Research

Death notification delivery

and training methods
Eoin Walker, Advanced Paramedic Practitioner, London Ambulance Service NHS Trust, London.
Email for correspondence: [email protected]

the patient, yet may have to deliver the worst

Abstract information they may ever hear (Steen et al, 1997).
Thirdly, the delivery of difficult information may
For a paramedic, delivering a death notification (DN) is one of the most difficult
come after a prolonged and emotionally draining
and stressful messages they will have to communicate in practice. Stress and
resuscitation—possibly leaving the paramedic with
anxiety in both recipients and paramedics have been documented through
little capacity for further involvement and emotional
a limited literature base. The current review seeks to understand the existing
empathy (Steen et al, 1997).
educational tools and training around DN, and evaluates the applicability of these
There were approximately 28 000 cases out-of-
in the pre-hospital environment.
hospital cardiac arrest (OHCA) within the UK in 2016—
Key words and only 50% of patients were viable for resuscitation
l Paramedic l Pre-hospital care l Death notification (British Heart Foundation (BHF), 2015). Paramedics
in London saw 10 116 OHCAs with 4389 attempts at
Accepted for publication: June 2018 resuscitation (42.6%) in 2016 (London Ambulance
Service (LAS), 2017). Of these attempts, 3053 patients
had resuscitative treatment withdrawn, which resulted

D eath notification (DN) is a skill that is

required by most pre-hospital clinicians
when dealing with failed resuscitation
attempts (Vail et al, 2011). It is not intuitively learned,
nor is it made effective without training (Dosanjh et
in clinicians delivering 3053 DNs to family members in
London in 1 year alone—contributing to a significant
demand on pre-hospital clinicians.

Search strategy
al, 2001; Amiel et al, 2006; Douglas, 2013). If poorly The literature search ranged from 1995 to 2018 to
delivered, it can become a lasting negative memory include contemporaneous literature and historical
for the person receiving the news and it is shown empirical data. The search used the CINAHL
to negatively affect the health outcomes of relatives electronic database and other sources, such as
(Baile et al, 2000). Consequently, this can increase Google Scholar, for grey literature results. The
the strain on the wider health service. It has been following search terms were used:
evidenced that paramedics use colleagues as a ll‘out of hospital’
source of informal support to mitigate the stress of ll‘breaking bad news’
giving a DN (Douglas et al, 2012). The aim of the ll‘pre-hospital care’
current literature review is to examine and critique ll‘death-notification’
the existing methods and training of DN within all ll‘death notification tools’
areas of medicine—as well as to understand how ll‘educational intervention’.
these can be applied to pre-hospital care and aid Additional words that were searched include
clinicians to use existing tools for this difficult task. ‘paramedic’, ‘nurse’, ‘doctor’, and ‘EMS’.
The CINAHL database was used as it includes
Death notification delivery allied healthcare literature to capture nurse and
Delivery of DNs poses difficulties for a number of paramedic evidence. Palliative care and oncological
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reasons. Firstly, clinicians only receive one chance studies were included to capture the experiences of
to deliver a DN to family members, which is a health professions who frequently break bad news.
cognitive challenge and gives no margin for error
(Meunier et al, 2013). Inclusion criteria
Secondly, attending paramedics do not have To gather a variety of empirical DN intervention
a significant relationship with the families of literature, the review included:

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llAny medical form of DN within the remit of

chronic or acute conditions within medicine Additional records

Identification
Records identified through
llCase studies regarding DN identified through
database searching
llStress testing and psychological effects on other sources
(n = 93)
clinicians when delivering DN (n = 128)
llAny practitioner level including pre-registration
students (paramedic, nursing or medical)
llDN educational interventions within any medical Records after duplicates removed
specialty (n = 54)

Screening
llAdult and paediatric literature
llAssessment-based tools regarding DN.
Exclusion criteria involved DN not relating to Records screened Records excluded
health care, editorials and commentaries on DN. (n = 54) (n = 31)
Figure 1 shows the search methodology.
Full-text articles assessed Full-text articles
Results for eligibility excluded, with reasons
There were three qualitative pre-hospital studies Eligibity (n = 23) (n = 9)
found in relation to paramedic emotional responses
to DN (Steen et al, 1997; Marco and Wetzel, 2012;
Studies included in
Douglas, 2013). These studies had small single-
qualitative synthesis
centered sample sizes and have been included
(n = 6)
in the results as a representation of existing
literature. The only pre-hospital tool found was
Iserson’s (2000) 10-step tool used by the College of Studies included in
Included

Paramedics (CoP). quantative synthesis

It is known that cross-specialty education translates (meta-analysis)
into different practices; therefore these studies are (n = 8)
included in the results (Bowyer et al, 2009; Paul
et al, 2009). The majority of research comes from Figure 1. Search methodology
oncological literature (Colletti et al, 2001; Amiel et al,
2006; Vail et al, 2011; Fieschi et al, 2015). Five studies llGRIEV_ING mnemonic (Hobgood et al, 2005)
were based on emergency department focus of care. ll10-step model (Iserson, 2000).
Four studies focused on training and measuring The literature revealed that DN educational
efficacy of training. Only one systemic review was intervention conferred greater impact when
found, although this was 20 years old. It showed the candidates had various assessments, e.g.
useful information from 10 randomised controlled simulations, multiple-choice questions, case studies.
trials (RCTs) (n=1294); therefore this was added to This involves simulated patient feedback (i.e.
the synopsis of results (Walsh et al, 1998). All results non-medical actor feedback through global rating
can be seen in Table 1. communication scales), pre-test and post-test scores
and Objective Structured Clinical Examinations
Discussion (OSCEs) format style training.
The majority of empirical evidence summarised in
the results originated from medicine rather than Pre-hospital DN tools
paramedic practice or other health professions The CoP advocates online learning for paramedics
(Fallowfield and Jenkins, 2004; Goncalves et al, 2005; and provides the 10-step model based on Iserson
Vail et al, 2011; Reed et al, 2015). These authors (2000) (Figure 2). It provides headlines to prepare
proposed that great emphasis is placed on technical for giving bad news and advocates giving a
skills (procedure and clinical skill), but this negates ‘warning shot’.
the importance and use of non-technical skills This is useful for changing the expectations of the
(listening and communication) used in DNs. relative prior to DN delivery. The tool is not specific
Paul et al (2009) and Bowyer et al (2009) to the actual delivery, e.g. being concise and clear,
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© 2018 MA Healthcare Ltd

state that demand-laden and time-pressured eye level delivery, active listening—but it does
clinicians can forget the importance of these skills. reflect emotional and cognitive empathy through
Justifications aside, non-technical skills are equally stating ‘acknowledgment of feelings and support
as necessary in certain circumstances. Three tools of feelings’. Such extensive steps could make it
were found in the literature: difficult to translate into practice—this is partly
llSPIKES mnemonic (Baile et al, 2000) because extensive steps might be challenging to

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Table 1. Synopsis of inclusion literature

Author Date Study design n Aims/outcomes Results
Amiel et al 2006 Prospective observational cohort 34 Determine whether educational Study group significantly increased
study. Simulated patients as intervention amongst GPs was their average grade on the post-test as
evaluators assessed GP’s ability to measurable and demonstrated change. compared to the pre-test (58.5, SD 12.7
deliver bad news. Half received an vs. 68.4, SD 9.2; range: 20–100), effect
intervention/educational package size 0.94, improvement in performance
(90-minute lecture with break out of the control group was minimal.
groups) and half not (control).
Authors used the eight OSCE
stations used to test the 17 GPs.
Bowyer 2009 Pilot study. Educational package 553 Determine whether use of SPIKES All four groups had highly significant
et al (SPIKES mnemonic used) on mnemonic can alter BBN performance improvement (P value range < 1.3 3 10
3rd year medical students. The in variable levels of BBN education. 15 to 2.4 3 10 41) over baseline (mean
authors split them into four all groups 2.74 6 0.79) on the self-
groups and gave them escalated reported assessment.
levels of BBN education.
Colletti 2001 Prospective observational cohort 21 To assess the effectiveness of these Students who had previously had a
et al study. Intervention arm taught BBN interactions on a student’s BBN experience performed significantly
BBN content and a control group subsequent ability to deliver bad news better on the OSCE than students
over four scenarios (two in each in either a similar or different scenario. without this experience.
sub-specialty).
Douglas 2013 Qualitative retrospective study 28 To explore the experiences of Four themes arose: practical
aspects of
et al examining paramedics views on paramedics and communication DN, how paramedics acknowledge the
death notification of death notifications, their coping emotional toll, how they manage this toll
strategies, and their support needs. and the support mechanisms they used.
Fallowfield 2002 Literature review regarding NA Literature review of clinician/patient No convincing evidence supporting the
and palliative care interactions interactions, clinician interviews (expert contention that terminally ill patients die
Jenkins between doctors and patients opinion), and educational intervention. fully informed
Fallowfield 2004 Literature review on DN, 6 studies 6 Literature review on the impact of BBN training produce benefits for
and examining the views of doctor’s and BBN on doctors and patients, and clinicians as well as patients, but these
Jenkins views on DN and 12 studies on 12 assess whether interventions are training needs to be based on sound
patient views of DN. helping patients educational principles, informed by
evidence, and assessed and monitored
adequately.
Goncalves 2005 Prospective qualitative study 47 Review of cancer patient experiences Main problem is the difference between
et al involving a questionnaire of to identify areas of improvement the information provided and the
patients with advanced cancer within one unit patients’ own information needs.

recall. An aide-mémoire for clinicians may serve as The ‘space’ criterion within the GRIEV_ING
a reminder to increase compliance to this tool. The mnemonic is important for information-processing
final step, to make apparent what help is available, and allowing the person to express emotion in
is a key function of the tool. Relatives are often too response to the initial information. It also articulates
emotionally overburdened to plan ahead for the that the clinician needs to give clear communication
immediate future (Fallowfield and Jenkins, 2004). saying the word ‘death’ or ‘died’ to avoid
misunderstanding. The GRIEV_ING mnemonic may
Emergency medicine DN tools still be perceived as having too many steps (a total of
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The GRIEV_ING mnemonic (Table 2) has been 9) to retain compliance, which could be a limitation.
adapted for use in emergency medicine from oncology The ‘nuts and bolts’ criterion (which includes
(Hobgood, 2005). Despite its origins, the tool is inquiry around organ donation; funeral services;
appropriate for pre-hospital care as it offers an intuitive personal belongings; and offering relatives the
approach to DN through gathering family and offering chance to see the body) illustrates that this was
them external support—unlike the 10-step model. not designed for pre-hospital care. While this is

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Table 1. Synopsis of inclusion literature (continued)

Author Date Study design n Aims/outcomes Results
Marco and 2012 Mixed-method retrospective trial 26 Patients involved in a RTC between A majority of people (n=15) had to
Wetzel 2005 and 2009 were approached to ask about the outcome of other people
participate in a telephone survey using involved in the incident and 11 people
a trauma registry database. believed they were given insufficient
information about the status of other
people in the RTC (four people were
unsure about this); however most
participants (n=17) considered that the
hospital staff had given them adequate
information about their own condition.
Reed et al 2015 Prospective qualitative cohort 29 Self-selected first year doctors were Performance on the 3-month
analysis assessed via videotaped SP encounters BBN retention showed significant
at 3 time-points: baseline, immediately improvement (p = .035) compared to
post-intervention, and 3 months post- immediate post test scores.
intervention. Designed to assess the
acquisition and retention of BBN skills
Steen et al 1997 Qualitative prospective study of 33 Question need for attitude changes to- Lack of training can lead to a lack of
semi‑structure interviews with wards the paramedics, based on the competence and high emotional burden
paramedics information obtained by a closer look by being unsure of best practice. Authors
at the organisational culture. conclude that paramedics have an
important caring function towards the
relatives of OHCA
Paul et al 2009 Literature review of palliative 4 Research assessing psychosocial Much of the intervention effort was
care/cancer educational outcomes for patients as apposed to directed towards improving provider
interventions among all clinicians clinician ability skills rather than patient outcomes
Ungar 2002 Prospective cohort analysis 37 Proposed educational intervention for Participants noted that they had gained
et al GP trainees underwent educational GP trainees relevant communication skills for future
interventions over 4 years patient encounters
Walsh 1998 Systematic review 10 Ten RCTs evaluating communication Little evidence of any effect on the
et al RCT strategies with cancer patients in the patients’ psychological adjustment; the
diagnostic phase effects on patients’ knowledge and
satisfaction levels were inconsistent
Vali et al 2011 Multi-centered cohort trial 285 Consultant grade doctors in simulated Consultants are mainly focused upon
situations to explore how experienced providing biomedical information and do
clinicians from wide ranging specialties not actively involve patients within the
deliver BBN and investigate the consultation
relationship between physician
characteristics and patient-centredness
GP = general practitioner; OSCE = Objective Structured Clinical Examinations; SD = standard deviation; BBN = breaking bad news; DN = death notification; RTC = road traffic
collision; SP = standardised patient; OHCA = out-of-hospital cardiac arrest; RCT = randomised controlled trial

an important section, it must be noted that organ the GRIEV_ING mnemonic, the SPIKES mnemonic
donation in sudden OHCA may be perceived as advocates gathering close relatives in one place and
insensitive as a result of the lack of emotional controlling the environment as much as possible.
preparation relatives are afforded. This is difficult in pre-hospital care as settings
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change constantly, yet the principle of collective

Palliative care and oncology support in a controlled environment is helpful.
The SPIKES protocol (Table 3) is the most widely Certain criteria within the tool, i.e. ‘perception
used tool taught to doctors (Baile et al, 2000). criteria’, do not translate easily to pre-hospital
Its origins are in oncology and are therefore not care as they are focused on the patient being the
adaptable for the pre-hospital care environment. Like receiver of the news rather than a relative. One of

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1 1.
10 2 2.
Preparation
Establish what the person knows
3. Establish what the person wants to know
4. Give a warning shot
Available 5. Communicate bad news sensitively
9

3
help and 6. Acknowledge distress and support the expression
what of feelings
happens 7. Identify and prioritise concerns
8

next 8. Check their information needs

4
9. Identify what support is available is available or
can be sought
7 5 10. Make apparent what help can be available and
6 explain what happens next

Figure 2. Iserson’s (2000) 10-step tool has been used by the College of Paramedics to deliver DN

the positive aspects of this tool is that it provides a The second study was from Douglas et al (2013).
structure for bad news and forms a plan of support This was a qualitative retrospective study examining
for the recipient. As with all algorithmic aids, it paramedics’ views on DN including experiences,
is dependent on user compliance and emotional communication, coping strategies and support
empathy through each step in the tool. needs. The authors set up paramedic focus groups
Further benefits include giving ‘warning shots’, to discuss all four aspects of DN. The authors do
putting a plan in place for the recipient, and not state inclusion or exclusion criteria or how
empathetic responses. These additions provide they analysed results, which reflects poor internal
support for the recipient who may need a re- validity. Four themes arose:
alignment of expectations, a simple plan to feel llPractical
aspects of DN
empowered, and application of the clinician’s llHow paramedics acknowledge the emotional toll
emotional intelligence in delivery. llHow they manage this toll
llThe support mechanisms they used.
Paramedic studies The paramedics were from rural or urban
The three pre-hospital studies from the literature Ontario, Canada, and self-selected to participate,
search had qualitative components, were poorly giving rise to selection bias. The researchers took
powered, contained high levels of methodical bias, note of length of service but not how many times
or lacked mention of statistical analysis. They either the paramedics had broken bad news. Dosanjh et
relate to the emotional consequences of delivering al (2001) found that when testing clinicians’ ability
DN or the timings of delivery . to deliver DN, years of service did not equate
The study conducted by Steen et al (1997) was to proficiency. The research includes accounts
a retrospective qualitative interview of paramedics of paramedics waiting for the police to arrive to
(n=33). Almost 50% of the participants (n=16) deliver the DN; this deferral of delivery should
suffered from anxiety and stress and felt ill-prepared not be counted as paramedic-delivered DN and
to break bad news. The authors stated that this led can lead to heterogeneous results. The clinical
to difficulties in personal lives and relationships. relevance of this study confirms that the previously
The importance of training and debriefing in these mentioned four domains exist but never explored
situations are key to maintaining wellbeing and methods of how to give an adequate DN that
positive experiences for staff (Ramirez, 1995). The would benefit the wider paramedic community.
study was highly descriptive and subjective with The third study (Marco and Wetzel, 2012)
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poorly powered numbers (n=33) creating poor examined timings of DN among survivors (n=26)
external validity. The results are concordant with of road traffic collisions. This research had no
more powerful in-hospital studies regarding clinicians formal methodical explanation of inclusion
feeling poorly prepared (Fallowfield and Jenkins, criteria, data-recording processes or synthesis of
2004). Therefore, these results infer clinical relevance results. The authors concluded that there was no
to paramedic practice but cannot be used in isolation. conclusive timeline as to when to deliver DN.

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The study was poorly powered (n=26); contained

retrospective (recall bias); has no information Table 2. The GRIEV_ING mnemonic
regarding data analysis; and divides results of G Gather Gather the family; ensure all members are present.
on-scene delivery (split between police and
paramedics) at the emergency department or in Resources Call for support resources available to assist the family
outpatient departments. This study has minimal R with their grief, e.g. chaplain services, ministers, family
clinical application but confirms that survivors are and friends.
ill-prepared for DNs regardless of timelines. Identify Identify yourself, identify the deceased patient by
I name and identfy the state of knowledge of the family
Relevance to paramedic practice relavtive to the events of the day.
Recurrent themes throughout all three tools (Baile Educate Briefly educate the family as to the events that have
et al, 2000; Iserson, 2001; Hobgood, 2005) that bare E occurred, educate them about the current state of their
relevance to paramedic delivery of DM are: loved one.
1. Gather relatives in a calm environment
Verify Verify their family member has died. Be clear! Use the
2. Introduce yourself at eye-level, sit down as this V
words ‘dead’ or ‘died’.
gives perception of extended time and focused
clinician attention. Finish the opening interaction Space Give the family personal space and time for an emotional
[-]
with your name again as they may forget it the moment; allow the family time to absorb the information.
first time owing to contemporary cognitive load Inquire Ask if there are any questions and answer as many as
3. Use ‘warning shots’ to realign expectations and I
you can.
understand relative’s tendency to desire as much
Nuts and bolts Inquire about organ donation and personal belongings.
information as possible N
Offer the family the opportunity to view the body.
4. Use simple language to deliver the death
message (‘died’, ‘death’) with frequent pauses to Give Give them contact information for resources that can
G
allow for assimilation of the information assis them.
5. Support the relatives with a plan of action for
the onward proceedings. If they are alone, make
sure they have company over the following time Table 3. The SPIKES protocol
period. Setting Prepare for the invitation by reviewing the notes and inviting
the patient to involve people important to them. Prepare
Conclusion the environment, ensure time and privacy. Take note of body
All three tools have been shown through the language, be seated, not standing.
literature to help health professionals prepare Perception Find out the patient’s perception of their illness.
for this cognitively demanding task and show
significant differences in how survivors perceive Invitation Find out how much infomation they would like, and to what
and respond to DNs (Paul et al, 2009; Kaplan et level of detail.
al, 2010; Studer et al, 2017). This has also been Knowledge Impart the bad news clearly and simply, avoiding jargon, with
shown to result in better physiological health, for frequent pauses to check for understanding. Use a ‘warning
paramedics and patients alike, after the delivery shot’ statement first so that patients are prepared that bad
(Steen et al, 1997). The literature review shows news is coming.
that akin to other medical procedures, DN within
paramedic practice could be improved by training Emotions Allow the patient to express their emotions, using empathatic
in technical and non-technical skills in these responses to acknowledge their feelings and show support
demanding circumstances. Strategy and Make a plan with the patient for the future and summarise the
For instance, include teaching clinicians simple summary discussion, checking the patients understanding
guidelines or acronyms that are easily recollected, Source: (Baile et al, 2000)
as cognitive stressors can reduce memory
recollection (Shaw et al, 2015). Palliative care
literature emphasises the importance of behavioural often unexpected news with no prior emotional
and cognitive empathy as well as active listening resilience from the family involved.
within education to be highly valued among The lack of pre-hospital literature highlights
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© 2018 MA Healthcare Ltd

patient feedback (Vail et al, 2011). Rapport-building the need for a systematic review of DN tools and
through names, same-level eye contact and honest training drawn from multiple medical specialties.
recollection of events are all fundamental principles Beneficial facets of this tool would need to have
within the literature (Fallowfield and Jenkins, easily recalled steps (less than 10), a pre-hospital
2004). This is extremely relevant within pre‑hospital plan for recipients, and an educational intervention
care where no rapport initially exists and a DN is to implement this tool that could be adopted across

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©ADOBESTOCK/GRETALAROSA

Despite not having a significant relationship with patients’ relatives, paramedics may deliver the worst news they will ever hear

UK-based ambulance services. This would serve Douglas LA, Cheskes S, Feldman M, Ratnapalan S. Paramedics’
experiences with death notification: a qualitative study. J
to support paramedics in what is an extremely Paramed Pract. 2012;4(9):533–539. https://doi.org/10.12968/
challenging message for any clinician to deliver. JPP jpar.2012.4.9.533
Douglas LA, Cheskes S, Feldman M, Ratnapalan S. Death
Conflict of Interest: None. notification education for paramedics: past, present and future
directions. J Paramed Pract. 2013;5(3):152–159. https://doi.
org/10.12968/jpar.2013.5.3.152
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CPD Reflection Questions

llWhat are the three key mnemonics that relate to death notification (DN)?

llWhat are some of the key non-verbal tools we can use?

llWhy are ‘warning shots’ so useful in DN?​

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