Rituals for, and Attitudes toward Death22
Chapter 24: Medics, Firefighters, and Search and Rescue
Table 24-1: Protocol for Emergency Medical Services In-home
Table 25-1: Protocol for Military In-Line-of-Duty Death Notifications
Table 25-2: Protocol for U.S. Navy Death Notification
Chapter 26: Disasters: Survivors and Workers
Table 26-1: Protocol to Support Disaster Survivors
Table 26-2: United Airlines’ Emergency Response Protocol
Table 26-3: Federal Family Assistance Plan for Aviation Disasters
SECTION 4: Important Information
Chapter 27: Survivors’ Questions/Some Answers
Table 27-1: Criteria for Organ and Tissue Donors
Table 27-2: Procedure for Organ Recovery Team
Chapter 28: Dealing With the Media
Chapter 29: Learning More/Educating Others
Table 29-1: Notifying Survivors: Fears, Learning Needs, and Methods to Learn
Table 29-2: Principles of Effective Adult Education
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Acknowledgements
Many people provided assistance during the writing of this book: I would like to thank them for their input.
The reference librarians at the University of Arizona Health Sciences Library, Tucson, AZ, continue to amaze me with their ability to find obscure (and not-so-obscure) information. Special thanks to Hannah Fisher, R.N., M.L.S., AHIP, Associate Librarian–Reference; Nga T. Nguyen, B.A., B.S., Senior Library Specialist; and Mary L. Riordan, M.L.S., Associate Librarian–Reference. Also thanks to an ingenious researcher, Robert Fisher, M.L.S., Tucson, AZ.
I would like to thank the following people for taking the time to review the book and for their excellent advice concerning the content: Reverend Patrick Andresen, M. Div., Chaplain, Univ. Medical Center, Tucson, AZ; Vicki Began, R.N., M.N., Director, Women & Children’s Services, Univ. Medical Center, Tucson, AZ; Kate Christenson, M.D., Internist and Director of the Regional Ethics Dept. for Kaiser Permanente, Martinez, CA; Liz Criss, R.N., Prehospital Services, Univ. Medical Center, Tucson, AZ; Myra Christopher, President, Midwest Bioethics Center, Kansas City, MO; Colleen Anne Ducke, Child Life Specialist/Volunteer Coordinator, Emergency Dept., New England Medical Center, Boston, MA; Ellen Fox, M.D., Adjunct Assistant Professor, Center to Improve Care for the Dying, George Washington Univ., Washington, DC, and Clinical Assistant Professor of Medicine, Univ. of Illinois at Chicago; Anna Graham, M.D., Pathology Dept., Univ. of Arizona College of Medicine, Tucson; Larry Graham, Deputy Sheriff, Pima County (AZ) Sheriff’s Department; Joseph Hanss, M.D., Phoenix, AZ; Patricia Ruth Hastings, D.O., LTC, MC, Deputy Director, Center of Excellence in Disaster Management and Humanitarian Assistance, Tripler, HI; Andrew R. Iserson, M.S.B., North Potomac, MD; Lawrence S. Iserson, Freehold, NJ; Mary Lou Iserson, Tucson, AZ; Jay A. Jacobson, M.D., Div. of Medical Ethics, Internal Medicine Dept., LDS Hospital & Univ. of Utah School of Medicine, Salt Lake City, UT; Tammy Kastre, M.D., President, First Correctional Medical, Inc., Tucson, AZ; Ruth Kimmons, R.N., Recovery Coordinator, Donor Network of Arizona, Tucson, AZ; Steve Kohler, M.D., Emergency Physician, Kaiser Permanente Hospital, San Diego, CA; Gary H. Lambert, M.D., FACEP, Medical Staff Executive Secretary, Cottonwood Hospital Medical Center, Murray, UT; Cendra Lynn, Ph.D., GriefNet Founder & Director, Ann Arbor, MI; Mary Ann Matter, R.N., Prehospital Services, Univ. Medical Center, Tucson, AZ; Kyle Nash, D.Min.(c), Associate Faculty in Clinical Thanatology/Humanistic Issues in Ethics & Medicine, MacLean Center for Clinical Medical Ethics, Pritzker School of Medicine, and Consulting Thanatologist, Univ. of Chicago Hospitals, Chicago, IL; Steve Nash, J.D., Executive Director, Pima County Medical Association, Tucson, AZ; Sue Ogden, R.N., John Corey Ogden, and Randy Ogden, EMT-P, Tucson, AZ; Tammie E. Quest, M.D., Assistant Professor of Emergency Medicine, Emory Univ., Atlanta, GA; Alan Reeter, M.S.E.E., President, Medfilms, Inc., Tucson, AZ; Ron Salik, M.D., Assistant Professor of Clinical of Surgery (Pediatric EM), Univ. of Arizona College of Medicine, Tucson; David L. Schiedermeyer, M.D., Associate Professor of Medicine, Dept. of Medicine, Medical College of Wisconsin, Milwaukee, WI; Terri Schmidt M.D., M.S., Associate Professor & Vice Chair, Emergency Medicine Dept., Senior Scholar, Center for Ethics in Health Care, Oregon Health Sciences Univ., Portland, OR; Mary Jo Villar, D.O., Section of Hematology-Oncology, Jackson Memorial Hospital, Miami, FL; Donald Witzke, Ph.D., Associate Professor, Pathology & Laboratory Medicine, Univ. of Kentucky School of Medicine, Lexington, KY; and Robert Wrenn, Ph.D., Professor of Psychology, Univ. of Arizona, Tucson.
For their stories: Vicki Alexander, R.N., Emergency Dept., Univ. Medical Center, Tucson, AZ; Ken Briggs, EMT-P, Tucson, AZ; Jennifer G. Gilbert, Tucson, AZ; Joshua Helman, M.D., Resident, Emergency Medicine Dept., Detroit Receiving Hospital, Wayne State Univ., Detroit, MI; Mark Ivey, M.D., Payson, AZ; Sam Keim, M.D., Sec. of Emergency Medicine, Univ. of Arizona College of Medicine, Tucson; Fran D. Kunz, Pima County Search & Recovery Divers, and Southern Arizona Rescue Association, Tucson, AZ; David Lebiner, M.D., Associate Professor, Neurology Dept., Univ. of Arizona College of Medicine, Tucson; Joseph W. Rossano, Medical Student, Univ. of Arizona College of Medicine, Tucson; Alan Taplow, M.A., Plainfield, VT; and Charlotte Yeh, M.D., Emergency Physician & Medical Director, Medicare Policy, National Heritage Insurance Company, Charlotte, NC.
For indicating how important this topic is and how little good information is available, as well as for providing some excellent information: Mr. Bill Byrnes, Regional EAP Representative, United Airlines, Chicago, IL; Commander Gilbert D. Gibson, Office of the Navy Chief of Chaplains; Mrs. Alicia Gonzalez, Emergency Medicine, Univ. of Arizona College of Medicine, Tucson; L. Wayne Harris, Senior Mortician, Pathology Dept., Univ. Medical Center, Tucson, AZ; Sara Pace Jones, Public Affairs, Donor Network of Arizona, Phoenix, AZ; Herbert L. Lawrence, Director, Field Support, Armed Forces Emergency Services, American Red Cross; Betty McEntire, Ph.D., Executive Director, American Sudden Infant Death Syndrome Institute, Atlanta, GA; Richard Nelson, M.D., FACEP, Professor & Vice Chair, Emergency Medicine Dept., Ohio State Univ. College of Medicine & Public Health, Columbus, OH; Robin Perin, R.N., J.D., University Physicians, Inc., Tucson, AZ; Suzanne F. Sawyer, Executive Director, Concerns of Police Survivors, Camdenton, MO; Lt. Col. Michael C. Whittington, USAF Chaplain Service Institute, Maxwell AFB, AL; and Jennifer Wolpert, M.S.W., Victim Service Project Specialist, National Organization for Victim Assistance, Washington, DC.
I also want to thank the folks at Galen Press, Ltd., especially Christopher W. McNellis, Jennifer G. Gilbert, and Mary Lou Sherk, as well as Lynn Bishop Graphics of Tucson, AZ, for the great cover design.
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INTRODUCTION: The Problem
Mortality tables fractionate the certainty of death into a variety of separate causes . . . but the statistics about death itself are easy to remember—100%. Weisman, Avery D., Coping with untimely death. Psychiatry. 1973 Nov;36(4):366-78
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Chapter 1: The Problem
Directness, truth, consistency, and clarity are the key factors when delivering information about a sudden, unexpected death. These points were driven home for Jennifer Gilbert, a Galen Press editor, while she was reading this manuscript for the first time. She encountered sudden death one evening and describes the experience:
Hearing Kathy scream my name, I rushed next door. “My baby is dead,” she moaned in disbelief as she met me at the door. She had just returned from work to find her 40-year-old fiancée lying face down on the kitchen floor. It was obvious from his coloration that he had been dead for hours. I hugged her hard while I tried to swallow my own mounting panic, fear, and grief. Instinctively, I knew there was nothing I could say—just being there, hugging her, was enough.
“He’s asthmatic,” she had me relay to the 911 operator as she leaned over his body, “He’d just discovered that the inhaler he was using could cause his heart to stop.” Within minutes (it seemed much longer) the room began to fill with paramedics and policemen. Somehow Kathy was pushed out onto the front porch as they proceeded to do something to his now lifeless body. “They’re going to take him away from me,” she cried. “Why are they working on him? He’s not coming back.” A paramedic rushed past carrying syringes. “Is he breathing?” she asked. “No, he’s not,” the young man answered quickly, without pausing or turning his head.
I rubbed Kathy’s back as she crouched by a phone, trying to remember people to call. I asked if there was someone I could notify and she had me telephone a nearby relative. “Don’t say he’s dead,” she cautioned, “Say there’s been an accident and to meet us at the hospital.” I will always remember how clear she was—still thinking about others in the midst of her terrible shock and sadness.
A couple of men brought in a gurney in preparation for the short ride to the hospital emergency room. “I want to go with him. I have to go with my baby,” Kathy sobbed. My role had been to hug her whenever she needed support, inform the professionals entering the yard that the dogs were harmless. Now I rushed out to the ambulance and made sure she would be allowed on board. Everyone seemed extremely busy, absorbed in the tasks they no doubt performed efficiently several times a day, but they nodded a brief affirmative.
By the time her fiancée’s body was placed in the ambulance, a young policeman, who told her she needed to answer some questions, had stopped Kathy in the living room. “I have to go with the ambulance,” she pleaded. But three minutes later the ambulance sped away, carrying his lifeless body and leaving Kathy to follow behind in my truck. This created a lasting (and unnecessary) memory of callousness and pain for Kathy, who needed to spend those last moments with her partner’s body. At no time did any of the professionals involved in the response take a personal interest in the one person who would remember this evening forever—Kathy, the survivor.(1)
Death has replaced sex as the major taboo topic in Western culture. Imaginary death—such as cartoon-like violence on television and in movies—has replaced reality for most people. When death strikes, as it must, and especially if it strikes suddenly and unexpectedly, we respond with discomfort, distress, and dismay.
A sudden death is one that is unforeseen, unexpected, gives little or no warning, and leaves survivors unprepared for their loss. It comes from an unexpected injury or suicide, or from a medical cause such as heart attack, stroke, overwhelming infection, poisoning, or massive bleeding. Death might even result from fear.(2,3) We have no ingrained cultural responses to tell us how to deal with these crises.
Survivors are victims. Their reactions separate them from life, from reality, and often from caring about themselves, their future, or those around them. When a person learns of the sudden unexpected death of a loved one (bereavement), they experience “a sense of being lost and not knowing what to do. Their sense of being suspended from life, inability to concentrate, indifference to immediate needs, disbelief that the decedent is really gone, and feeling that life can never be worth living again hinders their ability to arrange for the funeral and to make plans for other ongoing life needs.”(4) This is grief.
No one likes to deliver the news of a sudden, unexpected death to others; it is an emotional blow, precipitating life crises and forever altering their worlds. Yet many health, law enforcement, religious, and social service professionals must repeatedly do this as part of their daily work. In fact, nearly every adult will eventually be in this position within his or her own family, acting not only as the messenger of grief, but also as an initial support system for the distraught recipients. Even for skilled professionals, this can be an emotionally draining and even harrowing experience. This book is designed to help us perform these duties with more skill, aplomb, and assurance.
Perceptive survivors can easily tell which notifiers care and which are only “going through the motions.” It often takes imagination to put oneself in the position of a grieving survivor, especially when wide cultural or age differences exist. Imagination, studying people, advance planning, and learning from experienced mentors is the only way to successfully perform this necessary, but tragic, task. Young physicians, nurses, police, chaplains, EMS personnel, and other notifiers, in particular, may not have enough life experiences to empathize with the elderly woman who has just lost her husband of fifty years or with the recent-immigrant couple whose child has just died from SIDS.
But, even if you cannot learn to empathize with survivors, you can learn to behave appropriately, speak correctly, and assist them in their time of grief. Using death-notification protocols and, hopefully, being accompanied by more experienced partners may be the only way to positively affect these survivors.
Why Sudden, Unexpected Death Notification Is Unique
Sudden, unexpected deaths severely shock survivors. These deaths, whether they occur in the young or the old, the healthy or the infirm, strike blows to the very essence of life for those left behind. The decedent’s sudden transition from being very alive to being very dead shocks all observers, both professionals and lay people alike. The degree of this shock is related to how independent, autonomous, and distinctive the decedent was when he or she died.(5) For example, the death of someone confined to a nursing home with Alzheimer’s Disease generally affects survivors less than a 40-year-old executive and father suddenly dying of a heart attack.
Some sudden deaths can even be considered “calamitous” when victims die unexpectedly from violent, destructive, demeaning, or degrading causes such as from murder or by suicide. These deaths can profoundly affect the victim’s community (some deaths more than others). (6) Victims’ relatives often have a much more difficult time dealing with the aftermath of these acts.
Once a person is dead, the survivors become the victims, the patients—those in need. Sudden deaths often represent major life transitions for the survivors. In an instant and with no warning, women go from wives to widows, children become orphans, and friends survive alone. They need someone to deliver the news to them sensitively and in the right context, support them through their time of shock and bewilderment, and direct them toward continued assistance.
In modern societies, people often don’t witness the events that bring them grief. Survivors need someone to communicate this news to them. That is the primary role of the death notifier: to “break the bad news.” At some point, nearly everyone fulfills this role in his or her private life. Both the occasional notifier and their professional counterparts, who must perform this function as a regular part of their jobs, often anguish over how to do this correctly and how to assess their own performances. This book provides a yardstick with which to measure performance, tools to use in training, and examples of both good and bad death notifications and practices.
A word must be said here about the commonly used terms, “breaking/ giving/delivering bad news.” As death educator Kyle Nash says,
These negatively value-laden phrases imply one-sided communication, which should never be the goal of any notifier-survivor relationship. If the communication is thought of in that manner at the outset, notifiers will tend to feel awkward, anxious, and uncomfortable about what they will be or are communicating. When notifiers feel uncomfortable, the type of communication that occurs in these situations does become one-sided.
While it may seem obvious that death notification will indeed be interpreted as negative (i.e., bad), I believe that only the survivors can determine what the information means to them. Preferable terms that I use when teaching are “initiating or engaging in difficult conversations.” These phrases clearly express two-way communication and are value neutral.(7)
Survivors’ first reaction when they hear the news is often, “It can’t be true! It can’t be happening!” But it is true, and the professionals around them must give all the support that they can. One of the hardest things for health care professionals to do, and certainly for other professionals tasked with this job as well, is to face someone whose loved one has just suffered a sudden, tragic death. Despite this reluctance, it is vital that these notifications be done correctly to attempt to lessen survivors’ subsequent distress and pathological grieving behaviors. Family members of those who die suddenly and unexpectedly, either in the emergency department or in the hospital (and also presumably outside the hospital) do much more poorly than do those whose deaths are expected. This may be because there is no time for psychological preparation.(8-10)
Who are the Survivors?
The “primary” survivors addressed in this book are the people with close emotional, social, and cultural ties to the decedent. Primary survivors are, in most cases, a spouse, parent, sibling, children, “significant other” or domestic partner, or grandchildren. Less often, they may be other relatives, friends, neighbors, baby sitters, or housekeepers.
While the most readily accessible survivors are notified first, all notifiers generally try to contact at least the decedent’s closest next of kin, which is usually defined in this order: current spouse, adult children, parent(s), and sibling(s). If a domestic partner or very close friend appears to have been the decedent’s closest relation, then they are usually notified. Once notified, family members can make notification calls to others.
Although it is considered more common in the elderly, even young survivors occasionally die when hearing the news of a loved one’s death. Engel cites two cases: a 14-year-old girl dropped dead upon learning of her brother’s death and an 18-year-old girl died when she heard that the grandfather who had raised her had died. (11) Appropriate notification techniques may lessen the frequency of immediate adverse incidents. Notifiers may have a profoundly beneficial effect on survivors’ future lives if they approach them with caring, knowledge, and professionalism.
Who are the Notifiers?
In the United States and Canada, approximately 70% of deaths occur in health care institutions, so their staff is usually responsible for making these notifications. In the other 30%, however, this job falls to the police, ambulance or fire department personnel, chaplains, medical examiners or coroners, or co-workers. In nearly all cases, whether or not the death occurs in a health care facility, family members and friends of the decedent must then notify others.
Custom, not law, defines who should be the notifier and who should be notified. Generally, this depends upon where and how the death occurs. For example, when death occurs outside of medical facilities, the police usually do the notification.
Resuscitations in Progress
Within most medical facilities, protocols determine who is considered to be the notifier. If a family arrives at the hospital while resuscitation attempts are still ongoing, a chaplain, social worker, or nurse may be delegated to inform the family of the patient’s status. These individuals may be more inclined to use non-medical words to explain what is occurring than would a physician. This is vital because, despite its wide use in the media, the “lingo” commonly used in hospitals is still unfamiliar to most people. To avoid any miscommunication, health care workers who act as notifiers should use “heart attack” rather than “MI,” “injury” rather than “trauma,” and “breathing machine” rather than “ventilator.”
These notifiers should continually update the family. When things are going badly, the same person, or at least one person from the group who initially spoke with them, should progressively inform the family “that things are not looking good.” This alerts them to the grave situation and gives them at least a little time to prepare for the bad news. Often disparagingly termed “hanging crepe,” survivors usually view this as “being gentle.” Technically, the strategy is called “presaging,” or allowing survivors time for “anticipatory grief“ and psychologically preparing them to lose their loved one. Some have also referred to these updates as “successive pre-announcements” and “preliminary suspicion announcements,” suggesting that it is a gradual buildup to what is expected to be tragic news. (12) Even if the outcome changes for the better (which, unfortunately, it seldom does in these situations), experienced notifiers think it best to tell potential survivors what they really expect to happen. As one notifier said, “I prefer to paint it as black as I can because it is, and if it changes, then I would go back and tell them differently.” (13) And when the bad news finally arrives, as it nearly always does in these situations, it is only a confirmation of what those individuals awaiting news have been anticipating.
In a typical emergency department scenario, a nurse, chaplain, or social worker acts as the liaison between the resuscitation team and the family. They meet family members as they arrive and guide them to a waiting area. Having already been into the resuscitation room, the liaisons have a sense of or have been explicitly told about the patient’s condition and what chance the clinicians think the patient has of making it out of the emergency department and the hospital alive and functional. They in turn deliver this news to the family. Initially, they may say, “The medical (surgical) team is working very hard, but he is very ill (badly hurt).” On subsequent visits, they will reassure the family that the team is still working, but will say “Things are not looking good” or “They are not sure they will be able to save him.” Ultimately someone, usually the physician in charge, will tell the family that the effort was unsuccessful. By that time, it is news they are expecting to hear.
In some instances, the physicians or surgeons only need to stop, shake their heads, and say “I’m sorry” for survivors to get the news they expect. In these instances, the physicians clearly mean they are sorry for the survivors’ loss as well as for their own inability to change the outcome. (Hopefully, after delivering the news in this fashion, they take the time to sit with and assist the survivors for at least a short period of time.) When these non- or minimally verbal announcements fail, clinicians must fall back on their standard death notification methods.
Occasionally, interactions between the clinician and survivors during resuscitation attempts convey important clinical information, as one experienced physician related: “Things weren’t going well during an emergency department resuscitation and I had ‘hung crepe’ a few times with the potential widow. Finally, I told her that we were only continuing with CPR because his pupils had not dilated, so that we thought his brain still might have some function. ‘But he has two glass eyes,’ she said. We stopped.” (14)
The Notification
Once death has occurred, especially within the emergency department, the physician usually has the task of delivering the news, often accompanied by a chaplain, a nurse, or a social worker. Most survivors, however, have no objection if more timely notifications can be made by other professionals, such as the nurse, chaplain, or social worker, as long as they have subsequent contact with the physician. (15) What survivors want most is a notifier who seems to care that their loved one has died—someone who will inform them in a warm, sympathetic tone of voice. As a survivor who didn’t have that experience said,
I could not believe that a death that was so important to me was so unimportant to the people in that emergency room. I left thinking that there must be something wrong with me, that somehow I should not be feeling the way I was feeling. I felt as though I was abnormal.(16)
Some professionals avoid this responsibility and pass the job to others. This is usually because they have difficulty dealing with one or more aspects of death or the interaction with survivors. This task, however, should never be relegated to the unit assistant, medical or nursing student, or other untrained or partially trained person. (The exception to this is when a student or resident, who is in the process of being educated to the death-notification process, is accompanied by an experienced, supervising mentor.) When these reluctant notifiers must speak with survivors, they often use a standard, rapid, unconcerned approach as a defense. Others, even those who try to do a good job, just “wing it,” using whatever method seems best. For professionals, these can be career-crippling strategies.
A key psychological response that often diminishes notifiers’ effectiveness is identifying too closely with survivors, thus becoming entangled in their emotions. This may be due to the notifier having experienced a similar event or closely matching the key survivor’s age, cultural background, and social or professional position. Such close identification may produce a sense of awkwardness or inadequacy in notifiers, causing them to rush through the process to hide their own emotions. Consequently, their presentation may seem callous or insensitive, and the exact opposite of what they desired.
Telling survivors about sudden unexpected deaths poses difficulties for those individuals responsible for doing it because they often:
• Lack training and experience.
• Fear being blamed.
• Do not know how to cope with survivors’ reactions.
• Fear expressing their emotions.
• Fear not knowing the “right” answers.
• Fear their own death or disabilities. (17)
The qualities of a good communicator are genuineness, warmth and respect for the survivors, active listening, empathy, and openness.
Survivors’ Perspectives
Understanding survivors’ perspectives helps notifiers realize the importance of their task, how they can do it better, and the lasting impact notifications have. The following are notifications from survivors’ perspectives:
On arrival at the hospital just after 10:15 P.M. no one was expecting us. “Everybody has gone now, and I should have gone too by now,” a social worker said. My friend and I were put in a small anteroom and the door was closed. We had been put into a box with the lid closed to spare us the sight of panicky people rushing to and fro, telephone calls being made, etc., while the system was being reassembled for us. I wouldn’t have that. I behaved myself for three to four minutes, and then I opened the door. I still couldn’t see anything but felt better. What would have made me feel much better was to have seen and shared the panic. That would have been human: being put in a small, quiet, impersonal room behind a closed door was not. . . .
[I had to be] interviewed by the coroner’s officer, who, not knowing I was to arrive, was somewhere else. Eventually he arrived. By now I was getting nicely institutionalized. I was behaving myself. I put him at his ease while he asked his questions—well, I tried. He, poor man, knew the formula and knew each question had to be put with a sympathetic preamble. He was unctuous. He was sorrowful. And I wanted to see my son. He knew what to do with grieving relatives. He knew the formula, so he did it—to the end. He had no idea whom, in reality, I was. (18)
No more support was available to Betty Jane Spencer, who came to the emergency department after her four sons were killed.
“Oh no, it can’t be.” Nurses were staring at me. “What happened?” I was having trouble making sense of it all. I didn’t want to think of the boys and what had happened to them. I was alive, so I reasoned they were too, even though I had seen them killed. Words hung in the air while I tried to make sense of them. Words like ‘dead’ and ‘autopsy’ floated through. I didn’t want to hear them. But all I could say out loud was, “Please don’t tell me how many of them are dead.” (19)
A nurse who observed a survivor’s (John) struggles in both the emergency department and the intensive care unit relates his story:
He had been summoned from work to learn that his wife, Lisa, and two of their children had been killed in a car accident outside a shopping mall. Only his 16-year-old son survived the accident. When John arrived at the hospital, he had been taken to the emergency department (ED) to identify the body of his 7-year-old daughter. The chaplain then accompanied him to the pediatric intensive care unit where John’s other daughter, who was only five, lay brain-dead. Within hours, cardiac arrest would end her short life. John was spared the awful task of identifying Lisa, who had suffered several facial injuries in the crash. A family friend offered to do this for him. His son was critically injured. John had only a brief moment to tell him how much he loved him before the boy was taken to the operating room for orthopedic surgery. (20)
This is a survivor’s description of a home notification she endured:
Being awakened out of a sound sleep in the early hours of the morning by an insistent knocking on the door, you finally get to the door and open it to find two strangers with radios, notepads, and maybe flashlights in hand. They introduce themselves by name, one being from the police department and the other, a chaplain. Their questions denoted their seriousness in making certain that they have the right person; their questions also reflect the fact that they are there to give you some information about a member of your family. You start wondering who is in trouble. Your mind begins to race down the checklist of family members: your husband is at work; your son has been staying out too late recently; your daughter is expecting her first child, and she and her husband have been arguing a lot recently.
As this stranger, these ‘intruders,’ continues asking questions, your own questions start flashing though your mind. Your world begins crumbling in on you. You are brought back to the present moment by an insistent voice gently, but firmly, calling your name. “Are you all right?” You look at the speaker’s face, trying to read what is being said. You hear your own voice, as from a distant point saying, “Yes, I’m all right.” Those probing, insistent voices then ask, “Is your husband at home?” You feel yourself beginning to feel faint. The voices urge you to go inside and sit down. As you sit, they ask about your husband again. You take a deep breath, trying to clear some of the cobwebs from your thoughts. Finally, you realize your husband is at home. He traded nights off with a friend and is sleeping. You call him several times before he answers, and you ask him to come downstairs.
Taking the stairs two at a time, he hurries to his wife’s side. “Who are you?” he asks, as he puts his arm protectively around his wife’s shoulder. You introduce your husband to these strangers who are bringing obviously bad news, although they radiate a calmness and a genuine friendliness which help you feel a little less anxious. Icy fingers of fear clutch your throat as you hear the question, “Do you have a son named Tom? He has wavy blond hair and a mustache?” Your hands move to your throat as though to seek release from that stranglehold of fear. The questions continue. “Is your son about eighteen years old? Does he drive a blue antique pick-up truck?”
Almost at the same instant as you say, “Yes,” the pent-up fear erupts as you cry out in anguish, “Oh my God, what has happened?” It seems an eternity before you hear those dreaded, but not unexpected words, “I’m sorry, your son has been involved in an accident.” The words, even though spoken softly and compassionately, shatter your world. Though dazed by this news, you feel compelled to strike out against its reality. With your heart pounding and aching, blinded by the tears that gush uncontrollably from your eyes, you jump up from the chair to vent your anguish by beating on these people who have torn your little world asunder. Your husband, stunned by this news, now moves to your side. One of the intruders gently but firmly has been holding your wrists, saying, “It’s all right, go ahead and vent your anger and hurt.” You feel your husband’s arm around you, and he leads you back to your chair. As you sit, your husband asks, “How bad is it? Is he hurt bad?” “Yes,” comes the reply, “it is very serious.” Looking at the intruders, and wanting them to deny the next question, you and your husband ask in a single voice, “Is he . . . dead?” Stepping closer to where they can touch both of your shoulders, the intruders answer very softly, “Yes.”
The dam of restraint can no longer hold back the deluge of tear-filled anguish. The intruders silently, and understandingly, wait with patience until the sobbing subsides. After a while, you and your husband look at them as sources of guidance, strength, and information. You ask “What happened?” The intruders, now companions in this sorrow, review the incident with sufficient detail for you to understand what happened. They answer, to your satisfaction, the questions of who was involved, where it happened, how it happened, and where your son’s body is now. They ask if they can contact your own clergy. As you look at your husband, he nods his head and says, “Yes, we would appreciate that. His number is ___.”
You begin to focus on the details, the arrangements for Tom’s funeral. A flood of questions begins to come into your mind. So many details to see to. What should you do first? “What should we do now?” you ask. They reply, “At your convenience, contact a funeral director, give him your son’s name, tell him that he was fatally injured in an automobile accident, and that he is at the General Hospital. The funeral director will lead you through the other steps. If you don’t have a funeral home in mind, we have a list of all those in the local area. If you want, we can call them for you.”
They then ask, “Are there family members or special friends you would like us to call for you?” You have a brother who is very close to you and you ask them to call him. After the call, one of the notifiers, the policeman, says that he must go back on patrol, but that the chaplain will stay with you. He gives you his card and says to contact him if you have additional questions he can answer. The chaplain then sits and begins talking with you about your family, home, jobs, and hobbies. He is interrupted when your clergyman arrives. Now that your own clergy is here, the chaplain quickly reviews the details of the event, including specifics that you will need to know later, such as where your son’s truck is and how to contact him later, if necessary. He promises to revisit within the week.
As she shakes hands with you and your husband, you find a smile of gratitude working its way through the tears as you thank her for coming and telling you about your son’s accident. As she walks out the door, you think, “Less than two hours ago, she came in as a stranger; intruded into and tore up our world. Now, as she leaves, she leaves as a friend.” (Modified from Reference 21. Used with permission.)
Expected versus Sudden, Unexpected Deaths
Most people’s deaths can generally be anticipated. Those who die are usually elderly people with chronic, often obviously progressive, diseases. Even if the exact day, week, or even month when the death occurs comes as a surprise, no one is surprised when it happens. The differences between these expected deaths and the sudden unexpected deaths highlighted in this book are illustrated in table 1-1.
This story from Mark Ivey, M.D., a general practitioner in Payson, Ariz., illustrates a case in which the death started out as unexpected, but progressed into an expected one.
Fifteen years ago, a previously healthy 67-year-old woman presented to the emergency department at our local rural hospital with an obvious cerebral vascular accident (stroke) affecting her speech, swallowing, and the ability to move her arms and legs. I expected that she would soon die, so I asked her husband, son, and minister to stay by her bedside. But she didn’t die.
For days this forlorn assemblage huddled by her bed, discussed her fate, prayed, and cried. After several days it seemed clear to everyone that she would die if disconnected from life supports. As they watched, I removed her from the ventilator and waited. The next 45 minutes as we clustered around that dying woman’s bed were the longest of my professional career. While we stood a deathwatch, I questioned whether I had made the correct decision based solely on clinical grounds (without transferring her to another hospital for an EEG, CT scan, etc.). I wondered whether the family thought I had made a mistake.
Then she died—calmly and quietly. I still wondered whether what I thought was compassionate care had been correct. The minister reassured me and the family of my wisdom, the family thanked me, and, after an autopsy, the pathologist congratulated me on my astute diagnosis. The family still sees me professionally—and I still think about that case. What was it that made me do the right thing and involve the family in this decision?
Why Use Protocols?
It’s been claimed that “effective grief support cannot be reduced simply to a protocol-driven response.” (22) It is true that no protocol can anticipate every eventuality; every notification will differ in some way. Neither can it enable notifiers to break bad news painlessly. It can, however, help notifiers prepare for their task and help them understand what to expect. Protocols combined with staff education have made significant differences in how survivors perceive and respond to sudden-death notifications. (23)
Obviously, optimal survivor notification, especially in cases of sudden unexpected deaths, includes individuals’ emotional commitment to and a personal investment in the process. There must be a place to start learning the process and a way to measure the quality of notifications. Protocols fulfill these two goals.
For many in the healing professions as well as other professionals tasked with notifying survivors of sudden, unexpected deaths, protocols have become a standard method of learning complex material. Certainly, as they become more experienced in the process, these professionals will deviate from the protocols to meet the needs of individual situations. But protocols provide both notifiers and death educators a framework to build on.
References
1. Gilbert J: Personal communication with author, January 1999.
2. Harvey WP, Levine SA: Paroxysmal ventricular tachycardia due to emotion—possible mechanism of death from fright. JAMA. 1952;150:479-80.
3. Engel GL: Sudden and rapid death during psychological stress: folklore or folk wisdom? Ann Intern Med. 1971 May;74(5):771-82.
4. Silverman PR: Services to the widowed: first steps in a program of preventive intervention. Comm Mental Health J. 1967;3:38-44.
5. Weisman AD: Coping with untimely death. Psychiatry. 1973 Nov;36(4):366-78.
6. Ibid.
7. Nash, Kyle: Personal communication with author, April 1999.
8. Tolle SW, Bascom PB, Hickam DH, et al.: Communication between physicians and surviving spouses following patient deaths. J Gen Intern Med. 1986 Sep-Oct;1(5):309-14.
9. Parkes CM, Brown RJ: Health after bereavement. a controlled study of young Boston widows and widowers. Psychosom Med. 1972 Sep-Oct;34(5):449-61.
10. Levinson P: On sudden death. Psychiatry. 1972 May;35(2):160-73.
11. Engel GL: “Sudden and rapid death.”
12. Glaser BG: Time for Dying. Chicago: Aldine, 1968; As cited in: Clark RE, LaBeff EE: Death telling: managing the delivery of bad news. J Health Soc Behav. 1982 Dec;23(4):366-80.
13. Clark RE, LaBeff EE: Death telling: managing the delivery of bad news. J Health Soc Behav. 1982 Dec;23(4):366-80.
14. Anonymous physician, March 1999.
15. Tolle SW, Bascom PB, Hickam DH, et al.: “Communication between physicians and surviving spouses.”
16. Jones WH, Buttery M: Sudden death: survivors’ perceptions of their emergency department experience. J Emerg Nurs. 1981 Jan-Feb;7(1):14-7.
17. Modified from: McLauchlan CA: ABC of major trauma. handling distressed relatives and breaking bad news. Br Med J. 1990 Nov 17;301(6761):1145-9.
18. Awoonor-Renner S: I desperately needed to see my son. Br Med J. 1991 Feb 9;302(6772):356.
19. Lord JH: Trauma, Death, and Death Notification: A Seminar for Professional Counselors and Victim Advocates. Washington, DC: Mothers Against Drunk Driving and the U.S. Dept. of Justice for Victims of Crime, 1996, p. 32.
20. Coolican M, Vassar E, Grogan J: Helping survivors survive. Nursing. 1989 Aug;19(8):52-7.
21. Cunningham WA: Thoughts on Making Death Notifications. Presented to the International Conference of Police Chaplains, July 1980.
22. Wolfram RW, Timmel DJ, Doyle CR, et al.: Incorporation of a “Coping with the Death of a Child” module into Pediatric Advanced Life Support (PALS) curriculum. Acad Emerg Med. 1998 Mar;5(3):242-6.
23. Adamowski K, Dickinson G, Weitzman B, et al.: Sudden unexpected death in the emergency department: caring for the survivors. CMAJ. 1993 Nov 15;149(10):1445-51.
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SECTION 1: Notifications
Dealing with death . . . You have to be aware of your own feelings and biases because if you don’t, you’ll wind up dealing with yourself first and the other people second. This isn’t the best way to do it.
Clark RE, LaBeff EE: Death telling: managing the delivery of bad news. J Health Soc Behavior. 1982;23:366-80.
2. Communicating With the Living
3. A Protocol for Sudden-Death Notification
4. “Helping” Phrases: The Good, the Bad, and the Ugly
5. Telephone Notification
6. Survivor Information Forms
7. Requesting Organ/Tissue Donations and Autopsy Permission
8. Viewing the Body
9. Follow Up With Survivors
10. Acute Grief Reactions
11. Support Groups
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Chapter 2: Communicating With the Living
Excellent communication skills represent the basis for correctly delivering tragic news of sudden death to survivors. But the ability to empathetically communicate is rarely taught and is an even rarer natural gift. How to correctly deliver bad news is thus often left to practitioners’ intuitions, rather than to skills they learned and practiced during their education. Poor clinician-patient communication disappoints both the patients and the clinicians. Often, this failure occurs when clinicians
• Use highly technical language.
• Don’t show appropriate concern for problems voiced by patients.
• Don’t pause sufficiently to listen.
• Don’t verify that the listener has gotten the information presented.
• Take a generally impersonal approach to the interaction, which includes their manner of speech.(1)
Emergency situations demand excellent communication skills. This is especially true when sudden unexpected deaths occur within emergency medical services (ambulance systems), emergency departments, and trauma centers, or when police, coroners, or chaplains must make home notifications. In these situations, the notifiers and the survivors rarely enter into their relationship by choice, do not know each other, and may view each other with mutual distrust and negative stereotyping. Given the stress inherent in these situations, the potential for miscommunication is enormous.
Delivering the news about sudden unexpected death provokes strong emotions in both the notifier and survivors. Communication is improved if the notifier acknowledges those emotions. Notifiers must be prepared to vocalize and demonstrate their sadness, and to recognize and acknowledge it in the survivors.
Para-verbal and Verbal Communication
Using the voice to communicate does not always mean talking. In some instances, para-verbal behavior is preferred. Para-verbal communication means the sounds we make, such as mmmmm, ahhhh, or mhmmm. These are often sufficient to show that a person is listening and understands if they are accompanied by appropriate non-verbal cues, such as nodding the head.
Beyond that, it often helps to use “facilitative listening.” This has three components:
1. Echoing: repeating back key words, often as questions, from what the person has just said. This prompts them to continue in a specific direction. For example, when a survivor says “I feel so sad every time I think about her,” a response of “Sad?” prompts him or her to talk about that feeling.
2. Reflect Content: summarizing what the survivor has just said, with interpretation, if necessary. This helps survivors focus and clarify their thoughts. If they feel uncomfortable talking about important issues, this helps them do it. For example, after a rambling discourse about the stresses of having to face the various monthly bills, children’s demands for expensive toys, and the need to reciprocate for a gift received from a neighbor, the listener might say, “It sounds as if you are concerned about how to make ends meet.”
3. Reflect Feeling: to help a person label the emotions they are expressing. This requires the listener to put into context both the survivor’s words and their sentiments. This should be done in a non-critical and non-dogmatic way, such as by saying, “You sound as if you are frightened to return to work.”
The combination of reflecting content and feeling is the basis of what we often call “empathy.” Some phrases to use when actively listening that both summarize and reflect content and feeling include:
• I’m picking up that you . . .
• I gather . . .
• To me you’re conveying a sense . . .
• I wonder if you’re saying . . .
• If I’m hearing you correctly . . .
• It seems that you are concerned with . . .
• Listening to you it seems that . . .
• Let me check to see if I understand . . .
• I really hear you saying . . .
• It sounds as if you’re concerned about . . .
• You often feel . . . ?
• Sometimes you . . .?
• You seem to be saying . . .
• So your world right now is a place where . . . (2)
The following open-ended questions and requests perform similar tasks. Be careful when asking questions that may sound critical of the survivor, such as “How did you decide that?” They can be either helpful or hurtful, depending on the speaker’s tone of voice and the context in which they are asked.
• Can you tell me more about how you see this?
• How do you perceive the situation?
• Help me understand the situation.
• Can you tell me more about . . . ?
• What alternatives have you considered?
• How did you decide that?
• What do you mean by . . . ?
• How can I help you do something about that?
• In what ways is this important to you?
• What other possibilities are there?
• Where would that lead?
• What might be some of the consequences if . . . ?
• What have you done so far about that?
• Explain this to me again . . . I’m having a hard time understanding.
• What are some other ways you’ve thought about doing it?
I could write many more words about effective verbal communication and active (facilitative) listening, but the following poem from the ubiquitous “anonymous” seems to say it best: (3)
PLEASE LISTEN
When I ask you to listen to me and you start giving advice,
You have not done what I asked nor heard what I need.
When I ask you to listen to me and you begin to tell me
That I shouldn’t feel that way, you are trampling on my feelings.
When I ask you to listen to me, and you feel [that] you have to do something
To solve my problems, you have failed me—strange as that may seem.
Listen, please!
All I asked was that you listen. Not talk nor “do”—just hear me.
Advice is cheap. A quarter gets both “Dear Abbey” and astrological
Forecasts in the same newspaper. That I can do for myself,
I’m not helpless, maybe discouraged and faltering—but not helpless.
When you do something for me that I can and need to do for myself,
You contribute to me seeming fearful and weak.
But when you accept as a simple fact that I do feel what I feel,
No matter how seemingly irrational, then I can quit trying to convince
You and can get around to understanding what’s behind what I am
Saying and doing—to what I am feeling.
When that’s clear, chances are so will the answers be,
And I won’t need any advice. (Or then, I’ll be able to hear it!)
Perhaps that’s why, for some people, prayer works, because God is mute,
And doesn’t give advice or try to fix what we must take care of ourselves.
So, please listen and just hear me.
And if you want to talk, let’s plan for your turn,
And I promise I’ll listen to you.
Non-verbal Communication
In addition to verbal communication, notifiers also need to be aware of their non-verbal communications We often think of communication simply as the words we speak. At least as important are the non-verbal cues we generate, including bodily contact, physical proximity, posture, gestures, facial expressions and eye movements, and appearance.
Non-verbal communication becomes especially important in the highly charged atmosphere surrounding sudden-death notification. Notifiers may inadvertently send incomplete, erroneous, or distorted non-verbal messages, especially if they have been involved in the resuscitation, are simultaneously dealing with personal or professional stress, or have personal issues surrounding the decedent or the survivors. Table 2-1 illustrates common non-verbal cues among most, but not all, Western Europeans and North Americans. They may need to be adjusted for other cultures.
Touching is the most obvious communication between notifiers and survivors. Hold their hand with a firm, but friendly, grip. Physical contact demonstrates that the survivor is still part of the community despite the devastation he or she has suffered, eradicating what has been called the “leper complex.”(4) As one nurse described, “A man, a big man, told me how a staff nurse held his hands when his wife died. ‘I didn’t want her to take them away,’ he said.”(5) Feelings and signals from the survivors should guide staff. If you err and unintentionally do something a survivor seems to feel is inappropriate, remain calm, explain why you acted as you did, and apologize.
Being aware of the non-verbal signals we send is the easiest way to control this part of the message. One excellent method for both teaching and learning the impact of non-verbal messaging is to test out various positions, expressions, etc. with a partner or in front of a mirror while simply saying, “I’m sorry.” Note the enormously different impacts you make, depending on your facial expression, head and body position, and tone of voice.
One other aspect, actually a part of verbal communication, is how we say our words. Whether they are said with sorrow, anger, or ambivalence greatly affects the way survivors hear and interpret our words.
Working through Interpreters
As worldwide mobility grows and increasing numbers of people don’t speak the majority’s language, interpreters are frequently needed to help relate the news of sudden unexpected deaths to survivors. For example, the 1990 U.S. Census found that almost 14 million people living in the United States have “limited English proficiency.” (The U.S. Department of Health and Human Services Office for Civil Rights uses “Limited English-proficient” to define the non-English speaking or limited-English speaking portion of the population.) In five states (California, Hawaii, New Mexico, New York, and Texas), more than 10% of the population has such limited English skills, and in three more (Arizona, Florida, and New Jersey), it is at least 8%.(6)
The Deaf
Another commonly necessary “translation” is that of verbal language to communication for the deaf. In the United States, American Sign Language (ASL) is commonly used. Not all deaf people read lips and, even when they can, frequent feedback is necessary to be sure that the spoken message is what they have received. Written communication is usually possible, but it can be very slow and laborious, especially in the highly charged atmosphere surrounding a sudden death. When possible, it is best to have a fluent ASL interpreter to assist with communications. In December 1998, Arizona’s Attorney General warned all hospitals that under the 1990 federal Americans With Disabilities Act (ADA), they must have sign-language interpreters available to help patients or family members. This ruling stemmed from a case in Sun City West, Ariz., in which a deaf woman was unable to communicate with the staff while her husband was dying in the emergency department.(7)
The Interpreter’s Job
Medical interpreters must translate three different things simultaneously. This is a difficult job, especially when dealing with such complex issues as the medical and social events surrounding an unexpected death. First, they must translate medical terms and procedures into language that their listeners can understand. How difficult this is depends upon the events surrounding the death, the amount of medical intervention that took place, and the listeners’ knowledge of medicine—which may vary immensely depending upon when and from where the listeners came. Survivors may have a high level of sophistication and knowledge of medical terms, may be baffled by most of what is said, or fall somewhere between these extremes. If the listeners do not know much about the medical system, the translator must take the time to completely describe the context as well as what is being said.
Second, the translator must interpret the clinician’s view of events into the survivors’ cultural perspective. Survivors from other cultures may view the world and the events being described through a window quite different than the one the notifiers use.
They tried to explain to Mui, a recent Vietnamese immigrant, that she could neither personally prepare her husband’s body for burial nor dress him in his best clothes, as was their custom. He would need to have an autopsy, the doctor tried to explain. She didn’t understand how this could happen and the refugee workers doing the interpreting weren’t very good at providing an explanation. They told her that she would have to perform prefuneral ceremonies at the mortuary, rather than at home—and they would be delayed—imperiling the spirit. She was sure that the doctor’s words and the strange culture were denying her husband a peaceful last rest.(8)