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Letting a Loved One Go: When Someone Dies in the Emergency Room (Part 2)

by Douglas S. Phillips MDiv BCC
 
APC Forum, May 2019, Vol. 21 No.3

 
Part 1 of this article was published in the April 2019 edition of the APC Forum.

Is the ER busy and the hospital room will be needed quickly?  Or did the death happen at a “quiet” time of day and there is less time pressure, so the family can linger with their loved one?

Time of day, the overall busyness (or lack of same) of the ER, along with the medical condition of the deceased are critical factors in determining how much latitude a family can have in remaining in the room with the body of a loved one.  It is recommended that your hospital adopt a formal or informal policy for how long you will allow a body to remain in the room after pronouncement.

Official Policies are good to have in place, if even to fall back on when needed.  The hospital where my colleague Paul Bryant Smith works  has an official policy about this.  He often says to a family after their loved one has died “We would like to give you all the time you need to be with your loved one, but the Department of Health allows us only two hours from the time s/he was pronounced before we have to take him/her to the morgue.  While you are here with us, I will be with you as much or as little as you need me to be.”

This is important for several reasons.  First, often families are in shock and they are not in the position to make decisions about what to do next after a loved one dies.  It is important for hospital medical staff to let families know if an autopsy is needed or required.  If the patient has died as an act of criminal violence, that patient’s body becomes a crime scene. Often families will not be allowed to touch the body.  Or if family is allowed near the body, the police are in the room with them.  Naturally, this will affect the family’s grief process.

As mentioned previously, in the midst of a sudden and unexpected death, after the doctor tells the family how their loved one has died, the family doesn’t absorb much of the information.  So chaplains present with the families should be prepared to have the doctor come back and reiterate the circumstances and be prepared to answer more medical questions.
 
If the Medical Examiner will take the case for an autopsy, it typically delays the time when the body will be available for burial by a day.

Families will also need to know about burial arrangements. They should simply choose a funeral director who will help them through the process and who will receive the body from the morgue.
         
If the patient’s death has occurred in an ER Trauma room at a busy time, often the body will have to be moved to another place.  Family members should be sent to the waiting room while this transfer is taking place.  The new space should be large enough to accommodate them, but a time and space limit must be set.  One of the realities of modern day social media is that word of a family death gets out quickly and emergency rooms can quickly become inundated with large numbers of family and friends present. It is important to have a hospital policy in place setting guidelines for how many visitors are allowed at a time in a patient’s room.  If it is a trauma room in a busy ER, the safety and anonymity of other patients and families can’t be compromised by allowing large numbers of visitors to linger outside in the hallway.

When I am with a family who has suffered a death, in getting the word out, I recommend that if they want someone present with them quickly, call only those whose helping presence is crucial and who can arrive within an hour.  The danger with having many people coming from far away is that it overwhelms the family and the ER staff. The danger is that it can also become a wake. ERs are not funeral homes.  They can accommodate grieving families to a degree, but the business of caring for the living remains paramount. Eventually the body must be moved and the room will be needed for a new patient.

As well, it is important to honor the memory and appearance of the deceased loved one.  The longer the body remains in the room, the more it takes on the appearance of death. The body cools and stiffens.  The skin loses color. Mouths and eyes remain open. Chaplains should be prepared to call upon medical personnel to temporarily remedy these further indignities , but not for too long.  The family can be further traumatized by having to witness this deterioration for extended periods.   As well, children under 12 should be discouraged from viewing the unprepared body of a loved one.
  
Do not be surprised by family’s initial reactions to seeing their loved ones’ body.  Reactions can range from stunned silence to family members throwing themselves on the body, shaking it, crying and screaming. Unless there is danger with the body falling to the floor, let families grieve as they need to.
         
There are subtle signs I’ve observed through the years that indicate when a family has seen enough of the deceased’s body and are ready to leave the hospital for home.  First, overt acts of mourning decrease. The family becomes quieter and less agitated, even when newcomers arrive.  There is less back and forth visitor migration between the trauma room where the body is and the waiting room where the family has gathered.

As well, no additional visitors have arrived in a while and the family speaks of no more coming. Discussion among them transitions to questions about “How will we tell (name) at home about this?  We can’t bring him here to do it.  Somebody will have to tell him at home.”  Family members realize they can’t deliver the news by telephone, so they understand they must leave.  Or sometimes the family simply gets up and leaves on their own, quickly and unexpectedly.

But one of the more curious signs in which families hint they see the remains of their loved one now as more of a body  than their spirit happens like this:

First, as chaplains, we work with the medical staff to prepare the room where the patient has died for the family to visit.  It’s good to have chairs on hand around the patient’s bed and in the room.  It’s also important to watch family closely when they first see the body, because sometimes family members pass out. A well placed chair is important, as are tissues and water. (As said before, a cup of cold water has a steadying effect). 

Boxes of tissues should be placed on tables nearby the bed. I’ve noticed after a family has spent time gathered around the bed, the tissues move from the tables to the bed.  And when the tissue boxes move from the bed to be left on the patient’s body, the family is showing signs of transitioning from seeing that person as their loved one, to it being a body on a bed.  It implies a certain recognition that the spiritual essence of that loved one has left the room and only their body remains behind. 
         
The first time I saw this, I thought it was an aberration. But I’ve seen it happen time and time again.  It’s a sign that the family is beginning to think about funeral arrangements.  Or they’re exhausted and now realize it. Or they know they will have to go to the homes and break the bad news to family members who were not, or could not be notified by telephone. 

When it comes time to let go of the body and there is reluctance on the family’s part, ask for a nurse to be present and for him/her to receive the body. As a way to reassure them of their loved one’s dignity and safety, I tell the family that we will treat their loved one as if they were our own family member. Even in their absence, we will be present with them after they leave.

This time of letting go and departure also offers the opportunity to pray with the family and offer some sort of brief end-of-life ritual. Depending on the family’s spiritual tradition, it is good to read appropriate spiritual texts, offer a prayer of committal and to speak a benediction.

Then it is good to offer the family a few more minutes of time alone with the body for their final goodbyes. Encourage other family members to go to their cars and be ready to pick up the remaining family from the ER entrance. Stand outside the trauma room. Give them a short time and go back into the room and offer to escort them to the door.

When they are ready to leave, make sure arrangements have been made to ensure the family won’t have to pay for parking.  If parking is nearby, it would be a loving gesture to escort them to their cars.  Encourage family members to ride with one another so that no one will be alone, unless they desire to be. Encourage other family members to stay together so that no one will be alone that first night, as well.

Another way to help the family segue from the hospital back to their homes is to offer a packet of resource literature on grief.  As well, a recent development in providing memories of the deceased is to make ink handprints, final EKG readings and allowing the family locks of the patient’s  hair.  As an act of hospitality, many ERs offer trays of food for a grieving family.  Even if the family doesn’t eat it, the staff always will.

Before they leave, what if the family wants to stay long enough to see the body wrapped up and taken to the morgue?  That would be possible only if allowed by the medical staff, but it is not a pleasant sight to see and those who do this work would prefer families not to be present.  A better solution would be to allow the family (especially if the patient was a child) to simply wash the patient and leave it at that.

Unless there are extenuating circumstances with the family, visiting a patient’s body in the morgue should be discouraged. Seeing a loved one in this advanced state of deterioration can be traumatic, and further wounding by the sights and smells of most morgues.  It is better to encourage the family to wait until the body has been prepared by the funeral director.

After the family has gone and you’ve walked them to their cars and arranged safe passage from the parking lot, if it feels appropriate, you can also suggest that they visit a place where their loved felt peace and joy.  I’ve often heard families say that they experience the presence of their loved one when they do this. My chaplain colleague Stephen Ott gave me this suggestion.  I have recommended it myself and have heard families speak of the value of such a visit.

When you’re done with the family,  it is good to follow up with your staff and help them process what they have seen, felt and heard.  Especially keep in touch with those who were especially affected, particularly young and new staff. (Everyone remembers their first death).  As chaplains, we owe it to those with whom we share this journey to watch out for them, just as they watch out for us.

What is appropriate follow up with family? Decide how much or how little (if at all) it feels appropriate to stay involved with them.   In addition to offering the previously mentioned literature resources and family handprints, if you have developed a relationship with the family, it would be appropriate to follow up with a call afterwards.  Or else, go to either the viewing or funeral.  Perhaps you may even be called upon to perform the funeral. If you’re not performing the service, and you are looking to connect more with the family, it is generally better to go to the viewing rather than the funeral. You have a better chance to spend more quality time with the family and it is less of a time commitment than to stay for an entire funeral.

Finally, a welcome gesture of hospitality and remembrance would be to call the patient’s family on the date of the patient’s birthday. That sort of information can be easily obtained from the family and friends present either in the room or during the viewing. And particularly, if weeks to months have elapsed since the patient’s death, the family is grateful to have their loved one remembered.  



Douglas Phillips M.Div BCC is a Trauma Chaplain at Westchester Medical Center in Valhalla, New York.