Notification of Unexpected, Violent and Traumatic Death: A Systematic Review

Practical strategies for care of individuals impacted by suicide in the emergency department: A narrative review

Introduction Suicide is among the leading causes of death and nurses care for survivors of suicide at many points in their grief journey. Every individual who dies by suicide leaves behind multiple affected survivors and how they are cared for immediately following the suicide influences how they cope with the death. The purpose of this article is to make recommendations for the care of survivors of suicide loss in the emergency department.

METHODS

A narrative review of the current literature was conducted using the databases CINAHL and ProQuest. Articles focused on survivors of suicide loss and their care in the immediate period after the death were utilized.

RESULTS

Four hundred and twenty-nine articles were found. Applying established inclusion and exclusion criteria and quality assessment using the SANSA guideline, 29 were included in the review.

DISCUSSION

Three themes were identified: 1. Risks for suicide in survivors of suicide loss; 2. Interventions in the immediate period after suicide loss; and 3. Active suicide postvention as suicide prevention. Emergency department nurses need to have the ability to readily assess and recognize the survivors of suicide loss who are at higher risk for complicated grieving, and providing rapid and immediate services and resources will help promote coping and positive mental health outcomes in survivors.

Breaking the news of the violent death of a close person to children under 18 years of age: A qualitative interview study

Children who lose a close person to suicide or homicide will most likely receive this news from a carer. The caregiver's personal beliefs and approaches to addressing the topic will influence the child. A total of 10 interviews were conducted with carers of children aged 0-17 years, and the data were analyzed using reflexive thematic analysis. Four themes were developed, exploring: (1) how carers attempted to manage the task of delivering the news of death to the child and discussing it using careful wording; (2) how some carers' desire to protect the child from the truth hindered honesty and open conversations; (3) how and why some carers deliberately challenged societal taboos; and (4) how external influences prompted conversations about the topic. The discussion projects potential consequences for the children and their families. It also derives necessary societal changes, support measures, and further research suggestions.

The Disclosure of Bad News Over the Phone vs. in Person and its Association with Psychological Distress: a Systematic Review and Meta-Analysis

BACKGROUND

Communicating bad news such as a new cancer diagnosis to patients may have a major impact on their well-being. We investigated differences in patients' psychological distress due to the disclosure of bad news by telephone compared to in person in a systematic review and meta-analysis.

METHODS

We included all studies that investigated anxiety, depressive or post-traumatic stress disorder (PTSD) symptoms in adult patients in whom bad news by telephone compared to in person were disclosed. We systematically searched PubMed, Embase, PsycINFO and CINAHL from the inception of each database to October 18, 2022. We included randomized and non-randomized trials.

RESULTS

We screened 5944 studies and included 11 studies in the qualitative analysis and 9 in the meta-analyses, including four randomized controlled trials. Overall, the quality of studies was moderate to good. There was no difference regarding psychological distress when bad news was disclosed by telephone compared to in person with similar symptom levels of anxiety (3 studies, 285 participants; standardized mean difference [SMD] 0.10 [95% CI -0.15 to 0.35]), depression (3 studies, 284 participants; SMD 0.10 [95% CI -0.30 to 0.49]), and PTSD (2 studies, 171 participants; SMD -0.01 [95% CI -0.48 to 0.36]). Results were similar for satisfaction with care.

DISCUSSION

This meta-analysis found no difference regarding psychological distress regardless if bad news were disclosed by telephone or in person, but there were overall only few and heterogeneous studies with a small number of eligible patients. The findings suggest that the modality of disclosure might play a secondary role and the way in which the bad news are communicated might be more important.

Best Practices for Notification of Unexpected, Violent, and Traumatic Death: A Scoping Review

BACKGROUND

Death reporting is a delicate task. The ways in which it is carried out can have a significant impact on both the recipient and the notifier, especially in the event of a sudden, violent, and traumatic death. Empathetic, sensitive, and attentive communication with survivors can represent a first opportunity to support the bereavement process. The acquisition of specific skills for the delivery of the death notification is necessary for the professional who carries out the communication to increase self-efficacy, knowledge, and perception of competence in this area.

OBJECTIVE

To map what the literature has produced on the theme of best practices for the notification of unexpected, violent, and traumatic deaths and to provide guidance for the formulation of appropriate best practices and the development of effective educational programs.

METHODS

A review was conducted using the PRISMA Scoping Review extension on English language literature published between 1966 and 2022.

RESULTS

Starting from the initial 3781 titles, 67 articles were selected. From a thematic point of view, the analysis of the contents made it possible to identify five dimensions: (1) general guidelines in relation to various professional figures; (2) specific protocols; (3) guidelines for notifying death to children; (4) guidelines for notification of death by telephone; and (5) recommendations and suggestions for death notification training programs.

DISCUSSION

Death notification is configured as a process, divided into sequential phases. The act of notification constitutes the central phase during which communication is carried out. The communication of death is context-specific; therefore, it should require the creation of specific protocols for the various professions involved in the task, along with targeted theoretical and practical training.

CONCLUSIONS

The importance of defining specific guidelines for the various professionals and standardized programs of theoretical and practical training emerges. The implementation of future sectoral studies will allow evaluations of the effectiveness of these protocols and programs.

Effects of patient deaths by suicide on clinicians working in mental health: A survey

In the UK, at least a quarter of suicides occurs in patients whilst under the care of mental health services. This study investigated the effects of such deaths on non-medical mental health clinicians. An online survey was conducted within a single NHS mental health Trust to elicit both quantitative and qualitative responses from staff across a range of professions. The survey focused on personal and professional impacts and available support. Participants reported significant negative emotional and professional effects that were long-lasting for some. These included mental health difficulties, loss of confidence regarding clinical responsibilities, and actual or contemplated career change. However, there was also some evidence of positive effects and professional growth. Support from colleagues and line managers is clearly important following deaths of patients by suicide. Clinicians' experiences of the support they had received in the workplace were polarized, suggesting that there is no single nor ideal approach that will meet everyone's needs. Participants made recommendations for the types of support that may be helpful. Most commonly, clinicians desired opportunities for focused reflection and support and help with the formal processes following the death. Sensitivity around how clinicians are notified about the death was highlighted as being particularly important. Conclusions are drawn as to how training institutions and employers can help staff to be better prepared for the potential occurrence of patient suicides and the formal processes that follow, with a view to mitigating risks of more serious harm to staff and hence indirectly to patients, and potential loss of highly trained clinicians to the workforce.

Communicating Unexpected and Violent Death: The Experiences of Police Officers and Health Care Professionals

BACKGROUND

The notification of unexpected and violent death represents a challenging experience for police officers and health workers. These professionals are exposed to very intense emotions during this task.

AIM

We aimed to investigate the degree of preparation, and the emotions and attitudes of police officers and health professionals while communicating such a death.

METHOD

An ad hoc online questionnaire was created and disseminated through Qualtrics software. The participants were recruited through the institutional channels of Police, the College of Physicians, the ONG De Leo Fund and the Department of General Psychology of the University of Padua. In this qualitative study, thematic content analysis was used to examine the responses.

RESULTS

A total of 155 individuals participated in the study (44 females, 111 males): 102 individuals were police officers, 23 were doctors and were 30 nurses. Five main themes were identified: (1) how the communication took place; (2) the experiences during the communication; (3) the difficulties encountered; (4) coping strategies, and (5) forms of support. Most communications were performed in person, and most represented an intense emotional experience for the notifiers. There is a generalised lack of specific preparation and training for this practice. The recipient's characteristics (culture of origin, language, age, health conditions, psychological vulnerability) may add to the difficulties of the notification process. Professionals unload their tension by practicing sport, relying on their hobbies or interacting socially. The presence of other colleagues during and after the death notification is usually able to alleviate the burden of the communication.

CONCLUSIONS

Communication modalities can have a profound impact on the recipients and intensify the trauma of the loss; however, they also have the possibility of mitigating it. The notification of a violent and unexpected death remains a difficult and challenging task for the notifier, which is potentially stressful and emotionally charged. The topic is of great relevance and more research should be promoted in this area.

Receiving Notification of Unexpected and Violent Death: A Qualitative Study of Italian Survivors

(1) Background: The loss of a significant person can be especially traumatic when death comes without warning and is due to causes such as suicide, murder and accidents. The way an individual is informed about the loss can affect the way of adapting to the loss and the quality of life of survivors. Communication modalities of the notifier may deeply influence the bereavement process. Aim: The present investigation aimed to explore the experience of those who received communication of such a type of death by a professional figure. (2) Method: Snowball sampling was used to recruit the participants to this qualitative study. Social networks, word of mouth and researchers' acquaintances were used, including clients of the NGO De Leo Fund. A total of 52 Italian people (eight males and forty four females, mean age = 49.44; SD = 14.23) who received notification of the death of a loved one by police officers or by health professionals participated in the study. Deaths involved cases of suicide, murder, road accident and mountain accident. (3) Results: The following four key themes were identified: (a) how the communication took place; (b) reactions; (c) support; and (d) coping strategies. Only 22 participants reported having received clear information about the dynamics of what happened; the rest of the sample obtained only poor or ambiguous information. The majority of participants sought or received informal support from family and friends immediately after notification; however, some participants experienced a total lack of support. The opportunity to see the body of the loved one for the last farewell, when denied, caused discomfort in recipients of the news. (4) Conclusions: Even the impactful notification of a traumatic death such as suicide or road accident can be mitigated by the appropriate behaviour and attitude of notifiers, who should always avoid providing generic or ambiguous information about what happened. The notification process should not end with the simple transmission of the communication, but should also look at the following phases by including referral to supportive networks or bereavement services, aimed at assisting individuals in the immediate aftermath but also in the long term.

Re-Conceptualizing Bereavement Care Practices: Insights Gained from Service Providers

The management and delivery of bereavement care and support services present practical challenges. A national-level, qualitative study was conducted to examine the current practices in Singapore. The study's purpose was to inform bereavement care practices by drawing from perspectives of service providers offering death, dying and bereavement-related services. This qualitative study was undertaken using focused group discussion (FGD) with service providers from the health, social and death-related sectors. Ten FGDs were conducted with a total of 69 participants. Thematic analysis yield two themes - identifying challenging circumstances to provide bereavement care and strategies for dealing with the gaps in service delivery. The service providers' experiential knowledge could be borrowed to strengthen the current bereavement care practices for the good of the community. The findings have informed the reconceptualization of a local bereavement care and support service model, with the public health model as the recommended underpinning conceptual framework.

The "CONNECT" Protocol: Delivering Bad News by Phone or Video Call

The COVID-19 pandemic has changed the principles of communication within the health-care setting. Communication skills as developed for use in the context of a direct and personal encounter have become insufficient. As a result, numerous health professionals came to believe they were not sufficiently prepared to deliver bad news in relation to medical care. The CONNECT protocol is a tool designed to help health-care professionals in the delivery of such messages. The name of the protocol is an acronym derived from C – context, O – organization, NN – near and niceties, E - emotions, C – counseling, T – taking care. The objective of the protocol is to improve the effectiveness of the delivery of bad news in relation to medical care by ensuring proper organization of the key elements of the encounter with the patient and/or their family.

The Impact of Police Behavior During Death Notifications on Mental Health of the Bereaved: A Cross-Sectional Study

The delivery of death notifications may affect the mental health of bereaved individuals. Police officers are often the first people with whom the bereaved have contact in this exceptional situation. Therefore, it is essential to assess the behavior of police officers and the impact on the bereaved. We examined the experiences of 86 individuals who received the notification through the police and assessed symptoms of prolonged grief, depression, and posttraumatic stress symptoms. The interaction with police was associated with posttraumatic avoidance behavior and the presence of another supporting person was associated with higher scores of depression. Handing out information material and staying with the bereaved was related to a positive evaluation of police behavior. It appears important to identify helpful and problematic behavior for a better understanding and for an adaptation of existing guidelines.

An Evaluation of a Suicide Prevention E-Learning Program for Police Officers (COPS): Improvement in Knowledge and Competence

Background: Police officers are at high risk for mental and physical health problems and suicidal ideation. The specific risk factors are numerous and concern stressful missions and administrative aspects of the police profession. So far, the police get only little training on specific missions as well as on coping with stress and suicidal ideation in the police profession. In this study we test the efficacy of the online training COPS (Coping with Suicide) for police officers. Methods: A total of 142 police officers from Germany and Switzerland participated in the study; complete data (baseline and post) are available from 102 participants. The training consisted of three modules covering the topics of delivering death notifications, dealing with individuals with suicidal ideation and dealing with one's own distress and suicidal ideation in the police profession. The primary outcomes are perceived knowledge and self-rated competence regarding the contents of the program, actual knowledge as well as symptoms of depression and anxiety (PHQ-9), and attitudes toward suicide (ATTS). The data are collected at baseline and after completing the training. Results: We found a significant increase in knowledge as well as in perceived competence after completing the training. Mental health and attitudes toward suicide did not change significantly. Years on the job had no moderating effect on the effectiveness of the training. Discussion: The results suggest that a short e-learning program significantly improves knowledge and self-rated competence in delivering death notifications, in suicide prevention and stress management. It can be easily integrated into the daily routine of police-officers, and participants could participate at their own pace and from any location. One limitation of this study is the lack of a control-group. Further advantages and limitations of this study are discussed. Clinical Trial Registration: https://www.drks.de/drks_web/, identifier: DRKS00023882.

The COVID-19 Disappeared: From Traumatic to Ambiguous Loss and the Role of the Internet for the Bereaved in Italy

In Italy, in the very first phase of the COVID-19 pandemic there was a dramatic rise in mortality. However, families were forbidden because of lockdown regulations to be with their loved ones at their deathbeds or to hold funerals. This qualitative study examined bereavement experiences among family members, how they processed their grief, and how they used social networks in particular by uploading photographs during the working-through of bereavement. The sample was composed of 40 individuals aged 23-63 (80% women) from different Italian cities severely impacted by the virus, including a subgroup from the province of Bergamo, which was the city with the highest mortality rate during that time. All interviews were conducted by phone, Skype, or Zoom. Then, the transcriptions underwent a thematic analysis using Atlas.ti. The main themes that emerged were: abandonment anger and guilt, dehumanized disappeared, derealization and constant rumination, and social support and the importance of sharing photos on Facebook. Importantly, the use of social networks proved to be a valuable source of support and photographs were a powerful tool in facilitating the process of mourning by encouraging narration and sharing. Grief had a complex profile: on the one hand, it was traumatic and characterized by all the risk factors causing mourners to experience prolonged grief, but on the other, some features were similar to ambiguous loss (that occurs without closure and clear understanding) because of the impossibility to be with their relatives in their final moments. The possible relationships between ambiguous loss, the use of internet, and the risk of prolonged grief are discussed.