DEATH FROM TRAUMA—MANAGEMENT OF GRIEF AND BEREAVEMENT AND THE ROLE OF THE SURGEON

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CHAPTER 105 DEATH FROM TRAUMA—MANAGEMENT OF GRIEF AND BEREAVEMENT AND THE ROLE OF THE SURGEON

Patricia A. Murphy, Anne C. Mosenthal

Death from trauma is a tragic event, often affecting young and previously healthy people. It is rarely peaceful or dignified. Traumatic sudden death leaves in its wake confused, disoriented, angry, sad, and overwhelmed survivors. Their reactions separate hem from life, from reality, and sometimes from caring about themselves. This is grief. When death occurs from sudden, unexpected events such as car crashes, suicide, or murder, grief reactions are more severe, exaggerated, and complicated. The griever’s ability to use adaptive coping mechanisms is limited.

Despite all life-saving efforts, trauma surgeons must occasionally deliver news of the death or impending death of the patient. In reality, 10%–15% of trauma patients who present to the hospital will die from their injuries. The majority succumb during resuscitation or surgery within hours, but others will linger in the intensive care unit and die days to weeks after injury. Physicians often are called on to communicate with grief-stricken families and support them. The manner in which this is done can have long-term consequences for the bereaved families as well as influence end-of-life decisions. Good trauma management must include knowledge of basic grief and bereavement theory as well as skills in communication of bad news.

INCIDENCE

Violence and motor vehicle crashes continue to be a leading cause of death in young people in the United States. This leaves many survivors to cope with lifelong grief and bereavement. Increasing evidence suggests that traumatic injury and death are not necessarily isolated events, but can be part of larger social conditions (poverty, substance abuse) in some communities and families. In inner city neighborhoods, children are exposed to violence and loss at an early age. This may influence a family’s ability to cope with a new loss or death. In order to care for the survivors of violent death, the trauma surgeon must be aware of the family’s loss history: Is this the first (or second, third, etc.) member of the immediate family to die violently? How has the survivor coped in the past? This assessment is essential to providing competent grief support.

Even if patients die after weeks of a long illness or injury, this is still an acutely disruptive event for the family. Some trauma patients spend weeks in the surgical intensive care unit hovering near death. During this time the family is desperate for any information that gives them hope. They ride the rollercoaster of hope and despair with every conversation they have with the trauma surgeon. They are exhausted, and frequently ignore their own needs for rest and food. If their loved one dies, it is perceived as a sudden event—even if weeks have gone by since the trauma. This is because they have probably coped using the defense of denial, and the death shatters that defense.

Profound grief occurs not only after death, but after any major loss. Even if the patient survives, grief may complicate recovery and care, especially after spinal cord injury, brain injury, or traumatic amputation where lifelong loss of function means loss of hopes and dreams and expectations. This can be devastating—families and patients may experience the same sequence of grief and coping mechanisms as is apparent after the death of the patient.

GRIEF

Bereavement refers to the objective situation of having lost someone significant to death. Throughout their lives people have to face the death of parents, siblings, partners, friends, or even their own children. Bereavement is associated with intense distress for most people. This distress is grief, defined as a primarily emotional reaction to the loss of a loved one. It includes diverse psychological and physical manifestations (Table 1).

Table 1 Manifestations of Grief

Affective	Behavioral
Despair	Agitation
Anxiety	Fatigue
Guilt	Crying
Anger	Social withdrawal
Hostility
Loneliness
Cognitive	Physiological
Decreased self-esteem	Anorexia
Preoccupation with image of deceased	Sleep disturbances
Helplessness	Energy loss and exhaustion
Hopelessness	Somatic complaints
Self-blame	Susceptibility to illness/disease
Problems with concentration

TRAUMATIC GRIEF

When the death of a loved one occurs under traumatic circumstances, the survivor’s grief is predisposed to be complicated by many factors. The suddenness of the loss, violent circumstances, preventability, and/or randomness of the event and the survivor’s sense of vulnerability to harm are all factors that complicate the grief. Sudden, unexpected, or violent death is a significant factor in complicated mourning. Researchers have studied the relationship of post-traumatic stress disorder (PTSD) and bereavement. PTSD was found among the bereaved and frequently correlated with the perceived inadequacy of the goodbye said to the deceased. The overlay of PTSD-type symptoms in some individuals who have lost someone to death from trauma may complicate the bereavement and capacity to grieve. Theorists have suggested that there are many issues inherent in sudden, unanticipated death that complicate mourning. Those relevant to trauma surgery in the acute care setting follow:

The capacity to cope is diminished as the shock of the death overwhelms the self.

The assumptive world of the mourner is violently shattered (the world as orderly, predictable, and meaningful), and causes intense reactions of fear, anxiety, and loss of control.

The loss does not make sense and cannot be absorbed.

There is no chance to say goodbye and finish unfinished business with the deceased.

Symptoms of acute grief and physical and emotional shock persist for a long time.

The mourner obsessively reconstructs events in an effort to both comprehend the death and prepare for it in retrospect.

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