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:

image The capacity to cope is diminished as the shock of the death overwhelms the self.
image 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.
image The loss does not make sense and cannot be absorbed.
image There is no chance to say goodbye and finish unfinished business with the deceased.
image Symptoms of acute grief and physical and emotional shock persist for a long time.
image The mourner obsessively reconstructs events in an effort to both comprehend the death and prepare for it in retrospect.
image The mourner experiences a profound loss of security and confidence in the world and increasing anxiety.
image The loss cuts across experiences in the relationship and tends to highlight what was happening at the time of the death, predisposing to problems with unrealistic recollection and guilt.
image The death tends to leave mourners with relatively more intense emotions, along with a strong need to determine blame and affix responsibility for it.

GRIEVING ACROSS THE LIFE SPAN

Numerous authors have defined “tasks of mourning” as activities that facilitate the resolution of significant loss. Adults and children experience grief after a loss, but the manifestations are developmentally determined (Table 2). It is important to recognize the different ways that children express grief; the age of the child is an important determinant and should be taken into account when information is shared and support provided.

Table 2 Tasks of Mourning: Children versus Adults

Adult’s Tasks of Mourning Child’s Tasks of Mourning
Accept the reality of the loss. Understand that someone has died.
Experience the pain or emotional aspects of the loss. Face the psychological pain of the loss.
Cope with periodic resurgence of pain.
Adjust to an environment in which the deceased is missing. Invest in new relationships.
Develop a new sense of identity that includes experience of the loss.
Emotionally relocate the deceased (this relocation process still allows for continuing bonds to the deceased). Reevaluate the relationship to the person who has died.
Return to age-appropriate developmental tasks.

Special attention should be paid to bereaved children because there is often confusion about age-appropriate information and support. In working with children, you must remember that a mature understanding of death is tied to the cognitive capacity to understand that death is permanent. This occurs in children at about the age of 5. The child’s developmental needs help to define the significance of the loss.

Simple, clear information about the young child’s reaction to the death should be given to the primary caregiver. Printed, easily understandable information should be given to caregivers to take home. Iverson has published a simple but complete list of adult behaviors that are helpful to young children. It is essential that the child be told the truth in words that he/she can understand. Real words should be used to describe what has happened, such as, “Your mom was in a terrible car crash. The doctors have worked real hard to try and fix her but her body just stopped working and she died.” Children take their cues from their adult caregivers, and closely watch adults’ reaction.

Some basic principles for grief in children follow:

image Children as young as 3 years can understand the concept of death.
image Do not tell children the dead person has gone away or is sleeping, as this will only confuse them.
image Use real words to describe the death.
image Answer the questions that the child asks. When a death occurs, children often worry about 3 issues: Did I make it happen? Will it happen to me? Who will take care of me?
image Give the child the opportunity to attend the family ritual surrounding death. If the child asks to attend, that usually means he/she is old enough to do so.

MANAGEMENT OF ACUTE GRIEF AFTER TRAUMATIC DEATH

The sudden and often violent nature of death from trauma can lead to complicated mourning as described previously. However, certain strategies for support and communication can and should be applied in the immediate situation that may facilitate long-term coping and bereavement. These can be divided into three time frames around the death of a patient: support for family contact with the dying patient prior to death, communication of bad news and death notification, and facilitation of postmortem rituals and time with the deceased. While the physician may not be primarily responsible for bereavement support immediately after death, he/she is usually called on to deliver bad news and can facilitate other members of the health care team to support the family.

Because the inability to say goodbye is associated with PTSD and complicated grief, the surgeon should offer the survivors an opportunity to see the patient before death if at all possible. Reliable research supports having family members attend resuscitation; of course, this applies only if they want to attend. They should be brought into the room two at a time and never left unattended. This process allows the family to witness attempts to save the patient’s life and also prepares them for the eventual death. This process creates opportunities for the family to say goodbye. Not all families want to be present, and not all resuscitations are amenable to family presence. What is most important is that a bereavement support person who is not caring for the patient must be free to accompany the family. This can be a social worker, pastoral caregiver, bereavement counselor, nurse, or other experienced member of the team.

Communication of bad news or death of the patient to surviving family members is one of the most difficult tasks of the trauma surgeon. Research has demonstrated that the manner in which this is done is long remembered by families, and will affect their lifelong bereavement. However, several studies have revealed some simple, yet important skills for compassionate and effective communication in this setting. First, create an appropriate setting for delivering the news: it should be private, quiet, and secure. Prepare yourself as to the identity of the family members and their relationship to the patient. Do not assume that family members already know their loved one has died, even if they have witnessed the event. Your news will come as a shock, so for this reason it is helpful to give a warning shot: “I am afraid I have bad news.” Then follow with a clear, direct statement about the death of the patient. Avoid vague euphemisms such as “passed away,” “passed on,” or “we lost him”; instead, use the word “died” or “dead.” Elaborate explanations of medical details at this time are confusing; time is needed for the news to sink in first. Listen and provide support by acknowledging the family’s emotions. Then allow time for questions if they arise. Reassure family members that they can see and spend time with the deceased, and provide a plan for follow-up support and questions. Family-support personnel, social workers, and pastoral caregivers can and should be called in during this process (Table 3).

Table 3 Cardinal Rules for Communication of Bad News

Include communication with the family and bereavement support in routine trauma care after death of the patient.
Provide timely and straightforward information.
Give families frequent updates, even if there is no significant new information.
If you have bad news, fire a “warning shot.”
If you have inconclusive news, invite people to “hope for the best and plan for the worst.”
Always pledge constancy: “I (we) will stick with you through this regardless of what happens.”
Remember that people are usually tougher than we give them credit for.
Remember that good information enables most people.
Know your limits and get help.
Use the knowledge and skill of colleagues who specialize in bereavement work.
Avoid giving advice about what the family should do that is not based on evidence or best practices.
Remember that the more someone differs from you (age, ethnicity, religious orientation, etc.), the less you can rely on your empathy to know what they feel or want or value.

After sudden death, there is usually no chance for the family to say goodbye while the patient is alive or conscious. The only chance is in the immediate aftermath of the news, and this is often in the hospital or emergency room. As the ability to say goodbye to the deceased is correlated with a positive bereavement outcome, the opportunity to see, touch, and hold the deceased is especially important after trauma and should be provided as soon as possible. Many physicians are concerned about this in circumstances when there is mutilation or disfigurement. There is no research data in the grief literature to support the idea that family members are harmed by viewing the body of their dead loved one. One of the authors (PM) has been involved in family support in trauma services for more than 20 years. In all that time no family member ever reported an adverse reaction to viewing the body. It is important that the family be prepared for what they are going to see, that is, all physical trauma should be explained in advance, and the body cleaned and covered. Usually the family can and should decide how much they can handle. The worst thing that could happen, the death, has already happened! The role of the health care team is to support them as they cope with the tragedy. Do not leave them alone, unless they ask to be alone. Encourage them to cut a lock of hair, sit with the body, and ask if they want a clergy person to be with them. This is particularly important for parents after the death of a child, and they should be supported if they wish to hold the child. However, if the family continually declines to view the body, they should not be coaxed into doing so.

COMPLICATED GRIEF

There are many characteristics of acute traumatic grief that can lead to complicated grief. Death that is sudden and unexpected, violent, mutilating, and random can lead to complicated grief reactions. Often the griever has some of the following complications: cognitive dissonance, murderous impulses and anger, guilt and blame, and emotional withdrawal.

Cognitive dissonance occurs because the mind is overwhelmed with events prior to, during, and after the event. There is a constant rehearsal of the event, and the person continually asks when, how, where, who did what, and the unanswerable “why(???).” The most helpful intervention involves giving the person whatever information you have and referring them to others who may have the answers to their questions. They may ask the same questions over and over, and sometimes the only answer is “I don’t know.” Often there is no answer to their questions, but they need to keep asking.

Many survivors have murderous impulses and anger toward whoever they think caused the death. If the death was caused by someone in the commission of a crime, such as an auto accident caused by a drunk driver, assault, and shooting, then the normal anger of grief is compounded by rage, and the desire to violently destroy whoever is perceived as the cause. It is in the venting and verbalizing of some of theses impulses that the anger begins to lose some of its intensity. It is important to remember that thoughts that can be expressed do not have to be acted out.

Guilt is intricately embodied with a sense of control and the search for a reason. The traumatic loss is internalized, and the barrage of “If only’s” is endless. Human beings seek to blame others or themselves in order to make sense of the tragedy and to confirm a sense of control over their lives. Family members often blame each other. Immediately following the loss, this dynamic is expected and part of the process. If it persists for more than 3 months, professional help may be necessary to resolve the loss.

Emotional withdrawal often occurs as members of the family withdraw from each other. They nurse their own psychic pain and grief separately. Individuals may also withdraw from friends and activities that provide comfort and support because they believe that no one else could ever imagine their level of pain and despair. Often survivors have thoughts of suicide as an attempt to avoid the intense pain.

Complicated grief requires specialized interventions beyond the scope of this chapter and beyond the scope of practice of surgeons. What a surgeon must know is that there is help available and how to access that help. Every hospice program offers support groups for bereaved individuals that are open to all in the community. In addition, hospital pastoral care departments can be very helpful in complicated grief situations. Do not hesitate to reach out to other professionals for help.

SUGGESTED READINGS

Buckman R. How to Break Bad News: A Guide for Health Professionals. Baltimore: Johns Hopkins University Press, 1992.

Iverson K. Grave Words: Notifying Survivors about Sudden, Unexpected Deaths. Tucson, AZ: Galen Press, 1999.

Jurkovich G, Pierce B, Pananen L, Rivara F. Giving bad news: the family perspective. J Trauma. 2000;48:865-873.

Mosenthal A, Murphy P. Trauma care and palliative care: time to integrate the two? J Am Coll Surg. 2003;197:509-516.

Murphy P, Price D. Dying and grieving in the inner city. In: Doka K, Davidson J, editors. Living with Grief: Who We Are, How We Grieve. Washington, DC: Hospice Foundation of America, 1998. Philadelphia, Brunner/Mazel

Oliver RC, Sturtevant JP, Scheetz JP, et al. Beneficial effects of a hospital bereavement intervention program after traumatic childhood death. J Trauma. 2001;50:440-448.

Rando T. Treatment of Complicated Mourning. Champaign, IL: Research Press, 1993.

Redmond L. Surviving When Someone You Love Was Murdered. Clearwater FL: Psychological and Educational Services, 1990.

Stroebe M, Hansson R, Stroebe W, Schut H. Handbook of Bereavement Research. Washington DC: American Psychological Association, 2001.

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