Following best practice can help to facilitate normal grieving for bereaved relatives
In this article…
- How, when and where to tell relatives about a death, and who should tell them
- Honesty, sensitivity and ethics on breaking news of a death
- Advice on support, respect and privacy
Megan Reid is a staff nurse in the intensive care unit, Royal Alexandra Hospital, Glasgow; Joan McDowell and Robert Hoskins are both lecturers in the Nursing & Healthcare school, Faculty of Medicine, University of Glasgow.
Reid M et al (2011) Breaking news of death to relatives. Nursing Times; 107: 5, early online publication.
Breaking news of death can have a significant impact on bereaved relatives if it is not carried out appropriately. This article explores best practice on breaking news of death, and discusses why it is so important for nurses to get it right.
Keywords: Communication, Death, Relatives
- This article has been double-blind peer reviewed
Five key points
- Breaking news of death is one of the most stressful and sensitive tasks that a nurse will have to perform
- The amount of information about the death wanted by relatives will vary
- Information must be given clearly, and euphemisms such as “passed away” avoided
- Staff who avoid telling the truth on the telephone, and ask the family to come to the hospital, may lose the family’s trust when they find out the death occurred before they were contacted
- Relatives should be advised on practical matters after death, such as registering it and organising a funeral
Breaking news of death to relatives is a frequently performed task for nurses, and one of the most stressful and sensitive they are asked to take on. Using best practice guidelines to break news of death (see Box 1) can help prevent relatives enduring complicated grieving processes.
This article explores how news of death should be communicated, including where and when it should be delivered, and who should be the bearer of the news. It discusses the nurse’s role in this process.
Because there has been a surprising lack of research on this subject over the last five years, literature from the past 30 years has been used.
Box 1. Best practice in breaking news of death
- A doctor and nurse who are familiar with the relatives and who have provided care for the patient.
- A private, non-clinical area which can be used by the relatives for as long as they need. This needs to be a spacious room with adequate seating where interruptions will be kept to a minimum.
How and when?
- Where possible, death should be anticipated and relatives encouraged to spend time with the patient before death occurs.
- Face-to-face communication with relatives is preferable to a telephone conversation
- Consider body language. Medical professionals are advised to sit when breaking bad news and maintain eye contact.
- Assess the relatives’ existing knowledge before breaking the news
- Information should be honest and accurate, tailored to meet the family’s needs and shared in an empathetic and caring way.
- Avoid euphemisms. Words such as “dead” and “died” should be used and repeated several times.
- Respond appropriately to relatives’ reactions and give them time to ask questions. All questions should be answered.
- Prepare the family for dealing with practical matters, such as collecting the death certificate.
- If the relatives are not present when the patient dies, they should be contacted by telephone and encouraged to attend the hospital. However, if they ask if their relative is alive or dead, they must be told the truth.
Breaking news of death
When patients die, their medical practitioner has a duty of care to their next of kin and relatives (Buckman, 1992). Communicating the news of a patient’s death to a relative can be likened to breaking bad news to a patient with a terminal diagnosis. However, although both are covered by the umbrella term “breaking bad news”, the finality of death means communicating the news of a terminal illness and news of death have significant differences.
The initial communication of the death of a loved one is the first step in the bereavement process. In order to facilitate a normal grieving process, it is essential that relatives receive excellent communication and support from healthcare professionals. The way in which news is given will always be remembered by the bereaved, whether delivered well or not (Harrahill, 2005; McCulloch, 2004).
Who should communicate news of death?
Doctors have the legal authority to certify death (General Medical Council, 2009), so it is normally the medical practitioner in charge of a patient’s care who informs relatives of the death (Buckman, 1992).
However, this method was criticised by Wright (1996), who said the doctor communicating the news of death will usually be a complete stranger to the relatives. At this vulnerable time, it would be better to receive the news from an individual with whom they had established some sort of relationship and rapport, usually a member of the nursing staff.
Wright (1996) suggested this issue could be addressed by doctors continuing to break the news, but always accompanied by a nurse to provide support for the family; this nurse should be known to the family where possible.
Jurkovich et al (2000) conducted a study to investigate which of the key elements of delivering bad news were most important to surviving relatives. A survey tool was designed and administered to family members who had lost a relative, either in the accident and emergency department or the trauma intensive care unit over an 18-month period. The final sample included 54 interviews with relatives in relation to the deaths of 48 patients.
The authors found that 81% of participants were informed of the death of their relative by a doctor, with only 5% being informed by a nurse. Fewer than half (46%) of participants felt that the seniority of the news giver was of medium or high importance.
Faulkner (1998) said the responsibility of breaking bad news should rest with the person the recipient will feel most comfortable with. Lomas et al (2004) supported this, suggesting the person receiving the bad news should know the medical professional communicating it.
How and when should news of death be communicated?
Buckman (1992) created a six-step protocol for breaking bad news (see Box 2). This is based primarily on Buckman’s experiences of breaking bad news in a clinical setting, and was originally created for breaking bad news to patients. The protocol can be adapted, however, to provide nurses with a structured, organised approach to communicating with relatives.
Box 2. Six-step protocol for breaking bad news
Step 1 Get the physical context of the conversation correct. Avoid breaking the news over the telephone where possible.
Step 2 Assess how much the relatives already know about the patient’s situation.
Step 3 Find out how much the relatives want to know. It will be enough for some to simply know that their loved one is dead, others may wish to know in detail the events that lead to death.
Step 4 Provide information. This should include a diagnosis where possible, the treatment that was given before death, and an offer of support.
Step 5 Respond to relatives’ feelings. This involves using good listening skills and having an awareness of non-verbal communication.
Step 6 Prepare the relatives for what is expected of them after they leave the deceased, including advising them on practical matters surrounding the death.
Source: Buckman, 1992
The term patient is used in the original protocol, but is interchangeable with the term relative, which has been used for the purposes of this article.
Buckman (1992) stressed the need for face-to face interaction between the doctor and the recipient of the bad news.
Nurses can play a crucial role in this, particularly if they are the professional contacting the relatives. By inviting relatives onto the hospital ward to speak with the doctor, nurses can avoid the difficult situation of breaking bad news over the telephone.
According to Harrahill (2005), before the news is broken to relatives, it is good practice to assess their existing knowledge of the situation.
This provides a good understanding of exactly what information needs to be communicated. It also allows a quick assessment of the family’s style of language, enabling staff to adapt their communication style and use the most suitable vocabulary.
Nurses can facilitate this with statements such as: “I am aware you may have spoken to a number of my colleagues, tell me what you already know and I’ll try to avoid repeating what they may have previously told you”.
Harrahill (1997) said the person breaking news of death should tailor the information to the relatives’ needs and answer their questions.
It will be enough for some relatives to simply know that their loved one is dead, others may wish to know details of the events that led to death. It is in this step that nurses’ existing relationships with relatives will be useful — they may have an understanding of the relatives’ wishes regarding receiving information if they have communicated with them before.
The study by Jurkovich et al (2000) found a mixed reaction to the amount of detail families wanted. Only 13% of those studied wanted general information only, with 30% requesting far more detail.
Information should be given to relatives in an unhurried manner, giving them time to process the information and ask any questions (Cooke, 2000).
Technical language and jargon should be avoided to ensure the message is clear (Harrahill, 2005). Giving information in small chunks allows relatives to process it and reduces the likelihood of them becoming overwhelmed and not retaining any of the information (Buckman, 1992). Nurses will often have an important role in deciphering information for relatives, reiterating it and explaining any terms they may not understand.
The success or failure of the process of breaking bad news rests on how the relatives react, and how healthcare professionals respond to this reaction (Buckman, 1992). Good listening skills, and an awareness of non-verbal communication, are key to ensuring practitioners deal with relatives’ reactions in the most appropriate manner.
This stage of the process is reliant on a good relationship between the nurse and relatives, allowing the nurse to provide verbal and non-verbal support. The importance of responding to relatives’ feelings was emphasised by Harrahill (2005) who said staff need to ensure relatives have all their questions answered. It is also suggested that relatives are given contact details for the hospital to ensure they are able to contact staff if questions arise later (Harrahill, 2005).
Step 6 of Buckman’s original protocol involves planning a terminally ill patient’s future regarding treatment and prognosis. However, it could also refer to planning the future of bereaved relatives (Buckman, 1992).
This may be the first time relatives have had to deal with the death of a family member so they must be prepared for what is expected of them. Nurses can advise relatives on what will happen to their loved one next, such as the nurse carrying out last offices. They can also advise the family on when the death certificate can be collected, explain the format of the certificate, offer guidance on where to register the death and when they can begin to plan the funeral (Harrahill, 2005). The study by Jurkovich et al (2000) found that only 24% of relatives felt good attention had been paid in providing direction after death, showing this is an area requiring improvement.
After the relatives have been informed of the death, healthcare professionals staff should invite them to spend time with the deceased. According to Wright (1996), relatives feel they no longer have total ownership of their loved one once in hospital. They feel they must be granted permission to do things such as view the body, hold their hand, or speak to the deceased.
If families are not present at the time of death, they may feel guilty that their relative died “alone” and they were unable to say goodbye (Wright, 1996). This highlights the need for nurses to encourage family members to spend as much time as they wish with the deceased, allowing them to say final goodbyes, which will help to promote normal grieving processes (Cooke, 2000).
Best practice guidelines
The guidelines developed by Buckman (1992) provide direction on breaking bad news. However, Farrell (1999) argued that some families feel healthcare professionals rely too much on formulas or guidelines, resulting in the loss of a personal element with no emotion shown.
Finlay and Dallimore (1991) used a retrospective questionnaire to investigate how parents felt the death of their child was handled. Results showed that participants were more satisfied with how the news of death was communicated to them by a police officer than a nurse or doctor. These families felt they received a greater sense of empathy from police officers, who restrained their emotions less and appeared to be visibly upset when breaking the bad news. This gave the relatives the impression that the police officers had connected to them on a personal level (Finlay and Dallimore, 1991).
Buckman’s protocol is widely followed by medical professionals, however the suggestion that information should not be imparted to relatives until step 4 conflicts with the opinion of another researcher; Harrahill (1997). Harrahill (1997) said the death of the patient should be spoken of early in the conversation to prevent suspense building. This suggests that in some scenarios professionals should modify the guidelines, communicating the news earlier in the conversation, to avoid unnecessary apprehension.
The death of a relative is a traumatic time. Family members must receive clear, understandable information from a knowledgeable member of staff who is not afraid to speak of the death in an empathetic manner (Fallowfield and Jenkins 2004; Jurkovich et al 2000; Wright 1996).
Euphemisms, such as ‘passed away’ or ‘we lost them’ should be avoided as these are open to misunderstanding. Words such as ‘dead’ and ‘died’ must be used and repeated several times to ensure relatives understand what is being said and the message is clear (Cooke 2000; Harrahill 1997; Wright, 1996). The need for this is highlighted by Jurkovich et al (2000) who found that only 52% of the family members studied felt they were told clearly that their relative had died.
The literature is inconclusive on the dilemma often faced by nurses left in charge of wards – “do I break bad news over the phone or do it face-to-face?”
Telephone communication is not the preferred method of breaking news of death, because relatives may have no support to hand immediately after receiving the news (Kendrick, 1997). Wright (1996) suggested that if the hospital is near to the relatives, it is best to tell them face to face. However, this leaves nurses with the ethical dilemma of having to lie to relatives or avoid the truth. Kendrick (1997) suggested that lying in this situation can be ethically justified as staff are trying to prevent harm to the relative, and are trying to provide the best possible environment for the news to be given.
However, staff may feel uneasy about lying, and may feel unable to do it due to their own morals. Wright (1996) said that if the relatives live some distance from the hospital it is essential to be honest and disclose the news of death. This is to to prevent them rushing to the hospital, possibly endangering themselves.
However, Buckman (1992) said it is essential that healthcare professionals do not imply or state that a patient is alive if they are not. If asked a direct question about whether the patient is alive or dead, nurses must answer honestly, regardless of where they are in the process of breaking the news (Buckman, 1992).
If news must be broken over the phone, the informer should identify themselves at the beginning of the conversation and be certain of the identity of the relative, ensuring it is an adult (Harrahill, 1997).
When calling a mobile phone, it is essential to establish the location of the relative is established to ensure they are not driving or in an inappropriate place. If this is the case, they should be encouraged to move to a private, safe place where they can be called back (Taylor, 2007). This will act as a warning and help prepare the relative for the news to follow. The nature of a telephone conversation removes non-verbal support so it is essential to listen intently and respond appropriately to relatives’ reactions when breaking bad news (Taylor, 2007).
Although older literature mentions the need for support when attending the hospital (Adamowski et al, 1993; McLauchlan, 1990; Dubin and Sarnoff, 1985), it does not seem to have the same significance in recent literature. It is common sense to advise the next of kin to bring support, and it may not be included in protocols because it is done so routinely it is assumed healthcare professionals will do this.
Healthcare professionals know it is better to break bad news in person. However, by lying or avoiding the truth on the telephone they may lose the trust of the patient’s family when they find out that the time of death was before they were contacted. This has implications for nurses, particularly since the Nursing and Midwifery Council Code of Conduct states that nurses “must be open and honest, and act with integrity” (NMC, 2008).
The importance of body language should be considered throughout the conversation. Harrahill (2005) suggested that medical professionals should be seated, if possible, whilst breaking the news of death in order to reduce any “medical team intimidation” that the family may feel.
Regardless of the setting, medical practitioners should try and face the people they are communicating with squarely, with uncrossed arms and good eye contact. Undoing jackets or laboratory coats can also help create a sense of openness (Harrahill, 2005). The study by Jurkovich et al (2000) found that touch - through hand holding, hugging or a gently placed hand - was unwanted in 30% of participants, but 17% desired this human touch. The researchers noted that this may be gender dependent as those that objected to touch the most were men. Jones and Buttery (1981) found that relatives of patients who had died suddenly felt that being touched supportively and compassionately was beneficial to them. Additionally, McLauchlan (1990) said it is a natural reaction for staff to comfort the relatives by touching them or holding their hand. Radziewicz and Baile (2001) agreed, believing that touching may be supportive.
Where should relatives be told of death?
Best practice guidelines state that when giving bad news to others, a private, non clinical area should be used with interruptions anticipated and avoided.(Lomas et al, 2004; Department of Health, 2005; Harrahill, 2005; Cooke, 2000)
Wards will often have a dedicated relatives’ room and this should be used where possible. If no such room is available, the ward manager’s office can be used. There should be ample space for the family and healthcare professionals, with chairs provided for everyone.
Before inviting the relative to the room, it should be to avoid the embarrassment of a taking them to a dirty or occupied room (Harrahill, 2005). After discussions with the family, the room should be made available for them to stay for as long as they need to compose themselves (Lomas et al, 2004).
However, these guidelines are not always followed. Jurkovich et al (2000) found that 19% of study participants described the attention given to the location of their conversation as poor. The study also found that 56% of participants felt the location of the conversation was of medium or high importance.
Farrell (1999) said public disclosure of bad news shows a lack of respect and consideration. This can have wider implications for families, such as a lack of confidence in other aspects of care.
Excellent communication skills when breaking news of death are essential. The importance of both verbal and non-verbal communication should be recognised, along with the significance of setting and attitudes of staff.
It is widely recognised how important good communication is when breaking news of death, but quality research on this subject is lacking. The available guidelines and ideas around best practice are somewhat dated and do not appear to be evidence based. More research is needed to ensure conveying news of death is carried out appropriately.
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