Sudden Death: Intervention Skills for the Emergency Services 3030331393, 9783030331399

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Sudden Death: Intervention Skills for the Emergency Services Tricia Scott Editor

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Sudden Death: Intervention Skills for the Emergency Services

Tricia Scott Editor

Sudden Death: Intervention Skills for the Emergency Services

Editor Tricia Scott Hertfordshire UK

ISBN 978-3-030-33139-9    ISBN 978-3-030-33140-5 (eBook) https://doi.org/10.1007/978-3-030-33140-5 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

Sir William Gladstone was Prime Minister to Queen Victoria’s government on four separate occasions between 1868 and 1894. A liberal politician, he was a major reformist who achieved great public popularity, by remaining in touch with the needs and thoughts of the working class. Considered an inspirational orator, it is not surprising that his words have persisted through time with a resonance that is as pertinent to today’s world as it was to his own, over 125 years ago. One of his most famous quotes, which ironically may not be his at all but is very in-keeping with his style, acknowledges the importance of death and our attitude towards it. ‘Show me the manner in which a nation cares for its dead, and I will measure with mathematical exactness the tender mercies of its people, their respect for the laws of the land and their loyalty to high ideals’. The underlying sentiment behind this powerful declaration is that at the core of being human, we consciously recognise a duty and a responsibility to uphold the rights of those who are no longer able to do so for themselves. This, Gladstone tells us in his own inimitable style, is the apotheosis of a genuinely civilised society, the veritable deification of humanity and what it means to be human. The loss of life and the subsequent passage across an often-irreversible threshold into a different form of existence does not abrogate us who are left behind from the responsibility of care for our fellow humans who have gone before us. But rather, it should ignite our instinct of duty, our drive to serve and protect and uphold the highest core values of dignity, decency and respect. That we will all die in our time is a certainty. If we are lucky, that might happen when we are in our eighth or ninth decades but when death does come at that age, there can be no genuine surprise. Often referred to as ‘a good innings’ or a ‘good shake of the stick’, we have an expectation that in our modern world of medical care and vigilance towards safety, life will most likely be long. Knowing that the edge of the grave will inevitably keep creeping closer as every hour passes, does not in any way lessen the pain and devastation felt by families and friends when that long life is eventually brought to a close. However, there is a tacit and often unvoiced calm acceptance of the inevitability for the human who was born to die. Yet nothing can ever prepare us when the life is extinguished without warning and at an age where it was neither anticipated nor welcomed. Perhaps the result of an unpredictable incident that extinguishes that precious life in a moment, maybe through an accident, conflict, violence, suicide or medical emergency. Families and v

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friends are left confused, angry, inconsolably bereft, and often permanently scarred. As onlookers to their tragedy, often all we can do is offer our support, our friendship and our condolences. Yet those who tell their stories in this book go far beyond that. As strangers, they take purposeful steps to become inextricably intertwined with the event, the death, the grief and the pain. They are as much a part of the story as any other although sometimes they remain hidden and almost forgotten. They must do the jobs that many would reject out of sorts, but without them, the path to eventual resolution would be a much harder journey for the family and friends of those who are bereaved. Who are these modern day ‘sin eaters’? Who are these people who willingly take on the responsibilities of restoring order from the ultimate chaos and devastation that follows sudden death? What are these jobs that few could ever countenance undertaking? They are the paramedics who attend the fatal car collisions and work beyond the last moment trying to save the life, even when the odds are stacked against them. They are the firefighters who enter the burning building in truly appalling and dangerous conditions, often at considerable risk to self, searching and trying to save the life of someone trapped by smoke and flames. They are the men and women of faith who walk a fine line between grief, comfort and belief. They are the police officers or the forensic scientists who must recover and identify what is left of bodies from a terrorist explosion that caused a mass fatality event. They may not be dealing with the raw grief of the death of their own immediate loved ones, but they understand the importance of what they do, not only for the families and for the rights of the deceased, but because it is what Gladstone’s view of humanity expects of them in a caring and civilised world. Yet the truth is that they don’t just do this once, they do it again and again whenever their services are needed. Day after day, event after event, facing an often-relentless bombardment of unimaginable challenges, they are expected to remain stalwart and never fall short of the consummate professionalism that we all demand from them. Who protects their health and wellbeing? What toll does it take on their bodies, minds and souls? How deep are the scars caused by repeated exposure to the harsh reality that it is only a brief second that separates life from death? Who is there for them when that burden becomes too heavy to carry any further? Sudden death impacts on so many people and whilst the focus is rightly on helping those who are closest to the deceased to begin to cope with their loss, we cannot forget those who play the professional role as they are the ones who must do it all over again, tomorrow. We forget them; at our peril, because heaven forbid, we may one day be the family that needs them. Professor Dame Sue Black Lancaster University Lancaster, UK

Acknowledgement

This book is dedicated to the late Bob Wright, MSc, RMN, RGN, Clinical Nurse Specialist in Crisis Care, Emergency Department, Leeds General Infirmary, UK, who reassured me that in sudden death situations it is sometimes difficult to know how to respond. As a young emergency nurse, I recall my feelings of impotence at not being able to help a terribly distressed woman who had learned of the impending death of her son from head injuries following a road traffic collision. She desperately pleaded with me, almost commanded, with an offer of any specified amount of money to buy the best neurosurgeon and transplant a portion of her brain to replace her son’s perished brain tissue. It took a lengthy period calmly and repeatedly explaining that her request was impossible, ‘I’m so sorry, this procedure cannot be done’. When confronted with these situations, Bob felt it was helpful to begin with his own frailty and difficulties, ‘My struggle, my fumbling for the right words, my dissatisfaction with my performance and effectiveness is the beginning’ (Wright, 1991 p2). Bob invested in emergency professionals and beyond through his valuable national Cri-tec workshops to enhance care for bereaved relatives and victims of crisis encouraging us to untangle our feelings when working within the liminal life/death space. In so doing, we learn from our own struggle to care for people in overwhelming crisis and grow as human beings when we connect with patients and relatives during their worst nightmare and in the immediate period after death when they are bombarded with all sorts of painful emotions. We offer words of comfort knowing full well that there is absolutely nothing that will ‘fix’ their anguish. We learn that sometimes it may be better though harder, to sit with them in silence, creating space for their words to emerge which can be hard for

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emergency personnel chiefly because we are prepared for problem solving. In handling these events, we learn to know ourselves, our own pain and the boundaries of our own inner strength; what anchors us and what ‘spooks’ us. Finally, I dedicate this book to all emergency professionals and allied personnel who work tirelessly with human suffering and tragedy.

Tricia Scott

Contents

1 Sudden Bereavement: A Wife’s Perspective��������������������������������������������   1 Lorraine Mulholland 2 Sudden Death: A Pre-hospital Perspective����������������������������������������������   7 Nick Brown 3 Sudden Death: A Road Policing Perspective ������������������������������������������  19 Ruth McGrath 4 Sudden Death: A Fire and Rescue Perspective����������������������������������������  33 Steve Edwards 5 Sudden Death: An Emergency Medicine Perspective����������������������������  45 Joan Clancy 6 Sudden Death: An Emergency Nurse Perspective����������������������������������  57 Petra Brysiewicz, Amanda Klette, and Tricia Scott 7 Sudden Death: A Hospital Chaplaincy Perspective��������������������������������  69 Imam Rizwan Rawat, Rachel Allen, John O’Neill, and Mary Porter 8 Sudden Death: A Military Perspective����������������������������������������������������  81 Gavin Carr, Tony Kyle, and Di Lamb 9 Sudden Death: A Humanitarian Disaster Worker Perspective�������������  91 Ivy Muya 10 Sudden Death: A Disaster Mortuary Response—Practitioner Perspective�������������������������������������������������������������������������������������������������� 103 Mike Conway 11 Sudden Death: An Organ and Tissue Retrieval Practitioner Perspective���������������������������������������������������������������������������� 121 Lorraine Fahey and Anthony Clarkson 12 Sudden Death: A Funeral Service Perspective���������������������������������������� 133 Martin Jeffrey 13 Sudden Death: A Multidisciplinary Emergency Service Perspective ������143 Tricia Scott ix

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Sudden Bereavement: A Wife’s Perspective Lorraine Mulholland

Abstract

Living through the anguish of the sudden death of a spouse remains acute in the mind of the partner for a long time after the event. This chapter provides a reflective account of the sudden death of a man who one moment was enjoying life with his family and, the next, collapsed due to a heart attack. Despite immediate effort by the cardiology department, he died unexpectedly during surgery. This chapter reports on the suddenness of the situation and how the relatives were able to get to the hospital swiftly in order to be at their loved one’s side at the time when he most needed them. It also provides an authentic account of his wife’s journey toward widowhood.

1.1

Reflection

On 28 April 2008, we’d been married for 31 years. Scotland was home to us where we raised our three children who were 26, 22, and 21. My husband had worked for 40 years for a multinational company, and during that time, we enjoyed three international assignments. Two of those included having the children with us while posted in USA and Hong Kong. Jack had retired 3 years earlier and happily divided his time between continuing to be involved in our children’s lives, generally pottering about the house, gardening, and travelling. Now, I feel so grateful that that’s how he spent his time. He was interested in most sports, soccer in particular, and he followed Celtic Football Club with a passion. That day, I dropped him off to catch a train to Glasgow where he was to watch Celtic host Rangers Football Club at Parkhead Stadium.

L. Mulholland (*) Seamill, Ayrshire, UK © Springer Nature Switzerland AG 2020 T. Scott (ed.), Sudden Death: Intervention Skills for the Emergency Services, https://doi.org/10.1007/978-3-030-33140-5_1

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He enjoyed what appeared to be perfect health visiting his general practitioner only for health checks. Unfortunately, he had been a smoker for most of his adult life, although for the last 8 years had made great effort to cut back, but not to stop completely. It had always caused me distress, and I now blame his early death, aged 60, on this ghastly habit. It was a Sunday when he traveled to Glasgow to have lunch and a pre-match drink with our younger son though on this occasion they both went to the game but unsually were not sitting together on that paticular day. My son’s memory is of Jack jumping into a taxi heading to the game and giving him a ‘thumbs up’ as he was driven away. I had picked up my older son from the airport, and we were driving toward Glasgow when I received a phone call to say that Jack had taken ill during half time at the game and was being transferred to hospital. The hospital was only 10 mins away from the stadium. I asked what symptoms he had as I wanted to know whether it was perhaps a heart attack, a stroke, or hopefully just a faint. My son reassured me that as he was seated near the stadium dugout he would have had immediate attention while waiting for the ambulance and that he was sure that “Dad will be fine”. I called our son who was in the stadium, although not seated near Jack, to let him know that his dad was going to hospital, and with hindsight, I am so grateful that he didn’t witness his dad having a heart attack. At this point, I would love to point out just one of the many positive elements of that day. When my son tried to leave his seat, a police officer stopped him because, due to the heightened security at these Old Firm games, fans are not allowed to move from their seats. However, when my son explained his reason for leaving and, concurrently, the officer heard in his earpiece that there was a medical emergency in the crowd, he not only escorted my son from his seat but also arranged for a police car to take him to the hospital. For this, I am eternally grateful. By then, I had contacted my daughter who was studying for her final degree examination at a university library in the city. Fortunately, my three children and I all met up in the accident and emergency department not long after Jack had arrived by ambulance. I remember speaking to a receptionist, and I explained who we were and why we should be allowed quickly to wait in a very small room together rather than the general accident and emergency department waiting room. A doctor, who I believe was the receiving doctor that afternoon, came to see us and explained that Jack had a heart attack in the stadium and went into cardiac arrest in the ambulance but that they were “...working on him, though he wasn’t out of the woods yet”. I took that to mean that although seriously ill he would be fine. My memory of that room is of it being very small, windowless, with bare painted walls and just enough chairs for the six people present. My husband’s friend who had been with him at the game had joined us too. I remember noticing posters either there or in other areas encouraging people to be cancer aware. Later in the afternoon, I made a note that nowhere was there a prompt/reminder for organ or tissue donation which, for some reason, seemed to be significant at the time and for some time afterward. This doctor suggested that I go to see Jack in the resuscitation room and that the children join me one at a time, which they did. Jack managed to speak a couple of

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sentences to each of them. My thoughts on seeing him were that he looked well. His face and chest were flushed red which I misunderstood at that point to be a good sign even though his pale extremities were not a good sign. His skin was really tanned as we had just returned from a six-week holiday in Asia. So all of these aspects led me to a false sense as to how he actually was. I was aware that the medical staff seemed to be working with a sense of urgency, but again, by not anticipating the worst, I don’t think I was very upset by this. When the cardiac consultant arrived (she had been working in another hospital that afternoon), she seemed visibly concerned about Jack’s condition and wanted immediate updates on his condition and treatment thus far. She explained that Jack would be taken to a catheter lab for investigation and would be away for an hour or two and I would be told where to wait until I could see him again. I remember I asked that should he need a bypass, it would be helpful to know when the procedure would be carried out, and she assured me that he would have any necessary treatment as soon as possible and very soon. Before Jack left for the catheter lab, I asked him how he felt, and he said he wasn’t in real pain but felt “… a terrible tightness in my chest”. He asked me to “… give my feet a wee rub,” something I did almost every night as we sat relaxing at the end of our day. I turned back the blanket which was covering him, and it was then I was struck by the desperately white colour of his feet. I did massage his feet and lower legs till it was time for him to be moved. This especially personal moment between us in his last hours turned out to be the last thing he said to me and has become a hugely positive experience for me. We took the time to call his sisters who happened to be in the city; hence, they were able to get to the hospital quite quickly. We were planning shopping for toiletries, pyjamas, etc. assuming that he was going to be admitted to this hospital. I can’t remember who directed us to the second relative’s room near the catheter lab, but we sat and waited mildly concerned as I guessed that all the years smoking had caught up with him and perhaps he would require stents or a bypass. It never ever crossed my mind that he was in danger even having heard the doctor saying “He isn’t out of the woods yet”. When the cardiac consultant came along the corridor, I was struck by her demeanor, and when she sat down beside me, I somehow and suddenly wasn’t surprised when she said “I am so sorry to tell you that your husband didn’t survive the procedure”. I can still feel the utter disbelief and incredulity in what she had just said. However, with my mother’s instinct to protect, I immediately focused on my daughter who was so terribly upset, and I felt a need to console and take care of her before my own needs. I have no memory of other medical staff being around or involved. Despite no one suggesting donation, I offered organ donation immediately, although my son and sister-in-law were not very happy about it. It was something I felt strongly about and knew that Jack had expressed a wish to be a donor in earlier conversations. As it transpired, he wasn’t considered suitable for organ donation due to having recently traveled in Asia and the associated malaria risk. I had a call later that evening from the organ donation/tissue retrieval coordinator who took me

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through a lengthy questionnaire with great sensitivity. I agreed to Jack’s corneas being retrieved and have since heard that they were transplanted successfully which is a huge consolation and yet another positive element to this sad story. At times like this, we search for meaning and that something good will come from the sadness. I have no memory of any offer of spiritual support or of any support come to think of it. I suppose by then Jack’s sisters, brothers-in-law, and niece had joined the children and me, and perhaps, it looked like we were supporting ourselves. I will never know. We are practicing Catholics, and perhaps, we would have been happy to have had the opportunity to have a priest present to offer the last sacraments. After Jack had died, we were offered the opportunity to be with him, but only my younger son and one of Jack’s sisters went to see him. I recalled being very upset as a teenager when I saw my father in an open coffin and had vowed never to view anyone who had died in future. I had been with my mother and an aunt when they died, but once I left them, I didn’t return to see them. This is something I feel strongly about and have no regrets about at all. Our children and I drove from the hospital to visit Jack’s elderly parents who had already heard the sad news from a family friend. It was a very controlled sad feeling in their sitting room, and you could feel that everyone was being stoic, although it was very early in the bereavement process. The children and I then continued to our home, although they no longer lived in the family home all having moved to Glasgow for university and work. They all stayed with me that night and for several nights thereafter. We then began the sad and difficult task of calling our extended family and friends to tell them that Jack had died. That is such a heartbreaking task. You know that as you dial you are about to make someone feel so very sad in a second. In a very practical way to help, my daughter transcribed all phone messages as back then most calls were to the landline and not the mobile and printed these along with emails. I have kept all of these pages in a file, and I find comfort when reading them from time to time. I was asked to visit the hospital the following day to collect Jack’s belongings and his death certificate. I found that difficult, but we took the opportunity to thank some of the medical staff we encountered. Although I don’t remember interacting with many of the hospital staff, those who did speak to us from that first receiving doctor to the cardiac consultant were considerate, caring, and kind. The death certificate was ready for us as arranged. Jack’s belongings were in a black plastic bag which isn’t a pleasant way of collecting, but I’m not sure of alternatives. I do not remember a recorded property list, though I had already taken his watch and wedding ring from him in the accident and emergency department at his suggestion. Having collected the death certificate, we drove directly to the City Registrar’s Office to register his death. I found driving between hospital and home and hospital and Registrar’s Office and other car journeys in the days immediately after his death really difficult. Not wanting others to drive me is a vivid memory. I wanted the independence and privacy of driving alone or with our children and not with anyone else even family or close friends. Someone mentioned Auden’s (1938) poem which

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begins “Stop all the clocks” and that resonated with me. I found it surreal to be driving around feeling so utterly devastated when the world was carrying on without a clue as to how I was feeling as my life had been changed completely in an instant. So, on reflection, I feel the emergency/medical personnel with whom we had contact were each wonderful in all respects, truly, and that’s a great thing to be able to say, from the staff within the Parkhead Stadium who I hear all did a remarkable job in caring for Jack while he waited for the ambulance to arrive. Apparently it did not take long. The staff in the accident and emergency department at Glasgow Royal Infirmary were all caring and efficient. I have since heard from someone who was working in an administration capacity that at the time a doctor had commented that we or perhaps I was not taking the information on board. I only heard this the other day, and I’m not sure how I feel about it. Perhaps, I feel frustrated that if this was the case, more effort should have been made to make me aware of the reality and seriousness of the situation, a difficult one. As we left the hospital that afternoon, we met the cardiac consultant, and I remember speaking to her about how she felt and hoped that she would have some specialist support to help her having ‘lost’ a patient she was treating. I was able to thank her for her care as I had gathered myself and thoughts a little by then.

Learning Points

• Consider how to prepare a suitable relatives’ room in the emergency department. • Consider how to prepare relatives regarding the seriousness of the event. • How might you improve on the process of handing over property to relatives?

Reference Auden WH. Funeral blues. In: The year’s poetry. London: Readers’ Union; 1938.

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Sudden Death: A Pre-hospital Perspective Nick Brown

Abstract

The ability to deal with complex scenarios is the hallmark of a proficient paramedic practitioner. Sudden deaths occur regularly in the course of clinical practice and call upon the paramedic to handle not only the patient’s clinical condition prior to and after the patient’s death but they must also be able to handle the emotional reactions of the people at the scene including those of their colleagues who may be less experienced. The following chapter reflects on the paramedic’s preparedness for dealing with a range of sudden death encounters.

2.1

Introduction

The sun had not been up for long since starting my shift. I drove the Fast Response Car out of the ambulance station and headed south. Somewhere in South London a man in his mid-forties had returned home after a run where his wife was preparing breakfast and his son had started another day of homework. Having announced that he was feeling unwell, he went upstairs and collapsed. It is not always obvious why paramedics recall events surrounding certain call-outs over others after so many years, but in the following case, it is. The next 3 hours were about to have a huge impact on me emotionally and intellectually. Indeed, the events acted as a catalyst for significant changes to the way I thought about and managed the various factors around out-of-hospital cardiac arrest and subsequent death. I remember my exact location when the mobile data terminal mounted to my car dashboard jumped into life with details of an emergency call 10  miles away to a 45-year-old male who wasn’t breathing. N. Brown (*) London Ambulance Service, London, UK e-mail: [email protected] © Springer Nature Switzerland AG 2020 T. Scott (ed.), Sudden Death: Intervention Skills for the Emergency Services, https://doi.org/10.1007/978-3-030-33140-5_2

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It is estimated that UK ambulance services respond to 60,000 out-of-hospital cardiac arrests each year (OHCA Steering Group 2017), where half result in active resuscitations (Perkins and Brace-McDonnell 2015). Approximately 10,000 cardiac arrest 999 calls are responded to by the London Ambulance Service alone, of which 4500 result in continued resuscitation attempts following ambulance arrival (London Ambulance Service 2017). London’s Critical Care Advanced Paramedic Practitioners (APP) are tasked to the more seriously ill and injured patients in the capital. On average, within a 12  hour period, one APP attends 1.6 cardiac arrest patients, many of whom die (London Ambulance Service 2016). My 22-year career as a paramedic has afforded me a deep appreciation of the multidimensional aspects of unexpected death in the widely varied pre-hospital environment. Reflecting on these experiences has helped me to better understand sudden death in the community and develop key knowledge and skills to manage these events, aside from the clinical care that paramedics deliver. For paramedics, dealing with sudden and unexpected death is usually part of a continuum which involves a 999 emergency call, arrival on scene, a resuscitation attempt, management of various on-scene factors, a decision to stop resuscitation and formalise death and the conveyance of that decision to family members or friends. Additionally, there are medico-legal requirements. It is therefore unrealistic to explore how we should deal with unexpected death without providing a wider context and meaning to these events. For paramedics, dealing with sudden death usually comes after an attempt to save life. It is important to recognise that what we do and say from the moment we arrive on scene will have an impact on our overall ability to optimise ongoing decision-making and care and our own sense of accomplishment. Although key themes will run throughout this chapter, for clarity, it might be useful to explore paramedic involvement around death under four main headings: family-witnessed resuscitation, breaking bad news, preparing the body and staff welfare.

2.2

Family-Witnessed Resuscitation

After 20 min of blue light driving, I arrived on scene at a family home where local ambulance crews were already inside. As an APP, I was there to administer advanced clinical care, but on this occasion, it wasn’t required. On entering, the first people I saw were the patient’s wife and son, clearly upset. I remember the smell of breakfast. Upstairs, the ambulance crews had established advanced life support in a bedroom, but sadly, the prognosis was poor. In fact, I intervened very little clinically before asking if anyone had updated his wife and son. Interestingly, one of the attending paramedics couldn’t even remember seeing anyone else on entering the family home. I didn’t really have much of a plan of what to say which mostly reflected my then lack of appreciation for having a clear, considered and practiced approach in these situations. On explaining that a death outcome was likely, the reaction from both

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wife and son was immense. There was instant screaming and howling, quite feral in nature. Walls were being punched to my left, and homework was thrown across the room. The patient’s wife literally clung to and then hung off my uniform, pleading and begging me whilst using the most emotive language, to save her husband. She told me that she and their children could not live without him. He was “...their rock”. She asked me how she could possibly tell their younger children who were at primary school and completely unaware of events at home. Although not fully appreciated at the time, in a handful of apologetic words, I had taken them from mild concern to abject horror. I was hit by an emotional tidal wave of raw grief, and as I stared across the kitchen at three plates of uneaten breakfast, I had absolutely no idea of what to say next. I imagine the reaction described here would challenge even the most experienced bereavement specialist. Nevertheless, I came away from the experience certain that an ad hoc approach to managing the non-clinical aspects around death was not an option. Many of the strategies I have relied on since have developed from that experience, and the reasons should be evident as we move on. Paramedic exposure to cardiac arrest or death is rare when compared to overall paramedic workload. However, there is a strong educational focus on managing the clinical care aspects. During university-based education and in ongoing training relevant anatomy, pathology and resuscitation science are addressed. Psychomotor skills are practiced and honed frequently in simulated training environments to pass the necessary competency assessments. Although clinical signs associated with death are imbedded, there has been limited focus on dealing with family members, friends or work colleagues present. It is reasonable to imagine that when paramedics arrive on scene at a cardiac arrest, the focus is on delivering clinical skills rather than offering emotional support to relatives. Overall capacity to deal with rare high-acuity patient presentations will likely preclude detailed communication with those who know the patient. Invariably, initial communication with bystanders is largely directed at gaining a picture of the circumstances that led to the collapse or discovery of the body. Significantly, despite rising survival rates, pre-hospital cardiac arrest has a poor prognosis. Whether conveyed to hospital or not, only 8% of patients survive a cardiac arrest in England (OHCA Steering Group 2017). This fact can help us consider just who our patient is, because in most cases (from an emotional welfare point of view), it is unlikely to be the body on the floor. In my experience, most people who highlight bad experiences of healthcare do not object to the technical aspects of care but are concerned more with how they were made to feel, including occasions where they could not specifically remember what was said to them. Comments such as being ignored, having a lack of involvement and feelings of being out of control or being spoken to abruptly are common. It is appreciated that in the setting of a pre-hospital cardiac arrest, these are themes that may well feature amongst loved ones. It almost goes without saying that the death of a close relative can have a lifetime impact on family members. It is necessary to ask then whether paramedics can reasonably be expected to take on board the emotional as well as clinical care.

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If we do aspire to be truly holistic carers during out-of-hospital cardiac arrest or sudden death, we would need to formalise the care of relatives and friends into the structured clinical treatment delivered to the patient, which clearly cannot be compromised. Most cardiac arrests present three opportunities to make contact with the family: on arrival, after advanced life support has been initiated and following a decision to convey the patient to hospital or death. As will be seen, involving family and friends can have the two-way benefit of offering emotional support as well as facilitating clinical care. In situations where paramedics arrived too late for a resuscitation attempt, these approaches can be adapted accordingly. Even after 22 years, when I receive a call to attend a cardiac arrest, my nerves kick in. Unfortunately, evolution has not best prepared me for coping with high endogenous catecholamine and cortisol levels by driving an ambulance car on blue lights and sirens. Those hormones may be put to better use once we hit the ground on foot to make our way to the patient and most certainly during chest compressions. As focused and alert as we need to be in these situations in order to deliver essential clinical care quickly, we may also be able to begin the long continuum of psychological support for, say, a husband or wife. I remember once whilst off-duty and walking through a shopping centre seeing a male who had collapsed. Several shoppers crowded around him as a shop assistant offered a chair for his wife. Having seen he was awake and talking, I made my way over to his wife and introduced myself by name, stating that I was an off-duty paramedic and offered to help. Later, when the gentleman was in the ambulance having an electrocardiograph taken, his wife thanked me and explained that when I had first approached and told her who I was and what I did, it was like her “…guardian angel had arrived”. A few words I had barely attached any significance to had been incredibly powerful and reassuring to her. When we arrive at cardiac arrest or deceased patients with family or friends present, we clearly don’t have the luxury of time. However, quickly announcing ourselves by name and profession, explicitly stating that we are there to help, stressing that there are things that need to be done immediately and promising an update as soon as possible may be reassuring. It should take less than 10 seconds as we take in the scene and position equipment and can be an effective way to recruit bystanders who often then move back and allow us to get on with essential tasks. Activity with an appropriate sense of urgency will also impress on anyone watching that we are doing all we can and instils confidence in our general competence and professionalism. This confidence in attending paramedics will be important if a death outcome needs to be conveyed. The management of acutely unwell patients relies on optimising the whole scene though occasionally some family members will not wish to leave the patient. They may be hysterical and hold on to them making paramedic intervention very difficult. Although counterintuitive, there are times when we need to ‘slow down to speed up’. Taking a moment to stop, look someone in the eye and explicitly state facts in a way that can cut through the confusion and engage reason can avoid a longer period of suboptimal clinical care as you wrestle around family members. It is sometimes helpful to consider a statement that can reiterate who you are, offer reassurance, explicitly state the problem and recruit the relevant family member to comply.

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By way of example, let us consider how this might break down: “Look at me, my name is Nick, I’m a Paramedic (reiteration), I’m here to help (reassurance), but I can’t save his life unless you let go (explicit); please help me try to save him by moving back a little (recruitment)”. Nevertheless, I have been in situations where this has not been comprehended by the family member targeted, especially when the patient is a child. Sometimes another member of the family has stepped in to assist. Mindful of tearing away a parent from a child, a balance should be struck between facilitating space and capacity to work and allowing mum or dad to be present. In any case, it would be appropriate to rehearse this scenario by building this dimension into training moulages. Unlike the relative order and constancy of the emergency department, paramedics attend patients in all manner of settings from busy shopping centres to building sites. I am often amazed by how many patients collapse in a small bathroom and become wedged between the toilet and the bath. I recall resuscitating a gentleman on a narrow pavement once and being incredulous as the public stepped over his body or stared at close range as we carried out chest compressions. It needs to be remembered that other people on scene will have a very different interpretation of this unexpected event and so demonstrating annoyance at such seemingly callous responses may be counterproductive. Instead, we should anticipate this aspect of human behaviour and create a strategy to deal with it. In public spaces it may be essential to recruit police, security, shop staff or sensible bystanders to help you push the public back and provide the physical and mental room to work, ideally screening off the scene. Additionally, patients are invariably on the floor which involves kneeling down, sometimes in body fluid. I remember on one occasion swapping light bulbs over in someone’s high-rise flat to illuminate the room! It could be raining perhaps prompting a decision to make a quick initial move to stay dry, and we regularly work in extremely hot or freezing temperatures. With all this in mind, the first 10 minutes of resuscitation are intense as the patient’s position, the scene and the clinical care are optimised. Once underway and advanced life support is established, there will be further opportunities to speak with relatives or friends. Ideally, one person should act as family liaison for continuity purposes though not all staff will feel confident to undertake this role, including the conveyance of a death outcome. If possible, so they may learn, junior staff could accompany a more senior paramedic when speaking with family members. Again, in balancing time away from the patient, there are key messages to deliver regarding the situation. It is worth bearing in mind that not every lay person will associate chest compressions as carrying the same gravity as healthcare staff. Expectations too of what the high-­ profile television portrayal of the role of a paramedic can achieve may not reflect the prognostic reality. I remember being about 2 min away from recognising death of an elderly patient when his wife said, “When he wakes up can you ask him what he wants to take with him to the hospital?” That comment reflected my shortcoming in addressing the reality of the situation and preparing his wife for my impending death declaration. It is important to keep language simple, by clearly stating that the patient is in cardiac arrest. I have often found that there is public confusion regarding the term “cardiac arrest” and “heart attack”, so stating explicitly that the heart and breathing

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have stopped will help mitigate uncertainty. Often relatives will want to know why this has happened. You may have to state that you do not know but are investigating (reversible causes). However, many of our actions do not rely on causation, and to that end, perhaps four activities can be highlighted to explain why you are undertaking specific tasks that can seem foreign, even barbaric, to loved ones. Firstly, you are compressing the chest to pump blood, because their heart has stopped; secondly, you have inserted a breathing tube into the patient because they are unable to breathe independently. Thirdly, you have administered drugs to restart their heart. Lastly, you have placed leads on the body to monitor their heart for signs of a rhythm. At this point, you may offer the family an unpressured choice to be present at the patient’s side. This can be a cumbersome option for ambulance staff, but it might be the right thing to do. In making this decision, the logistics of the scene and the continuance of high-quality clinical care will need to be considered. Psychological benefits have been highlighted within the limited amount of literature on this subject although it exclusively focuses on the in-hospital environment (Jabre et al. 2013; Compton et  al. 2011; Boyd 2000). Barriers to allowing family presence tend to focus on healthcare professional concerns over decision-making becoming confounded, interference with clinical care and exposing relatives to distressing scenes and legal claims (Matincheck 2006; Walker 2008; Oman et  al. 2010). However, Brown (2016) states that these concerns seem unsupported by the evidence. The key is to give loved ones present a choice (Boucher 2010).

2.3

Breaking Bad News

Breaking bad news is often delivered by paramedics with implications for both the informer and recipient. It would be appropriate to rehearse how we deliver such news to strike the right balance between sensitivity and unambiguity. To that end, seminal texts have changed practise, and it is now widely considered that using the word “dead” to describe the outcome is appropriate and to avoid language and clichés which offer less clarity such as “passed away”, “gone”, “no longer with us” or “we have lost him/her” (McGuinness 1986; Wright 1991). I often find it useful to put death in the past tense. In this way, finality is clear, and the death decision is appropriately viewed as irreversible. We should also make sure we focus on the physical. I once overheard an ambulance staff member speculate as to where the patient’s soul was 10 minutes after their death. For those that may hold strong convictions on metaphysical concerns, it is worth remembering that it is quite beyond any guidelines to offer advice or opinion on the afterlife. Unexpected death is a whirlwind experience, and those caught up in it need to have confidence that you have done your professional best right up until the death decision. With family present at the patient’s side if they wish, the obvious analogy is to that of turning life support off for a patient in an intensive care unit with loved ones around the bedside to say goodbye. It is important to realise that we can’t possibly hope to make the process painless and many of our actions aimed

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at caring for others on scene won’t be realised until long after we leave when family members reflect on the events. I recall a very grateful wife of a patient I unsuccessfully resuscitated on the landing of their home. Having asked if she wanted to be present, she was able to sit at the top of the stairs throughout the treatment whilst holding her husband’s outstretched hand. She spoke softly to him about their life together until his death, yet it didn’t distract us from clinical care. Indeed, we all agreed during a teary debrief in the ambulance afterwards that it very much felt right and dignified. In my experience, reactions to the sudden death of a loved one tend to fall into one of three categories: stoic, obvious distress and stunned silence. I recall an elderly couple who were living out their retirement in a hotel when following their evening meal; the husband collapsed going into cardiac arrest. A short period into the resuscitation, I prepared myself to update his wife. There is always some anxiety in informing loved ones of the gravity of this situation. However, before I had fully approached her, she began showing more concern for me: “You look so worried dear, don’t worry… I know he’s gone”, and “He wouldn’t have wanted all this fuss”, then “We’ve had a good life”. The hotel staff seemed more obviously upset than she was. I still can’t think of a better example of a stoic reaction, though in my experience this is atypical. Usually, responses are more animated involving mild to extreme displays of grief. Relatives need to express grief in their own way and have their deep pain affirmed. This may help them deal with events in the future. It may also be helpful prior to breaking bad news to summarise clinician actions and impress upon those present that everything possible was done. However, on occasion and despite efforts to manage the relative’s expectations, questions regarding the clinical care arise. Importantly, we should not feel that their response negatively reflects the practitioner’s ability. Questioning care was a factor when trust between family and ambulance staff broke down resulting in aggression by family members and requiring police presence. After informing the wife and extended family of the death, the police tried to manage emotional outpourings and anger towards ambulance staff. Once calmer, one family member asked whether the patient, “…had the electric shock treatment”. He was of course referring to defibrillation, though the patient had a non-shockable heart rhythm. Often it is as important to understand why a question is being asked so as to simply and directly answer the question. The question from this family member partly reflected their distrust of the clinical care given, perhaps because the expectations of what paramedics are always able to deliver seemed unmet. Yet, it may be inappropriate to detail the science around defibrillation, risking further confusion. Instead, reassurance that the ‘shock pads’ were on the patient throughout and that he received full care may be comforting. Building trust and anticipating questions such as these may help when faced with challenging questions. Occasionally, relatives are struck with stunned silence after breaking bad news, and this natural reaction should not prompt assumptions about a lower level of concern. Ambulance crews may be tempted to avoid awkward silence, but it is helpful

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to allow space for relatives to make sense of what is happening. Regardless of the reactions encountered, an explanation of what will happen next is vital and should be directed to the next of kin or to another close family member on scene.

2.4

Preparing the Body

It can be an odd moment when the intense activity stops after the formal recognition of life extinct. Unexpected death must be reported to the police who fulfil the coronal process after arriving on scene. Ambulance crews complete the patient report forms and the locally agreed legal recognition of death form, formally justifying the death decision with reference to clinical guidelines. This paperwork is generally passed to or left for the attending police officers and forms part of the investigation and report to the Coroner. Once satisfied, the Coroner or Coroner’s Officer arranges an undertaker to transport the body to a hospital mortuary where a post-mortem examination may be undertaken to ascertain the cause of death. In most situations, the body should not be moved until the police arrive and have spoken with the Coroner. Unless instructed by the police (e.g. if the circumstances are suspicious), clinical equipment should be cleared away. Often additional relatives will arrive at this point to be with the deceased. Resuscitation invariably involves exposure, so to maintain dignity and respect, an appropriate cover should be laid over the body and, if available, a pillow placed under their head. Local protocol can vary; however, the post-mortem examination process may require invasive equipment to remain in place, such as an intravenous cannula, intraosseous needle or endotracheal tube (ET). The ET tube can look particularly unpleasant, and the rationale for leaving it in place requires explanation to the grieving relatives. Sometimes in situations even where death is expected, a call may be made to the ambulance service. Arriving paramedics may not be unequivocally clear whether it is appropriate to start resuscitation, and it can take time to ascertain that the patient should only be receiving palliative care or that a prior do not attempt resuscitation directive has been made. In these circumstances, basic life support is often undertaken whilst investigation is carried out. Ideally, emergency calls to these types of patients should be identified during call taking through reporting mechanisms usually involving the patient’s general practitioner so that control room staff can alert paramedics of the patient’s status prior to arrival to support decision-­making and avoid an undesirable and unnecessary resuscitation. However, the reality is that this is not always the case and there may be situations where the patient cannot be identified or the information is unavailable prior to paramedics arriving on scene. Quite often, the time from recognition of death to ambulance crews becoming available for the next call is greater than the clinical time spent with the patient. Indeed, there is much to do in this period. Equipment needs to be removed from the scene, cleaned and restocked and a considerable amount of documentation completed. Cardiac arrest management is rare, fast-paced and emotive, so allowance should be made for a slow time reflection on the event that both serve to generate clinical lessons learnt and, more generally, support staff.

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Staff Welfare

Dealing with death can affect ambulance staff in a number of ways. Naturally, each practitioner is unique and has a different perspective on each experience. Some experiences are simply upsetting to visualise, but quite often, dealing with the bodily presentation is less psychologically hard than facing the reaction of those who feel the loss most acutely. Unlike hospital staff, quite often, paramedics have not had the chance to build up a relationship with the patient who died. Instead, having managed intensive physical care, they are now in the position of witnessing the early consequences of the death when the patient-practitioner emphasis changes. Nevertheless, feelings can sometimes be tied up in the quality of the resuscitation. As tragic as circumstances are, some paramedics find comfort in knowing that they did their best and performed well. A more negative psychological impact may develop if performance was felt to be suboptimal, a real possibility when faced with a less frequently encountered event. Most of us recognise that there is often commonality amongst the situations that upset us the most and this is usually related to how we personally connect to the event. I remember arriving several minutes before the ambulance arrived on scene to a female who had been found hanging and spent what felt like a long time alone with her in the house. After quickly realising that she was beyond help and with my own adrenaline levels subsiding, I took time to look at her and the surroundings. She looked like and was dressed remarkably similar to a close family member of mine. I even recognised the scarf she had used to tie around her neck. I also made what many consider to be the ultimate mistake (from a personal welfare point of view) of reading the note she had left for her family and friends. Although nearly impossible to avoid, it was heart breaking to read and is still upsetting to recall. It is important for ambulance staff to know what formal processes there are for support, such as trained peer aids or professional counselling. However, in most circumstances, informal psychological support mechanisms are used. Getting together in the back of the ambulance after dealing with a cardiac arrest not only gives staff the opportunity to consolidate when writing the formal patient report but also offers an opportunity to talk about the job and unwind. Although it is rare to hear someone volunteer that they are upset or feel they have ‘done a bad job’, simply talking about the experience can help everyone to understand what went on and why events played out as they did. Sometimes a more structured debrief on return to the ambulance station can be helpful, although this is often better achieved when facilitated by an experienced senior member of staff to ensure a completeness to the reflections and to allow everyone to have their say. Despite the benefit this can bring, some staff may be more comfortable talking to their own crewmate when they are alone together. Where there is a need to cope, coping mechanisms can usually be found. When considering the intense and highly charged nature of their work, paramedics will try to achieve a balance between emotional investment in their patients and personal detachment. Colloquially, this approach is recognised as ‘care without burnout’. However, there are many examples where this optimal balance is lost, so

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paramedics should try to develop this awareness and regularly check that they and their crewmate are maintaining that healthy equilibrium. During a festival period, an ambulance crew was called to a male in cardiac arrest where, amongst others, three generations of the patient’s family were present. After the resuscitation was well-established, one ambulance staff member made an unfortunate observation regarding the absurdity of the scene. The comment prompted laughter until sense-checked by one paramedic who was aware of the proximity of the family. Black humour is widely recognised amongst the emergency services as a response which helps people to face emotionally traumatic events (Christopher 2015). Indeed, it can have therapeutic value (Scott 2007). In these quite tragic situations, there must be recognition of when such humour is appropriate and how it is dispensed. Caution should be exercised around those directly related to the deceased because at worst it would completely undermine confidence in the care and cause offence. Additionally, experienced paramedics should set the professional standards of their regulatory body on scene around more junior staff.

2.6

Conclusion

Paramedics often encounter death in its most raw and unrestrained form. It is reasonable therefore that they practice not only for the clinical aspects of care and scene management but also to support the family and friends of the deceased at a time when they are most vulnerable. Involving and supporting family members through their tragedy is supported by evidence and at the very least seems humane. Paramedics should practice for such scenarios so that clinical care and family support are symbiotic and that they are prepared for the potential spectrum of reactions to death. Breaking bad news should be considered as a continuance of care already established, rather than left until first contact after a death decision has been made. In this way, paramedics can build up a relationship of trust with relatives and help shape a realistic expectation of the outcome. Local death procedures and the coronal process will need to be appreciated, followed and explained to the family. Although ambulance staff should be aware of the support mechanisms available to them, peer support is usually more prolific, and therefore, strong and authentic peer relationships is vital.

Learning Points

• Devise a plan of what to do and say from the moment you arrive on scene. • Remember to keep your language simple when communicating with relatives. • Consider how best to manage emotional outpouring and anger directed at you.

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References Boucher M. Family-witnessed resuscitation. Emerg Nurse. 2010;18(5):10–4. Boyd R. Witnessed resuscitation by relatives. Resuscitation. 2000;43(3):171–6. Brown N. Pre-hospital resuscitation: what shall we tell the family? J Paramed Pract. 2016;8(2):86–9. Christopher S. An introduction to black humour as a coping mechanism for student paramedics. J Paramed Pract. 2015;7(2):610–5. Compton S, Levy P, Griffin M, et al. Family-witnessed resuscitation: bereavement outcomes in an urban environment. J Palliat Med. 2011;14(6):715–21. Jabre P, Belpomme V, Azoulay E, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med. 2013;368(11):1008–18. London Ambulance Service. Management information. London: London Ambulance Service; 2016. London Ambulance Service. Cardiac arrest report: 2016/17. London: Ambulance Service; 2017. Matincheck T. Nurses’ beliefs and practices of family presence during cardiopulmonary resuscitation and invasive procedures: review of the literature. Top Emerg Med. 2006;28(2):144–8. McGuinness S. Death rites. Nurs Times. 1986;82(12):29–31. OHCA Steering Group. Resuscitation to Recovery. 2017. https://www.resus.org.uk/publications/ resuscitation-to-recovery/. Accessed 3 July 2018. Oman K, Duran C, Denver A. Health care providers’ evaluations of family presence during resuscitation. J Emerg Nurs. 2010;36(6):524–33. Perkins G, Brace-McDonnell S. The UK Out of Hospital Cardiac Arrest Outcome (OHCAO) project. 2015. http://bmjopen.bmj.com/content/bmjopen/5/10/e008736.full.pdf/. Accessed 3 July 2018. Scott T. Expression of humour by emergency personnel involved in sudden deathwork. Mortality. 2007;12(4):350–64. Walker W. Accident and emergency staff opinion on the effects of family presence during resuscitation: critical literature review. J Adv Nurs. 2008;61(4):348–62. Wright B.  Sudden death: intervention skills for the caring professions. Edinburgh: Churchill Livingstone; 1991.

3

Sudden Death: A Road Policing Perspective Ruth McGrath

Abstract

Road deaths remain at a consistent level despite traffic-calming measures and greater road awareness campaigns, so road policing units continue to deal with the carnage of sudden deaths and, frequently, multiple sudden deaths. Families are often devastated by the news of the death of a loved one, but it is the police officer who often must deliver the death message and support relatives in the immediate aftermath of the event. This chapter describes the complexity of managing sudden road deaths: the scene, forensic aspects and the interface between the emergency department, mortuary and Coroner’s Office and the relatives.

3.1

Introduction

This chapter discusses the approach of the police service when dealing with the investigation of deaths on the road, from the initial attendance at the scene of a collision to the prosecution of a case. It refers initially to the police service professionalisation agenda, its impact upon the restructuring of investigation teams and training to prepare officers for dealing with such events. It recognises the role of appropriate agencies engaged in supporting the families of victims, referring in particular to one local agency and one national agency. Information is included regarding equipment carried by the Collision Investigation Team, actions at the scene of a collision and working with the Coroner. Examples of specific scenarios will be included to offer a more personal view of police officer experiences when dealing with road death, and these will indicate the effect that this type of work has on individuals and how the police service may support them in their role. R. McGrath (*) Teesside University, Middlesbrough, UK e-mail: [email protected] © Springer Nature Switzerland AG 2020 T. Scott (ed.), Sudden Death: Intervention Skills for the Emergency Services, https://doi.org/10.1007/978-3-030-33140-5_3

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Terminology changes over time; thus, it is acknowledged that supporting documentation mentioned may use terms interchangeably when referring to the same situation, e.g. ‘accident’, ‘crash’ and ‘collision’. For the purposes of this chapter, each term should be considered as having a similar meaning. Equally, the term ­‘sudden death’ was once used in relation to deaths on our roads; however today, a preferred term within the police service is that of ‘road death’. These variations should be acknowledged when observing differences in terminology used in other chapters. Statistics released by the Department for Transport (DfT) indicate that in the year ending June 2018, there were 1770 people killed on roads in Britain. Overall fatalities have remained at a similar level, year on year since 2012 (Dhani 2018). This gives an indication of the scale of such incidents nationally, statistics being based on information reported by individual forces to the DfT.  The College of Policing acknowledges that the police have responsibility for leading the investigation of collisions (College of Policing 2019). Since the 1970s, the police service has established a level of expertise in the field of collision investigation and reconstruction recognised by HM Coroners and criminal and civil courts alike. Currently, collision investigation is undergoing a process of change. Thus, it should be recognised that procedures do vary slightly from one policing area to another, although key documentation guiding the investigation of fatal and serious injury road collisions has been standardised as part of the remit of the College of Policing (2019) and as part of the professionalisation agenda. The College of Policing was introduced in 2012, one of its objectives being to ensure excellence in operational policing by setting and enhancing standards of professionalism (College of Policing 2018). The College of Policing sets out its goals for Workforce Transformation in the Police Service (College of Policing 2018b), which drives that professionalisation agenda, and supports the Policing Vision 2025, aiming to: …Attract and retain a workforce of confident professionals able to operate with a high degree of autonomy and accountability… (NPCC 2018, p. 3)

In 2017, the College of Policing published its Competencies and Values Framework (CVF) to support all those working within the police service and to ensure the embedding of the values of the code of ethics at all levels within the police service, including all roles related to the investigation of fatal and serious injury road collisions. Four core values are identified within the CVF: transparency, impartiality, integrity and public service. These are considered integral to determining how all tasks are achieved within the police service, irrespective of specialism (College of Policing 2017). The vision of the National Police Chiefs’ Council (NPCC) is one of “Policing Together for Safe, Secure and Efficient Roads” (NPCC 2018a) and refers to working with partners to progress that vision. In doing so, the NPCC promotes a safe system for policing the roads, which incorporates the strand of the post-crash response. This is particularly relevant to this chapter, outlining key aspects of the

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response process and introducing a series of changes, including the protocol Forensic Collision Investigation and Reconstruction within the Police Service 2018 (NPCC 2018b). Some of these changes are reflected in the structure of the Collision Investigation Team and partnership work with other agencies.

3.2

The Collision Investigation Team

The professionalisation process has led to the identification of more defined roles within the collision investigation function. This is an evolving function today, one which will gradually become governed by the Forensic Science Regulator whereby individual forces are likely to adopt a collaborative, regional approach in the near future. The team comprises road policing lead investigators who will attend the initial scene, their focus being securing the scene and scene management, review of initial actions and preservation of evidence for use in the subsequent investigation. Additionally, they have responsibility for the management of the investigation and deployment of the appropriate resources. Forensic collision investigators undertake an impartial and thorough investigation, drawing on all available evidence to determine what occurred: • Forensic vehicle examiners have a role which in some forces is carried out by collision investigators, members of police staff or the Driver and Vehicle Standards Agency. • Family Liaison Officers (FLO) may not be part of the permanent team but will be drawn from available trained officers and appointed to work with a family in the event of a road death (NPCC 2018a).

3.3

The Role of the Family Liaison Officer

Family Liaison Officers (FLO) have a key role in the event of a road death, i.e. to ensure effective communication with the bereaved family and friends (McGarry and Smith 2011; College of Policing 2019). Each force has a team of trained FLOs from a variety of policing backgrounds, some of whom are also trained investigators. Each FLO has completed a five-day training course in preparation for their role, readying them for a range of situations they may be required to be involved in, including road death. A FLO is appointed to a road death at an early stage, as part of the family liaison strategy (College of Policing 2019) on occasions even attending the scene of the incident. There is variation between police forces, so it could be the FLO who delivers the initial death message to the bereaved family who initiates communication and establishes a supporting role. The FLO upholds the duty of care of the police service to members of the public and to this end will even assist in transporting family members to and from hospital in the first instance to ensure their safety after receiving

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distressing information or being present in the collision. The FLO is the link between the family and the police and, where relevant, will attend court with the family as part of that supporting role. Often their role is enhanced by the engagement of other agencies, such as the Victim Care and Advice Service (VCAS) (see below). They are part of the investigative process supporting the lead investigator and agreeing an appropriate strategy for working with the family. They may contribute to key decision-making and the arrest process and will assist the Crown Prosecution Service (CPS) who may facilitate meetings with families prior to court. The FLO is a key link, helping to maintain the flow of information between the investigators and the family and to answer questions posed by families as the investigation progresses.

3.4

Other Agencies

Police forces recognise the limitations of their available resources and draw on the support of other agencies to ensure a holistic approach to care for victims and their families. Two of these agencies, the Victim Care and Advice Service (VCAS) and Brake the Road Safety Charity, will be referred to below.

3.5

Victim Care and Advice Service

One such service employed in the North of England is that of the VCAS. The service is supported with funding from two police and crime commissioners (PCC) and another local charity. This enables the service to provide free, independent and confidential support for victims of crime and their families. In the event of a likely prosecution, a family will be automatically referred to VCAS where staff will support the FLO in undertaking home visits, providing regular telephone support, offering emotional support including guidance on arranging funerals and taking Victim Personal Statements for use in subsequent court proceedings. This is a particularly beneficial service as it releases the FLO from some of those duties and allows them to return to the investigation (VCAS 2017; PCC 2019).

3.6

Brake the Road Safety Charity

Support is also available from Brake the Road Safety Charity. Through Brake’s services, families can access additional telephone support via a telephone care line, together with practical guidance via supporting literature. Topics covered within the literature include coping with grief plus information and advice on procedures. These guides are extremely beneficial for families who may not initially remember things they are being told verbally (Brake the Road Safety Charity 2019).

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Training

Neyroud (2011) an advocate of continuous professional development (CPD) for police officers recommended police officers should be registered with a professional body and required to demonstrate ongoing professional competence via CPD.  He also envisioned increasing links with higher education allowing staff to gain further professional recognition of a transferable nature (2011, p.  56). CPD is not a new concept in the field of collision investigation, with officers historically encouraged to undertake both internal courses and recognised external further and higher education courses including Business and Technology Education Council (BTEC) awards, National Certificates, City and Guilds Diplomas, National Vocational Qualifications (NVQ) and undergraduate and master’s degree awards. In recent years, opportunities for such development have reduced, not only for collision investigation but also for road policing generally, partially affected by austerity measures and subsequent police budget constraints impacting on funding of some training (Bryant et al. 2013), although at a national level there is recognition of the need for more investment for collision investigators as this responsibility is transferred to being overseen by the Forensic Science Regulator, by 2020, which has prompted the development of training for new members of staff in order to reach the required accreditation level for the role. This then is a stage in professionalising the role and an expansion of existing opportunities to study a foundation degree such as the Forensic Road Collision Investigation Foundation Degree (FdSc) awarded by De Montfort University; the introduction of professionally focused externally provided and accredited CPD is also available which, with further study, may lead to the award of Professional Studies in Forensic Road Collision Investigation BSc (Hons).

3.8

Equipment Contained in a Vehicle

The vehicle used by the Collision Investigation Team is equipped to deal with a broad range of situations which may be encountered when attending a scene. Some of the main items are shown below: • • • • • • • • • • •

Photographic equipment, cameras, tripods and video camera. Electronic surveying equipment primarily used to create accurate 2D plans. Laser scanning device to accurately record and create 3D environments. Scene marking paint, reflective markers and evidential markers. Forensic personal protective equipment (PPE), e.g. gloves, overalls and masks. Tools for vehicle examination. Towed force-measuring device. Skid testing unit to determine coefficient of friction. Lighting devices both static and portable. Evidence bags for forensic/evidential recovery. Body bags and tags which may be required for use following a road death.

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Actions Taken at the Scene

When notified of the occurrence of a serious or fatal road collision, the Collision Investigation Team will attend and secure the scene, or if initial steps have been taken by another officer, those actions will be reviewed and if considered appropriate will be extended. One such action will include the identification of the potential parameters of the scene. This is in recognition that establishing the scene will take into consideration not only the actual area where the vehicle(s) came to rest but also an extended area which will include viewpoints, debris and tyre marks. As part of this process the officer will take an unhindered walkthrough of the scene, without having a preconceived idea of what has occurred. This helps to locate key evidence which will ultimately ensure the maintenance of an unbiased approach to the investigation and the formulation of a forensic strategy. The preservation of life is paramount and will always be prioritised. In addition, there is a general awareness of the need to ensure safety for all. On occasions, the fire and rescue service will deflate the wheels of a damaged vehicle. Their purpose in doing so is to stabilise the vehicle whilst they work on it, to prevent it from overturning and causing further injury. Naturally, efforts by other emergency services attending and undertaking efforts to preserve life, i.e. by rescuing an injured person from a vehicle, can lead to the destruction of some forms of evidence. In order to reduce the loss of evidence, the Collision Investigation Team will attempt to capture key evidence at the scene. This will include the use of chalk/paint to mark key points, e.g. the resting position of a vehicle, tyre marks, gouges, kerb strike, marks in grass/mud, the state of tyres before deflation by the fire service to stabilise a vehicle or other debris which may later be relevant to the investigation. Initial photographs will be taken, and body cameras from the attending emergency services will also be viewed to ensure any changes in the scene have been acknowledged. Photographs of the scene will also assist in supporting the subsequent investigation. Whilst vehicles are equipped with cameras, it is becoming more common for modern technology to be used, including the use of drones to capture an aerial view of the scene, particularly appropriate where multiple vehicles have been involved in the collision or multiple casualties have been incurred. Applying the “investigative mindset” (College of Policing 2018c) is critical when at the scene of a collision. The police officer will consider factors such as the road layout. This will include road markings, road signs, the lighting at the time of the collision and lines of sight. Information of this nature will be recorded, together with any other evidence found at the scene, to ensure its preservation. This will include the photographing of the scene and of other evidence whilst still in situ. An electronic survey will be conducted, including laser scans of the scene. The vehicle(s) may also be subject to a partial or whole examination prior to their removal from the scene to maximise the opportunity of identifying relevant factors. Officers attending the scene will take steps to identify witnesses. This will include the recording of vehicle registration numbers in the vicinity, e.g. those who have stopped to assist or even those delayed in traffic close to a scene, to ensure they

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do not leave without information being gathered. Securing an initial account at an early stage will assist in identifying witnesses who may later be able to provide evidence to assist in the subsequent investigation (College of Policing 2019). Other information gathered at a scene will include the details of injured persons who leave the scene to attend hospital. The presence of other emergency services requires an appreciation of each other’s role and good communication, working to a common priority: the preservation of life. There will often be a meeting at the scene with a representative of the local authority, usually undertaken within days of the collision. The purpose of this is to address any potential issues that warrant discussion and to identify subsequent action, such as the need for additional signage on the approach to a hazard.

3.10 Major Incidents It is recognised that some road deaths are part of much bigger incidents on roads, which are subsequently declared as ‘major incidents’ and which require the attendance of all emergency services. An example of such an incident might be a collision involving a vehicle transporting hazardous chemicals, the spillage presenting a potentially high risk to others. The Joint Emergency Services Interoperability Programme (JESIP) was established to develop levels of cross-­organisational communication and understanding between UK emergency services when responding to major incidents, acknowledging the different priorities of each organisation. The JESIP Joint Doctrine: Interoperability Framework primarily focused on major incidents or critical incidents and developed cross-organisational communication and understanding (Stephenson 2015). The principles of the JESIP Joint Doctrine: Interoperability Framework are now considered good practice for joint working at scenes of collisions (JESIP 2016). It is acknowledged that prior to the introduction of the JESIP programme, each service had its own operational model, particularly in relation to communication; however, the JESIP programme led to the streamlining of some of those processes to aid a shared approach and shared understanding in the event of a major incident. Police officers generally report having a good working relationship with other emergency services.

3.11 Her Majesty’s Coroner It used to be the role of the first officer at the scene to become the investigating officer, gathering all evidence on behalf of the Coroner. The police continue to have a responsibility to pass on case information to the Coroner. The changing structure of the investigation team means that investigation will not necessarily be the responsibility of the first officer attending the scene; however, evidence will be gathered in the same manner as for any road traffic collision. In recognition of the need for early conclusions to cases appearing before the Coroner, documentation for case files is streamlined, and there is a reduced requirement for police officers to give evidence

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in Coroner’s Court. The salient points of the case are presented, ensuring that relevant information is contained. This is particularly so when there is no likelihood of a prosecution. An example might concern a single vehicle containing a lone driver, travelling at excess speed and colliding with a tree, causing the death of that driver. In this situation, there would be no prosecution, and it is appropriate for the Coroner to receive a streamlined evidential report to enable swift completion of the case and to avoid prolonging the process for the families of victims.

3.12 Informing Families of Their Loss As referred to earlier, often the FLO will undertake this duty though occasionally they may not be available initially. In this situation, the delivery of such distressing news would not be delayed but will be undertaken by another available officer at the earliest opportunity. Communicating the news of the death is a particularly important consideration as the use of technology increases, the public use of social media often conveying messages more rapidly than is possible in person, particularly during daylight hours. This occasionally leads to situations where family members arrive unexpectedly at the scene of the collision. Whilst it is recognised that there is never a good way to inform families of a loss of a loved one, being told directly by a police officer is a better option than finding out via, e.g. Facebook or Instagram. However, even the personal touch can be poorly handled on occasion, one example being when a family live in a different police force area to that where a road death occurs and the investigators have to rely on officers in another force to deliver the message—control of the situation is lost by the investigation team, who are no longer able to. Occasionally, friends and families may already be at the hospital with injured relatives at the time of their death, having also been present at the collision or subsequently taken to the hospital following the news of the collision. On such occasions, the information is often imparted by medical staff. On other occasions, police officers will be required to locate relatives and inform them directly. In some parts of the country, the police force offers a training package to prepare officers for delivering a death message to relatives. However, this is never an easy job for any officer to undertake, and it is suggested that no amount of training will help prepare for it. In most cases, an inexperienced officer learns how to undertake this process by working with another, more experienced colleague and learning from them. There is debate around the use of appropriate terms when informing families of their loss, with bereaved families placing different values on the interpretation of the words ‘died’ and ‘killed’, the former being a softer-sounding, almost natural, blameless means of dying, whereas use of the term ‘killed’ may be interpreted as being a more violent, potentially blameworthy death. Therefore, without intending to do so, the messenger can influence the interpretation by the family. What is generally agreed is that irrespective of the words used, the message needs to be succinct, clearly understood and not able to be misconstrued. An example of such a

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message might be “There has been a collision and [name] has died…”. This is clear and to the point; there will be opportunity for further information later. Even so, officers have found that direct messages are not always immediately understood and have on occasion passed the information at the start of a conversation, but then found fifteen minutes later that the family members have not actually taken in the situation and then must be re-informed. Officers describe the experience of knocking on a door, waiting for it to be opened and never knowing what reaction to expect, aware that their next words will amount to ‘throwing a hand grenade into a household and bringing the world down around their ears’. They explain how as realisation dawns for the first person their facial expression changes and then there is an awareness of a ‘ripple’ effect as each individual realises the meaning of the information given. This is an experience which officers never get used to. In contrast, some family members show none of the anticipated emotion and express only an indifference to and dislike of the deceased person. Officers find this reaction equally difficult to deal with. It is important to display empathy towards relatives during this sad time. This can be extremely emotional for all, and in some cases, empathy becomes very personal for the officer who may be aware of parallels with their own family and find they identify more closely with the situation. At such times, it can be extremely difficult not to absorb the emotions of bereaved families, and some officers may find it helpful to explore their own emotions. The officer will maintain professionalism, to enable them to be the conduit that the family may depend on to give initial information and support. This relationship and process are often described as physically and mentally exhausting. Reactions to the news will vary and can generally be placed into three groups: • Some individuals will be disbelieving, showing signs of shock, unable to take in the information. • Some will be calm and collected, taking charge of the situation and immediately commencing practical actions ranging from ‘putting the kettle on’ to calling others and planning the next steps. • Some will react with physical outbursts, punching and fighting, physically attacking the officers on some occasions.

3.13 Coping with the Sudden Road Death Event Some road deaths are easier for an officer to deal with than others. An example of this would be a driver as the sole occupant of a vehicle, experiencing a medical episode at the wheel, leading to the car driving into a fence. In this case, there is only one death, one vehicle involved and relatively minimal damage to property, with a medical explanation being given for the behaviour. In this instance, it is easier to come to terms with the incident for both the officers involved and the bereaved families. There is no prosecution of anyone which means the Coroner will hear the case more rapidly.

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More difficult cases are those where there is a blameworthy party, but it is not possible to undertake the prosecution of the case or where a sympathetic jury don’t convict. Deaths which occur as a result of the actions of others, which lead to prosecution, can also be difficult to deal with. Additionally, those cases which incur a ‘wave’ of people blaming themselves can be difficult. An example of this would be the situation where Angela asks Ben to pick up some shopping whilst on his way to an appointment—something she would normally do and which will take him slightly off his intended route. Ben willingly agrees, but on his journey, an oncoming vehicle crosses his path, and he is involved in a collision, subsequently dying as a result of his injuries. This can result in self-blame by Angela despite the collision being a result of circumstances over which she had no control.

3.14 The Human Factor An important point to be aware of is that the Collision Investigation Team is often sent to collisions which have already been determined as incorporating fatalities. This allows team members during their journey to prepare themselves mentally for their role on arrival and to deal effectively with the scenario they enter. This is often not the case for the first officer at the scene who may not have any indication of what they will be attending. This period of mental preparation is considered extremely important. Sometimes an officer can simply be in the wrong place at the right time. One officer described, as he came back from a routine job, a collision had occurred on the main road ahead. The officer was literally the first on the scene and was suddenly arm deep in blood trying to save the life of a female who later died. He was also the collision investigator on duty and subsequently found himself having issues dealing with the emotions this incident brought. His explanation was that he didn’t have the time to build a mental wall to prepare him. Attending a road death is difficult enough when the victim is unknown. In common with other emergency services, there are occasions when the victim is known to those officers attending. On one such occasion, the victim was a popular former colleague, so every police officer on duty knew that person well. Arrangements had to be put in place to inform colleagues in addition to family members. Attending the mortuary to check personal effects was particularly difficult for officers, one resorting briefly to the use of black humour (Charman 2013) as a crutch for their emotions. The comment was overheard by a mortuary attendant who considered it disrespectful to the victim, although was more sympathetic when the situation was explained. It was an experience which reminded of the need for maintaining an objective stance irrespective of knowledge of the individual. Even experienced FLOs suddenly get hit by the onset of an emotional outpouring by families. One officer described turning a corner into a street next to a club on a late Saturday night to be confronted by a car in the road and a female on the floor. Whilst securing the scene, requesting additional units and administering first aid, he was continually jostled, taunted and shouted at by family members. The female died

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at the scene, and the officer was requested to stay on as an FLO. Such was the intensity of the scene that the officer felt he had to step away from the job stating he wasn’t able to prepare mentally for the job he needed to do and that barriers had already been created by family members.

3.15 Welfare and Support Services Road policing is considered a high-risk area in terms of welfare services. There is a growing recognition that some policing roles incur greater levels of stress; consequently, police forces are increasing the availability of and access to welfare and other support services, many employing psychologists to support police officers who may be experiencing work-related stress. Each time an officer experiences an ‘incident contact’ relating to a death, they will be approached with an offer of support. In addition, in the event of an unexpected and sudden death of a serving officer, there will be a general offer of support to staff force-wide. In addition, some forces undertake twice yearly welfare checks with those in the high-risk areas to monitor the effect of their experiences upon their mental health. This is usually in the form of one face-to-face meeting per year and one written assessment each year. In this way, the police force is able to undertake regular checks of their staff operating in high-risk roles daily. Officers describe dealing with road death as mentally exhausting, the use of the emotional side of the brain, absorbing the emotions of others and constantly thinking of the best way to phrase questions and comments. At an informal level, officers often find it very helpful to discuss experiences together in an environment of common understanding, a form of cathartic release following stressful situations (Waddington 1999).

3.16 Conclusion This chapter has given an overview of the process applied by the Collision Investigation Team when called to the scene of a collision involving a death on the road. It has referred to the roles of individual members of the team and outlined the equipment carried to support them in their initial scene investigations. The role of the FLO, a more recent addition to both the team and to the overall investigation, has been considered, in accordance with guidelines produced by the police service for national implementation. Following the initial family support, their role involves linking them to the investigating team, to ensure they are fully informed about each stage of the investigation. Further support for families is available from several agencies both local and national, including VCAS and Brake the Road Safety Charity. The current police service professionalisation agenda appears to be having a positive impact upon the structure and operation of Collision Investigation Teams. The growth of relevant training to prepare officers for dealing with such events can

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only enhance this process. The personal examples of police officers give an indication of their empathy towards families and friends of victims. That the police service recognises the difficulties such work brings with it is seen in the examples given of supporting welfare services available to police officers and staff undertaking these investigations.

Learning Points

• How might you prepare yourself mentally to manage a road/sudden death? • Consider the impact on relatives of terms, e.g. ‘sudden death’, ‘road death’, ‘killed’ and ‘died’. • Consider the importance of securing the death scene and preserving evidence.

References Brake: The Road Safety Charity. Victim support. 2019. http://www.brake.org.uk/victim-supportt. Accessed 20 April 2019. Bryant R, Cockcroft T, Tong S, Wood D. Police training and education: past, present and future. In: Brown JM, editor. The future of policing. London: Routledge; 2013. p. 383–97. Charman S.  Sharing a laugh: the role of humour in relationships between police officers and ambulance staff. Int J Sociol Soc Policy. 2013;33(3/4):152–66. https://doi. org/10.1108/01443331311308212. College of Policing. Competency and values framework: guidance. 2017. http://www.college. police.uk/what-we-do/development/competency-and-values-framework/pages/competencyand-values-framework.aspx. Accessed 3 Dec 2018. College of Policing. About us. 2018. http://www.college.police.uk/About/Pages/default.aspx. Accessed 7 Jan 2019. College of Policing. Workforce transformation in the police service: an introduction. 2018b. http:// www.college.police.uk/About/Workforce-Transformation/Documents/COP_workforce_transformation.pdf. Accessed 10 Dec 2018. College of Policing. Investigation. 2018c. https://www.app.college.police.uk/app-content/investigations/introduction/#principles-of-investigation. Accessed 14 May 2019. College of Policing. Investigation of fatal and serious injury road collisions. 2019. https://www. app.college.police.uk/app-content/road-policing-2/investigating-road-deaths/?highlight=road? s=roadd. Accessed 18 Dec 2019. Dhani A. Reported road casualties in Great Britain: quarterly provisional estimates year ending June 2018. Department for Transport, 8 Nov 2018. https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/attachment_data/file/754685/quarterly-estimates-aprilto-june-2018.pdff. Accessed 19 April 2019. JESIP. Joint doctrine: the interoperability framework. (2nd edn). 2016. https://www.jesip.org.uk/ uploads/media/pdf/Joint%20Doctrine/JESIP_Joint_Doctrine_Document.pdf. Accessed 2 Jan 2019. McGarry D, Smith K. Police family liaison. Oxford: Oxford University Press; 2011. National Police Chiefs’ Council. Policing vision 2025. 2018. http://www.npcc.police.uk/documents/Policing%20Vision.pdf. Accessed 23 Dec 2018. National Police Chiefs’ Council. Policing our roads together: A 3 Year Strategy 2018–2021. 2018a. http://library.college.police.uk/docs/appref/Policing-our-Roads-Together-partners-copy.pdf. Accessed 19 April 2019.

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National Police Chiefs’ Council. Forensic collision investigation and reconstruction within the police service 2018. 2018b. http://library.college.police.uk/docs/appref/NPCC-Protocol-2018. pdf. Accessed 20 April 2019. Neyroud P. Review of police leadership and training: volume I. London: Home Office; 2011. Police and Crime Commissioner for Cleveland. Victim care and advice service. 2019. https://www. cleveland.pcc.police.uk/Victim-Services/Victim-Care-and-Advice-Service.aspx. Accessed 20 April 2019. Stephenson J. Interoperability and multiagency cooperation. In: Wankhade P, Mackway-Jones K, editors. Ambulance services: leadership and management perspectives. New York: Springer; 2015. p. 107–17. Victim Care & Advice Service. Fatal or serious road traffic collision. 2017. https://victimcareandadviceservice.uk/services/support-bereaved-families-following-fatal-road-traffic-collisions/. Accessed 20 April 2019. Waddington PAJ. Police (Canteen) sub-culture: an appreciation. Br J Criminol. 1999;39(2):286–308.

4

Sudden Death: A Fire and Rescue Perspective Steve Edwards

Abstract

The fire and rescue service provides a first-class immediate response to all types of fires and also focuses on preventative fire safety education targeted at the public. During call-outs, firefighters work in extremely difficult circumstances in which they are exposed to devastating images of human suffering and, inevitably, sudden deaths frequently occur. This chapter exposes the extent of suffering and pain which firefighters witness and considers the way in which their team camaraderie helps them to get through the awfulness of the sudden deaths they deal with daily.

4.1

Statistics

The fire and rescue service (FRS) attended 167,150 (30%) fires from a total of 564,827 incidents in 2017/2018. In England, 30,744 fires in England occurred in a dwelling, whilst 15,577 fires were in other buildings, 22,420 involved a vehicle, 5377 were outdoor fires, and 4015 involved chimneys. There were 334 fire-related fatalities in England, i.e. for every million people there were 6.0 fire-related fatalities. Further, “The fatality rate for older people was higher than for the total population: 8.8 per million people for those aged 65 to 79 and 19.5 per million people for those aged 80 years and over” (Home Office 2018). It is important to be aware that this is the first detailed analysis of fires which incorporate the tragic events at Grenfell Tower on 14 June 2017. Some of these findings are worthy of note, and most correlate with my own experiences over the same period mentioned although exceptions could be as a result of the demographics or affluence of the small area I cover as part of a watch at a station in London. S. Edwards (*) The London Fire Brigade, London, UK © Springer Nature Switzerland AG 2020 T. Scott (ed.), Sudden Death: Intervention Skills for the Emergency Services, https://doi.org/10.1007/978-3-030-33140-5_4

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Regarding dwelling fires, 48% were caused by what is termed ‘cooking appliances’, i.e. chip/frying pans, microwaves and grills. However, they only account for a small amount of fatalities, and the event tends to be smaller in nature. Smokers’ material, e.g. lighters and cigarettes, account for 7% of accidental fires in peoples’ dwellings which led to 20% of fire-related fatalities. Males are more likely to die in fires, and they feature prominently in the 55–64 age range. Other government studies reported that a higher proportion of smoking deaths comprise males aged 45–60 who were living alone and where alcohol or drugs were involved. Electrical distribution and appliances were the source of ignition in 37% of fatalities in dwellings though the Grenfell Tower should be taken into consideration. A most prominent cause of death was a result of being overcome by smoke or gas followed by burns alone. However, the most at risk from dying in fires are men aged 80 years plus and especially those with disabilities. On a more positive note, the reduction in fires and deaths since 2003 can be attributed to a mixture of the following factors, but as already noted, further reading should be carried out for a more detailed understanding. The main reason for this reduction is that 90% of all households in 2016/2017 now have smoke alarms fitted compared to 76% in 2001. This in itself does not prevent fires but will normally alert the occupier of a fire in the vicinity sooner, who would then be able to extinguish the fire themselves or leave the premises safely and call the fire service. Changed cooking practices are a major influence on fire reduction statistics especially as people are moving away from chip pan use and hot oils that used to account for 20% of all domestic fires to safer forms of heating food, e.g. microwave-­ready meals or grilling. Other factors such as a reduction in smoking throughout the population and also improved safety standards in buildings and furniture regulations have all in some way impacted positively on death by fire statistics. From a personal perspective, my advice would be to ensure that you have a working smoke alarm that is tested regularly. All fire services in England are operating free home fire safety visits where the local fire station team may visit your home, identify any potential fire risks, give advice and fit smoke alarms where necessary free of charge. I think it shows that prevention is by far the best policy in reducing fires and deaths.

4.2

Introduction

I joined the London Fire Brigade in 1990, at the tender age of 21. Up until that point, I had never seen a dead body or a sudden death event, so I was ill-prepared for what I would experience as soon as I joined the fire service. The first few days of training to be a firefighter were spent rolling out hose until my fingers bled, in the extremely hot summer sun, presumably to instil discipline into us raw recruits. At the time, it was a highly disciplined uniformed service whereby recruits in training lined up for morning parades, were shouted at, bulled up their shoes and marched and saluted. The first 16 weeks of training consisted of learning how to operate the pumps and put up the large ladders and carry hose aloft and fellow recruits down ladders; they were attached to safety devices in case we dropped them! The following 2 weeks, we were taught to use

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the breathing apparatus (BA) to work in confined spaces as well as first aid, and finally, we had the most boring 2 weeks of classroom-based fire safety legislation. By this time, we were all confident recruit firefighters looking forward to our first station posting. Yet, we had received no training on how to deal with traumatic events such as sudden death and post-traumatic stress disorder (PTSD). On arrival at my first station, I was told to stick close to another firefighter and do exactly as I was told. As a recruit fresh out of training, there were frequent ‘what if?’ questions that included ‘what if I see a dead body?’ The only answer offered was ‘you’ll deal with it, everyone does!’ There was no training at station level either on how to deal with the event or the aftermath. Instead, you would look to your peers to see how they would deal with it and then you would do the same. This continues to happen; until 1 day you realise that you are the experienced firefighter whom the recruits look to for support. In these instances, you are inclined to appear calm and unfazed by anything especially sudden deaths and traumatic incidents. Speaking with the other members of the watch with varying lengths of service all the way down to 6 months confirmed that there is still no training on dealing with sudden death or coping with the effect of the death afterwards.

4.3

Recalling Sudden Death Incidents

Over the years, I have attended many sudden death incidents from fires, road collisions, drownings, freak accidents and, more recently, an increase in what is termed ‘chemical suicide’. My most memorable involved an initial call to a fire in a living room with persons possibly involved. On arrival, smoke billowed from the open windows. We donned BA, broke down the door with a sledgehammer and entered the house with a hose reel jet and gradually made our way to where, due to the heat and the noise, we thought the fire emanated. On entering the fire compartment, and due to low visibility, we could only make out burning furniture and other items. The hose extinguished the fire, and we opened the windows to ventilate the property and improve visibility. It was then that we searched for casualties. It soon became apparent, once the smoke had cleared, that a person had been sat in the chair whilst it was alight. A cursory inspection confirmed full-skin thickness burns to the entire body and no movement nor signs of life. It was a woman, and her clothes had been burnt off; the springs in the seat appeared to be adhered to her body due to the burns making it virtually impossible to lift her out of the remains of the chair. A couple of other firefighters entered the room, and we were asked to remove her from the chair so that she could be taken to a mortuary. On our initial attempt to move her, and to our great shock, she opened her eyes and started to talk to us about whether we were there to help her. She appeared to be in no pain but said that she had difficulty trying to get up, closed her eyes and didn’t move or say anything further. After the initial disbelief, we summoned a paramedic/doctor who confirmed that there was no chance of survival due to the percentage of full-skin thickness burn coverage. We carefully took the chair out of the back door with what remained of the woman in it, into the fresh air, and quietly waited until she passed away. On

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returning to the station, we sat around the mess table in a quiet subdued state and agreed that what we had just experienced was not nice. Once said, it was never mentioned again. We were not offered any counselling at the time. Multiple deaths are invariably difficult to handle especially when children are involved. One incident comes to mind where in the early hours a fire call alerted us to a house fire with unknown persons possibly involved. En route, we received further messages confirming at least six people were involved, five of whom were children. The watch had been asleep at the station yet managed to arrive at the property within 3 min. I was the designated driver in one of two appliances and on entering the street witnessed a large property fully alight against the darkness of the night. Flames exited all windows and the front door, and a crowd of neighbours were panic stricken in the street. Both appliances stopped outside the property, and with the crews on the back now rigged in BA, my initial job as a driver, and with assistance from the second appliance team, was to get the hose off the appliance and engage the pump as quickly as possible to allow the firefighters to enter the property to commence firefighting, search and rescue. At that point, I wasn’t aware of any members of the public because I realised what was at stake, and this made me totally focused on the job. However, bizarrely, I was aware of a man running in and out of the house, obviously suffering burn injury himself, desperately trying to rescue those inside. Predictably, this turned out to be the father who was resisting all bystander effort to prevent him. Another appliance from a neighbouring station pulled up, and the officer in charge had taken his crew around to the rear of the property where they discovered a young girl lying on the patio suffering burns and suspected fractures. She had been literally blown out of the first-floor window. A few minutes later, the firefighters within the property carried a young child out and handed her over to another and re-entered the now totally alight house. Meanwhile, the firefighter ran to the rear of the ambulance with the extricated child, and realising they may need some help, we started cardiopulmonary resuscitation (CPR) with another firefighter, and the ambulance technician then continued CPR until the helicopter emergency medical service (HEMS) arrived and took over the management of the child. No other people were removed though the crew subsequently searched inside the building only to find burnt remains; the extricated child did not survive either.

4.4

Working Conditions

As firefighters in London, whenever we are called to an incident however minor, we will normally be rigged in full fire gear before leaving the station. This consists of our normal everyday uniform trousers and T-shirt, thick fireproof leggings that come up to chest height with a jacket of the same material over the top, thick fire boots, helmet and gloves. In the vehicle whilst making our way to an incident, we will already be getting pretty warm, regardless of the outside conditions. At road traffic collisions (RTC) and similar incidents, we would also wear a fluorescent bib. So, we may already be getting hot as these types of incidents

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can take a long time, especially when extricating a casualty from a vehicle. This would normally involve stabilising the vehicle and then allowing the paramedics and specialists into the vehicle to assess and stabilise the casualty before being advised on the way that they would need to be removed, based on their injuries and how time-critical it may be. There tends to be a lot of noise from the different emergency services whilst cutting equipment, lighting generators, etc. and from crews carrying out different tasks. It often seems chaotic, but underneath, it is organised and based on the casualties’ needs, and even though we may be extremely hot, our ability to work is uncompromised. The situation changes, however, when we attend a property to either extinguish a fire or search for and rescue those inside. On arrival, the designated BA teams don a balaclava-type fire hood, BA, turn their air on and put the mask and helmet on; then, after handing a name tally to a BA control operator, the team prepares to enter the building. Armed with a thermal image camera and a hose reel jet, the crew of at least two will normally make their way to a door that has been opened and may face differing conditions, normally one of the following: • A small fire in the house, minimal smoke and heat and good visibility. They would be able to enter, extinguish, ventilate and leave with relative ease and no ill effects. • A fully developed fire where there will be lots of flames and which looks dangerous, but there will also be fairly good visibility as the fire obviously has a good oxygen supply and the smoke will be exiting the building as well, and although it may be hot, it is often fairly easy to operate and search for casualties and see your way out to remove them quickly. • The last type that is the most dangerous and scary, and more common at night, will be the fire that has been burning for a long time with nobody noticing. All the windows may be closed, so the fire has used up all the oxygen inside and died down, but the temperatures are exceedingly high, sometimes well over 500 degrees. The smoke will be thick and black, so you may not even see anything obvious from outside. On opening the front door or access point, air enters the premises, and this is the most dangerous time where flames can increase suddenly and cause what is known as flashover, which may be witnessed from the outside as a sudden explosion and a suddenly fully developed fire. Presuming this does not happen, the crews will enter normally in a crouched position to try to get below the heat layer if possible, but visibility may now be zero, so even the thermal image camera may be of little or no use as you may not be able to see the screen. You may be told that there have been persons reported to be inside the building, but you have no idea where they are or any clue as to the layout of the premises. The team leader will start to follow a wall inside and stick to it all the way around. So, in theory, if you follow the right-hand wall of a house, you can find your way around all the rooms, searching the floor, behind doors and furniture, in cupboards and baths or anywhere somebody may try to go to escape the fire if they cannot get out.

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Your core temperature is increasing all the time as your body heat has nowhere to go, risking disorientation, heat stroke or heat stress. As you go further in, the noise levels may increase, you may feel the heat increase and hear sounds of ceilings collapsing, but due to the thick smoke, you may not be able to see it. If we are unable to use the thermal image camera, then the first you will know if you have found a casualty or body will be when you crawl into them or place a hand on them. This still makes me jump! The crews will do an assessment and check for signs of life, but this will not always be easy or obvious due to the conditions. You would then attempt to pull the casualty back the way you came, following the hose you have pulled in, or the wall. You would try to get assistance on the radio, but due to the noise around you and sometimes your own breathing, this may be difficult. By the time you exit and hand over the casualty, you will likely be exhausted, suffering the severe effects of heat exposure, and will be visibly steaming. All the above would have taken no more than 15–20 min on one cylinder of air. As we are wearing BA, then odour does not come into it; however, when somebody is burnt and charred in a fire, there is a noticeable sweet smoky smell that some describe as pork. You never forget it.

4.5

Causes, Presentation and Unusual Deaths

Many incidents involve fires, and most die due to smoke inhalation but may later be involved in the fire. Historically, the mode of death has altered according to societal change. When I first joined in 1990, it was common to have fires started by paraffin heaters or the old-style electric bar heaters which were readily available and, in the evening, chip pan fires in, e.g. bedsits where a person had come home after a drink at the pub and then they start to make chips and then fall asleep. Cigarette smoking was also a significant problem. Nowadays as trends change and technology advances, the causes of fires have evolved. Appliances such as televisions and routers or gaming devices can cause fires especially when they are left on standby overnight. Candles being left unattended, not in dishes and being placed on top of televisions, is fairly common, and open fires or wood burners left unattended are a modern cause of fires. In equal measure to the above deaths, road traffic collisions were common incidents. However, these have diminished recently due to advances in vehicle construction, testing and safety equipment such air bags and safety laws such as seat belts, and many people get out of the vehicle and walk away. But the car deaths I have dealt with more recently tend to be at night when alcohol is involved. Similarly, as the above statistics report, some types of fire deaths have decreased due to strengthened legislation governing fire-retardant materials and smoke alarms and reduced reliance on cooking oils and chip pans. We attend incidents that neither the police nor ambulance crew is able to deal with exclusively often where access is difficult or dangerous or where a person is trapped in or under, e.g. a vehicle or building. Sadly, one of the significantly increased incidents the Fire Brigade attend is suicides, in particular the type that is

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termed chemical suicide. This is where the person will use a chemical or gas to carry out the act. They will usually leave a sign on their door warning people not to enter due to a dangerous or noxious substance. The fire service would normally attend in BA to enter the room, check for signs of life and ventilate, so it is safe for others to enter. Other incidents we may attend can only be described as freak incidents, and below are some examples. One incident concerned the death of a woman who had just picked up her young granddaughter from school. They both sat on a low wall next to a bus stop. Directly behind was a large old oak tree, which had decayed over the years, and without warning, one of the largest branches broke off, striking the woman. Amazingly, the branch missed the child. We arrived just after the police and ambulance crew, and after initial checks by the paramedics, we were asked to start CPR. This continued whilst the paramedics and air ambulance crews desperately tried to save her, but due to her head injuries, she was pronounced dead at the scene. Another sad and random accident involved a young man crossing a road on the exit side of a roundabout. A vehicle with a large trailer attached was going around the roundabout when the trailer became unhitched from the tow bar and continued straight on, hitting the man, knocking him over and landing on top of him. When we arrived, we used large airbags to get to him as soon as possible. We carried out first aid including CPR until the paramedic was able to get access and stabilise him. We removed him from underneath the trailer, and he was taken to hospital, but he had suffered serious internal injuries and was pronounced dead on arrival at hospital. Another couple of seconds each way and the trailer would have missed him.

4.6

The Hardest Deaths to Handle

Thinking back over my career and trying to decide which deaths were easier or harder to deal with, based on whether they were young or old or whether they were single or multiple deaths, has been the hardest part to write about. This is not because I have compartmentalised emotions by treating each one objectively, in the same way. As a rule, as soon as I have left the incident, I try to leave the emotion there. So, it has been hard to put my finger on instances where one death has hung around longer in my memory than another. Although every death is sad, for me personally, it has more to do with the circumstances of the incident itself. Specifically, the emotions and reactions of family and bystanders as the incidents unfold. For example, when we attend a road traffic collision where a person is trapped and dying or has already died, it is not unusual for us to be called to the scene after the police and ambulance are already there, the area is cordoned off and the public and any family members have been moved away from the scene. We may well carry out CPR or first aid whilst the ambulance crew stabilise the casualty, and we would be directly involved with the casualty whilst we cut the car and remove them. A lot of emotion has already been dealt with, and the scene has already been managed, so we would be totally focussed on our role and assisting the

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ambulance service team. Those incidents, where deaths have occurred, are much easier to deal with. Conversely, I once attended a scene where a very old lady had been pulled out of a fire, there were no police to keep family and neighbours back and paramedics had not yet arrived. I and another firefighter confirmed that there were no visible signs of breathing and no pulse after she had been handed over to us by the BA crew, so we carried out CPR for a long time on this frail lady, with emotions running high amongst members of the public around us. We continued to carry out CPR, and on arrival, the paramedic administered various drugs and treatments, and we managed to get a pulse; she was stabilised and rushed to hospital, but sadly, she died the next day. Because of the emotions of people around us that evening, it took longer to process before moving on. Sometimes deaths can be harder to deal with at the time, as the circumstances may have been totally preventable, e.g. the fire I described earlier where most of the family lost their lives. Had the children been woken up straight away and had they all walked downstairs and out the front door and called the fire brigade, there would not even have been any injuries. Likewise, any death in car accidents caused by a seat belt not being worn is totally preventable. Fortunately, over the past few years, the fire services nationwide have had a programme where we visit peoples’ houses, fit smoke alarms for free and give safety advice, and although this may not prevent a fire, it may be detected early enough to allow the resident to leave the premises.

4.7

Various Ways that People Die

The majority of fire deaths are caused by smoke inhalation, at night when people tend to be asleep and other people are not around to notice a fire or smoke coming from a window or building. They may not have a working smoke alarm to warn them and suffocate without ever waking up. Also, people may die of smoke inhalation if their exit is blocked and they are unable to escape the toxic fumes. They may try to escape the smoke by hiding in cupboards or under furniture or even in baths. These casualties may become involved in the fire, but the initial cause of death would be smoke inhalation. There are times when people die in the fire, and it is not uncommon for them to be vulnerable due to their being very young or old, infirm or disabled and unable to escape the fire due to rapid fire spread in the building. When fire crews arrive, our first thought is whether there may be persons inside the premises. If we have persons reported, immediate attempts are made to enter the premises, and this is when we are always aware that seconds count and we try to move as fast as possible to find them. If we find a casualty who is suspected to be still alive, they are removed by BA crews and handed over to either other firefighters to carry out emergency care or hopefully ambulance crews who are better equipped to make a swift diagnosis. They may spend considerable time trying to stabilise a casualty before removing them to hospital. This may be due to a high percentage of the body that has suffered burns, and it may be that they do not make it to the hospital or die at the scene.

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Retrieving Dead Bodies from the Scene

When we are involved in retrieval of dead bodies from the scene, there are generally two circumstances: where we are attending an incident such as a fire or RTC and remove a body/casualty in the course of our duties or where we receive a call from another emergency service to assist in the retrieval of a body such as a suicide or to gain access into a building. If during firefighting we find a casualty, unless we are absolutely certain that they are dead, then we will always remove them, bearing in mind conditions such as heat and visibility which may make it difficult to ascertain. They would then be handed over to a paramedic. There are circumstances where even in difficult conditions, it is obvious that they are dead, and they will be left in situ. These may include full-body full-thickness charring from the fire, where rigor mortis has already set in due to the heat of the fire making the limbs stiff and deformed or where a suspected crime has been committed such as murder and the fire has been used to cover this up, but the injuries are so severe it is clear that they are dead. In these situations, although there may still be a fire, as little further damage will be done from water application, there will be no turning over of items involved in the fire, and there would be restricted entry to the premises or compartment to preserve the scene for fire investigation and/or police to carry out their investigative work. After firefighting has concluded, we would be interviewed by the Fire Investigation Team to ascertain the circumstances around the incident, what we saw, whether doors were open or locked and how we gained access. We would then complete statements and subsequently attend Coroner’s Court if required. Other times where we will assist in retrieving bodies from a scene may be where a person has not been seen for a while, and we will gain access to the property. This may be due to natural death, overdose or suicide, amongst other things. If we find somebody, we will check for signs of life, allow access for the other services and then hand over the incident to the police. Where we are in attendance at a car collision or similar and a person is declared dead at the scene but may be trapped, we would go through the same procedures and techniques with care to extricate them from the vehicle or machinery if it is an industrial incident and assist the ambulance crew in moving the body. Finally, at incidents, we may well be the first at the scene if we are called by members of the public due to our fast attendance times and heavy workload of the other services, so, if we attend a fire, we may well have entered the building and rescued a casualty before the arrival of the ambulance service. As stated before, unless we are certain they are dead, we will have removed the person from the premises and handed them over to crews with first aid kits containing oxygen, defibrillators, airways and dressings. This would be continued when the paramedic arrives to allow them to carry out their assessments, and we would only stop CPR when instructed by a doctor or paramedic. It may be slightly different at car collisions when it may be obvious that a person is alive but with serious injuries that may not be apparent due to the nature of the collision such as in the case of suspected internal or spinal trauma.

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If the casualty is still breathing and we have ensured an open airway, then crews would in the first instance not remove or move the occupant, but stabilise them as best as we are able to and ascertain any major blood loss. We would try to have an emergency contingency plan (as they may be trapped) to remove them if their condition deteriorates or they stop breathing. Crews would work under the supervision of the paramedic when they arrive, and this would dictate the speed that the casualty is removed from the vehicle.

4.9

Supporting Struggling Colleagues

I can only speak from my own experiences at the stations and watches on which I have been based. I would imagine that my experiences reflect those of my colleagues throughout a majority of stations brigade-wide. As mentioned previously, throughout my training and early years as a firefighter, there was no accepted training or courses or advice that we received on how to cope with sudden death incidents, and that continues, so it is sometimes hard to spot the signs of a colleague who may be struggling to deal with incidents they have attended. All the watches I have been on have been close with strong camaraderie and team spirit that we do not always appreciate, so we just take these events at face value. We work, eat, sleep, joke and argue together, and we take pride when we are a close watch. We tend to know about each other’s personal lives and what is happening in them and sometimes who is having problems. We would often all talk together and advise, sometimes joke and at other times console, but we would pretty often be aware if there were more pronounced problems at home or outside of work. There is and has always been an acceptance that we can deal with whatever is thrown at us but never actually talk about how we feel after an incident where people have died suddenly and in such tragic circumstances involving fires. Morse (2016) accurately describes the realities of firefighting for which the public are thankfully unaware: …We protect the public from whatever misfortune comes their way, and put out their fires, and tend their wounded, and keep them as safe as we can. We pull the dead from the car wrecks, and cover the bodies at fire scenes so the news cameras won’t bring the horror into the nation’s living rooms. We protect our people from more than just the physical; we keep them from knowing the truth. The truth is ugly, and devastating. People will tell us that they can imagine how horrific it was for us, but they will never, in a million years, really imagine the depth of that horror (p1).

We tend to go back to the station, have a cup of tea around the mess table, joke to lighten the mood and move on. I would imagine there is some sort of equivalent in all professional disciplines that deal with these situations. Again this is just personal experience, nobody has ever admitted to me that their problems were down to the tragedy they have seen or experienced, and I doubt that anybody would suspect

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that those experiences are impacting their home life. This could be enabled by some form of training, to spot the signs and ask the right questions. In London, we have a brilliant counselling and welfare services and multifaith advisors and, in normal circumstances, a management team who care about the welfare of their staff. I have over the years occasionally received a phone call from welfare services to ask if I am OK after an incident, but these used to be hit and miss and mostly just a message left on an answering machine. Firefighters may contact the counselling services for personal issues, and there may be occasions when they will arrange to speak with a counsellor following a particularly harrowing incident, but it would never be talked about. If there was an instance when it was noticed that a firefighter was struggling with an incident, we could only advise or encourage him/her to call welfare services as it can only be on self-referral and management cannot refer staff to counselling.

4.10 Conclusion It is apparent that over the years, fires and fire deaths have decreased, due to the introduction of smoke alarms, building and furnishing construction and advances in technology such as microwaves, and that can only be good news, but in the course of every firefighter’s career, there will always be incidents involving trauma and death with the potential for any of those incidents to affect the firefighters involved emotionally. Hopefully, with a recent public campaign bringing to light people from all walks of life suffering from mental health problems, there may be a culture change where it becomes normal to want to talk about any problems one may be experiencing due to incidents that firefighters have attended. It is to be noted that following some major fires and incidents over the last couple of years, there has been increasing recognition of mental health issues in the workplace, in particular PTSD. There is also a greater emphasis placed on the team to recognise the signs of PTSD in colleagues. Although in its early stage, the need to recognise increased levels of anxiety and the need to support colleagues should be taught from the first day of training; it is good to know that hopefully future firefighters will find it easier to recognise, talk and cope with any potential issues before they become a problem.

Learning Points

• Consider how to advise a trainee how to cope with their first death. • Consider the benefits of team camaraderie in coping with sudden death. • Consider whether or not you would take up welfare services if offered following a sudden death.

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References Home Office. Detailed analysis of fires attended by fire and rescue services, England, April 2017 to March 2018. Statistical Bulletin 17/18 6th September 2018. 2018. https://www.gov.uk/government/statistical-data-sets/fire-statistics-data-tables. Accessed 18 May 2019. Morse M. The ugly truth about firefighting the public doesn't understand. Jul 17. 2016. https:// www.firerescue1.com/health/articles/134918018-The-ugly-truth-about-firefighting-thepublic-doesnt-understand/. Accessed 27 May 2019.

5

Sudden Death: An Emergency Medicine Perspective Joan Clancy

Abstract

When a patient arrives in the emergency department for resuscitation, everything possible will be carried out to resuscitate them. Some will survive, while many go through a range of trajectories and eventually die. This chapter reflects on the collapse to death career of seven patients through various phases en route to a mortuary and considers some of the legal, ethical, practical and emotional challenges faced by emergency doctors when managing the sudden death event in the emergency department.

5.1

Introduction

The majority of sudden death events in the emergency department (ED) start with a telephoned pre-alert from the local ambulance service giving brief available details, their actions to date and an estimated time of arrival. In the current high-pressured NHS climate (Coster et al. 2017), this is a vital step as frequently, the resuscitation room (resus) will already be full with other critically unwell or injured patients receiving life-saving interventions prior to local admission or transfer to a regional centre for definitive care. This may be for conditions such as primary coronary intervention, paediatric intensive care, stroke care, management of aortic rupture or dissection, trauma care and malignant spinal cord de-compression. Where sites are geographically remote from these centres, local agreement will determine the optimum pathway for specific conditions. There is extensive literature on crowding in EDs with recognition that there is increased mortality and morbidity for patients and high stress levels for staff who continue to strive to deliver optimum care despite the enormous challenges. Many strategies have been proposed, but the pressures J. Clancy (*) York NHS Trust, York, UK © Springer Nature Switzerland AG 2020 T. Scott (ed.), Sudden Death: Intervention Skills for the Emergency Services, https://doi.org/10.1007/978-3-030-33140-5_5

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remain (Coster et al. 2017; Higginson and Boyle 2019; Morley et al. 2018; Stang et al. 2015). In 2017, there were 533,253 registered deaths in England and Wales (Office for National Statistics 2018a) with the top five causes overall being dementia and Alzheimer’s disease, ischaemic heart disease, chronic lung diseases, cerebrovascular disease and lung cancer. In 2018 adults between 45-49 had the highest suicide rates at 27.1 per 100,000 males (603 deaths) and 9.2 deaths per 100,000 for females (211 deaths), respectively (Office for National Statistics 2019). In adults under 50 years and children and young people between 5 and 19 years, suicide remains a leading cause of death. In 2016/17 there were 23.4 million attendances at EDs, i.e. 63,000 attendances each day on average (The King’s Fund 2019). Unfortunately, accurate estimates of sudden deaths are difficult to determine with confidence (Baker and Clancy 2006) though the percentage is generally believed to be approximately 0.2% of attendances. Hence, regular though small numbers of deaths occur each week in most departments and this, coupled with the increasing longevity of the population plus the still imperfect end-of-life recognition and planning, this figure will likely continue to rise. Most ED deaths in adults are due to ischaemic heart disease, stroke or brain haemorrhage, sepsis, chronic lung disease, malignancy, haemorrhage including gastrointestinal and ruptured abdominal aortic aneurysm, trauma including head injury and haemorrhage, self-harm and poisoning, frailty and severe dementia. The vast majority of those dying are adults, but tragically, children and babies also die suddenly (Office for National Statistics 2019). In children and young people aged 0-19 years, the commonest cause of avoidable death is injury (Office for National Statistics 2019). Sudden Unexplained Death in Infancy (SUDI), though decreasing steadily over the last decades, accounted for 219 infant deaths in England in 2016 (0.31 per 1000 live births) (The Lullaby Trust 2018). I have been privileged to have specialised in emergency medicine in more than ten emergency departments in the United Kingdom over the past 27 years with my very first experience in the specialty being before that in Dublin. Throughout, I have been involved with sudden deaths in adults and children and seen the absolute devastation on the faces of those left behind who try to make sense of what has happened. For the caring teams, dealing with patients (and their families) who die unexpectedly is emotionally draining and may have ongoing sequelae (Brake the Road Safety Charity 2019). Some of the deaths in ED though sudden are not totally unexpected particularly in individuals with steadily deteriorating chronic conditions who sadly may spend their last few hours in ED when end-of-life recognition and planning has been suboptimal. These conditions include severe dementia, chronic lung disease, severe heart failure and malignancy. The experience for these patients and their families is often completely different as it may bring with it a sense of relief that the family member’s ordeal is finally over, bringing them peace. Work continues nationally to promote early conversations and planning for end-of-life as none of us would envision the pace and demands of the ED environment as an ideal one for the last hours of life (Royal College of Emergency Medicine 2015a).

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To illuminate some of the dilemmas faced at various points in the chapter selected, patient scenarios are presented.

5.2

Patient Scenario A

A pre-alert call informed us that an in-bound ambulance crew was 10 min away with a 99-year-old patient who had been resuscitated in his care home and now had return of spontaneous circulation (ROSC). He was intubated and ventilated and had a normal pulse and blood pressure. His electrocardiogram (ECG) showed non-­specific T wave inversion and mild ST segment depression in the anterior leads. As he was making no respiratory effort, we connected him to a ventilator while reviewing his medical history. On arrival, his nephew explained that his uncle had stated very clearly in the last several months that he did not want to reach his one hundredth birthday which was just weeks away. There had never been any end-of-life conversations or discussion of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) with the patient or family. I explained that the likelihood of recovery was negligible and that he would likely die within minutes if we discontinued ventilation. The nephew was confident that this was in line with his uncle’s wishes. A DNACPR form was discussed and completed. When asked if he wished for any religious input he replied, ‘Yes’, so as a committed Christian and churchgoer, a Hospital Chaplain was contacted who attended within 40 min. While we waited, the nephew sat by his uncle’s bed holding his hand and talking to him while sharing stories of his life with the nurse and myself. He also shared that he was concerned for his mother who was ninety-seven in case she might also collapse; she too had never had conversations about end-of-life preferences or DNACPR, so he took a blank form to discuss with his mother and her general practitioner (GP). When the Chaplain arrived, he actually knew the patient and his family well. He administered last rites as I extubated the patient who took several shallow breaths which stopped as soon as the prayers were completed. Following the postdeath formalities discussed later in the chapter, the nephew thanked the nurse and me and offered his opinion that despite resuscitation and being brought into hospital, his uncle would have been happy that he had a ‘good death’. It is often very clear that a patient’s life will not be saved despite our interventions, and though this death is sudden and unexpected, it may give us, however brief, an opportunity to prepare those who have come with them for the inevitable. It may also allow a patient to be part of that discussion and give them some very limited but precious time to share with their loved ones.

5.3

Patient Scenario B

An 83-year-old lady with multiple co-morbidities and increasing frailty collapsed with lower back and abdominal pain. She was hypotensive with a pulsatile mass in her lower abdomen. Computerised tomography (CT) scan confirmed a leaking abdominal aorto-iliac aneurysm. After discussion with the vascular surgical team, it was agreed that she was highly unlikely to survive the one-hour transfer to them and

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subsequent surgery. She and her family were in agreement that we would provide symptomatic treatment and allow her a peaceful death. She was surrounded by family in ED as she deteriorated steadily over the next hour before cardiorespiratory arrest. They then stayed with her until the required formalities were completed. Some elderly patients may find themselves isolated at the end-of-life as siblings and friends may have already died and adult children or grandchildren live long distances away. In a very poignant instance, an elderly man was in our resus room with an unsurvivable and untreatable dissecting aortic aneurysm. He understood the hopeless prognosis and was overjoyed to speak for a considerable time by phone to his son who lived in Canada. He died very peacefully after an hour or so, and our department received a visit and written thank you letter when his son returned to arrange the funeral and settle his father’s affairs. He was very clear that being able to have that final conversation with his father had helped both of them enormously. Despite guidelines and availability of skilled resuscitation teams, the majority of those brought to ED after out-of-hospital cardiac arrest will not survive (Barnard et al. 2019).

5.4

Patient Scenario C

A 34-year-old pregnant woman was found collapsed at home by her husband on his return after being away for 2 h. A neighbour called ‘999’ and started CPR and paramedics were on scene to find her in cardiac arrest with pulseless electrical activity (PEA). Advanced life support was continued for 30 min in her home before transporting her to the emergency department (ED) after pre-alerting us. We were assembled and ready when they arrived 10  min later. Our extended resuscitation team included intensive care, obstetric and paediatric colleagues in addition to ED and medical personnel with at least eight nursing and anaesthetic support staff. Her husband confirmed that she was healthy and 12  weeks pregnant. We continued 2-min cycles of CPR with 1 mg of adrenaline administered every other cycle. In addition, we treated her with thrombolysis for a likely pulmonary embolus. Her family was kept informed throughout the resuscitation attempt and was present with her during most of it with our full support. Despite our combined efforts, we could not achieve ROSC and concluded after an hour or so that ongoing attempts were futile. Her family readily accepted support from the Hospital Chaplain, and following last rites, resuscitation was stopped, and death confirmed soon afterwards. They stayed with her for an extended period before leaving ED to return home after completion of post-death formalities detailed below. Post-mortem examination subsequently confirmed the presence of a massive pulmonary embolus.

5.5

Patient Scenario D

A 60-year-old male smoker who had shoulder and epigastric pain intermittently for 3 days was seen in an Urgent Care Centre on two occasions and discharged home with a prescription for symptomatic treatment of assumed gastroesophageal reflux.

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On the third day, he collapsed at home. An ECG confirmed an inferior wall ST elevation myocardial infarction. He had bradycardia and hypotension, and the ambulance crew was advised by the regional Percutaneous Coronary Intervention (PCI) centre to attend our local ED for stabilisation prior to transfer. Sadly, despite treatment with atropine and external cardiac pacing, he deteriorated and could not be resuscitated when he had a cardiac arrest. His large family was present throughout including rotating in and out of the resus room in smaller numbers. They realised soon after their arrival that his prognosis was very poor and he was unlikely to survive. After confirmation of his death, they stayed with him in ED for several hours. Post-mortem examination confirmed the diagnosis of myocardial infarction. An inquest into his death concluded that though he died from natural causes, there were missed opportunities for earlier diagnosis of myocardial ischaemia. Countries with active public access defibrillation programmes have a much higher survival rate from out-of-hospital cardiac arrest. Denmark introduced community access defibrillation programmes in 2011 following which survival rates were quadrupled (Bækgaard 2019).

5.6

Patient Scenario E

A six-week-old baby’s parents woke at 09:00 and realised their baby had not cried for an early morning feed. The previous feed was at midnight, and the baby was apparently completely fine afterwards. They called the GP who promised to do a home visit. Two hours later when this had not occurred, the grandmother decided they should attend the local hospital ED. Here, the baby was discovered to be ‘periarrest’ with drowsiness, poor respiratory effort and a heart rate of fifty with capillary refill of 6  s. An initial working diagnosis of sepsis was considered, but on commencement of CPR using the two-handed chest-encircling technique to deliver cardiac compressions, it was immediately detected that there were multiple bilateral posterior rib fractures. Over the ensuing number of hours, resuscitation continued with recurring episodes of ROSC following intubation and ventilation, bilateral chest drain insertion, intra-­osseous insertion, fluid bolus delivery and defibrillation on three occasions. CT scans were not carried out as the baby’s condition was deemed too unstable for transfer. The regional paediatric transfer team was contacted and made preparations to attend. After several hours, it was decided that the prognosis was extremely poor with minimal likelihood of survival and that CPR would not be performed at the next inevitable loss of cardiac output. Parents and grandparents were in resus for the majority of the time so were aware of the critical situation and agreed that this was appropriate. The Hospital Chaplain baptised the baby before giving last rites. This was possibly the most emotionally draining experience for most of our team including myself. There were many tears shed by those in the room. Within a short period, further cardiac arrest occurred with confirmation of death soon afterwards. Dealing with sudden death at any age is deeply upsetting, but death of a child is almost indescribably painful and distressing for all who are involved, and staff must be alert to the circumstances surrounding the death.

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Post-death investigations and post-mortem examination confirmed the cause of death as severe brain injury in addition to confirming multiple rib and limb fractures including already healed fractures of the upper limbs. One of the baby’s parents was eventually charged with murder and sentenced to life imprisonment. Staff debriefing after difficult situations is vital to ensure they feel supported and any individual struggling to cope is offered continuing support. For some staff, death of a baby or child in ED may be their first exposure to such an event, and they may feel overwhelmed. Increasingly, the NHS is working hard to maintain staff well-being and positive mental health. Newly bereaved families receive continuing support and are allowed to spend as much time with their relative as they would like or need. Once death has occurred, the ED doctor will formally confirm it and document in the patient record the time and confirmed or suspected cause. A majority of ED deaths are unexpected and thus are discussed with the Coroner’s Office which collates all the available information and decides if a cause of death is known and whether or not there is any cause for concern or suspicion that the death was not from natural causes. Post-mortem examination may be required if scans or other diagnostic tests were not performed at this last attendance or do not provide a definite cause of death. This is discussed with the family in the immediate period after the death. The Coroner’s Office is contacted in many areas in England through the local police service who acts as the initial referral point, but there may be variation, e.g. Scotland, Wales and Northern Ireland. Usually, the most senior doctor present will initiate contact. Typically, two police officers will attend ED to gather the information known at this time and talk the family through the next steps. There will be formal identification of the deceased following which many relatives decide it is time to return home. Ensuring that the bereaved relatives receive support is vital as for many it may be the first close death they have been involved in. This may be achieved by telephoning their GP though some EDs routinely have all those in attendance registered as ED patients so that their emotional needs can be assessed and managed (Royal College of Emergency Medicine 2015b). It has been my lifelong practice to offer families the choice of being in resus while the emergency team treats critically ill/injured patients and/or when patients are in cardiorespiratory arrest. Many publications confirm the overall benefits of this approach especially its value in aiding the grieving process (Johnson 2017). However, not all families are able to face this, so it is vital that they do not feel pressured into being present during disturbing and distressing scenes and that it is perfectly acceptable for them to wait in a suitable private room close by. Regular updates will keep them informed and allow them to change their minds should they wish. The advantage for the health team of family presence is that the family has a live and continuing update and will often observe the situation is not improving despite their desperation to the contrary. In such circumstances as team leader, I have prepared the family for this by restating what our actions to date have been and that sadly there is no suggestion of any physiological response from the patient and that we should consider stopping our interventions. This finality is clearly not what they are hoping for but, their witnessing of the team’s interactions and discussions

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in regard to terminating our efforts in some way, helps them to comprehend that the death of their loved one is inevitable. The husband of a wife in her late thirties who collapsed suddenly was present throughout the 50 min she was being actively resuscitated and became aware of the hopeless outlook and said to me, ‘I think doctor it is time to stop’. In fact, I was about to confer with him and the team with a proposal to do so. He told me afterwards that he had seen clearly that we had done everything to save her but it was futile. Post-mortem examination confirmed a massive subarachnoid haemorrhage. Having the family present in resus has not always been well-received by some team members who may express fears that they will interfere, be in the way or be looking out for errors. They clearly need support which is best achieved by allocating a trained team member to be spatially close to them, provide explanations for the unfolding events and recognise when they become overwhelmed and need a break. I recall an anaesthetist colleague indicate that the father of a young adult patient with severe injuries after a road traffic collision should leave resus as she was about to be intubated. I could see from their facial expressions that neither patient nor father wanted this, so after confirming their wishes, I let my colleague know that I would support the father who stayed by her side throughout. Sadly a short while later, she had a cardiac arrest from which we could not resuscitate her. Afterwards, though heartbroken, her father repeatedly expressed his thanks that we had let him be with his daughter at the time when she needed him most, at her death, and that she had not died alone. The following day, he returned with cards and gifts for the team stating that he could see that everything had been done in trying to save her life and confirmed that he and his family received great comfort from being with her. Meeting family for the first time who arrive after a patient has died is more traumatic for everyone involved as there has been no opportunity to develop a relationship with them and we may have minimal information regarding their relative.

5.7

Patient Scenario F

We were pre-alerted by ambulance staff that a 14-year-old boy would arrive in 15 minutes. On arrival, he was in asystole, and despite comprehensive resuscitation effort over a 2-h period, we could not achieve ROSC. The boy was taking part in circuit training at school when he collapsed and went into cardiac arrest. There was no evidence of trauma to his body. CPR had been started immediately by school staff. The family had been notified, and one parent arrived during resuscitation. An emergency nurse accompanied me to the family room to provide an update on his condition. The parents had been contacted by the school to say that he had an accident and had been taken to ED, so they assumed he had sustained a limb injury. However, soon after arrival, resuscitation had been withdrawn and death confirmed. This parent’s anguish and disbelief were probably the most profound I have ever encountered and similar to the rest of the family who started to arrive within the next few hours. I will forever hear the anguished screams from many of them at their sheer incomprehension that despite being fit and well, his life was suddenly ended

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completely without warning. They spent many hours with him in a quiet non-clinical room until they felt they could leave him and return home. He was discussed with the Coroner’s team as his death was completely unexpected and there was no clear cause of death. Post-mortem examination revealed no abnormalities, and the inquest held concluded that his death, though from natural causes, had no clear explanation. These difficult conversations are usually led by the most senior doctor available accompanied by an experienced emergency nurse. If feasible, a more junior doctor should also be present to gain experience of the process as no training programme can truly replicate the sensibility of the situation. Undergraduate and postgraduate curricula address difficult communication situations and specifically ‘breaking bad news’, but many professionals may never have had formal training in dealing with totally unexpected sudden death. Senior medical staff availability varies with larger departments more likely to have 24 h cover, while those with limited numbers may rely on non-consultants to lead these conversations especially when out of hours. My approach to communicating bad news which seems to resonate with families is to sit at eye level with them and introduce myself and any other team members present. I then ask what they know about the situation so far. When they have explained their understanding I then follow this with “We have been treating him for (condition) but I am really sorry to have to tell you that I don’t have good news for you and despite our efforts he has not responded and has died”. I then stop speaking so they may absorb this devastating, catastrophic and life-changing news. I may then add any further information which I believe may be relevant and ask them if they have any questions. I ask if they need to contact anyone and whether they would like other support from the multifaith chaplaincy team. I then leave them with the emergency nurse while I return to complete the patient records and contact the Coroner’s team which is required when the death is sudden and unexplained (GOV.UK 2019). I tell them that I will return in a short while in case they have further questions and to explain what needs to happen next. It can be an emotionally charged interaction, and I have occasionally shared tears with family members. It is essential to use the words ‘death’ or ‘died’ rather than euphemisms such as ‘passed away’, ‘gone’ or other phrases that may be misunderstood by family hoping desperately that their loved one is still alive (McGuinness 1986). In some instances, patients may be brought into ED either remote from home or when their family is unavailable. In this situation, we make all efforts to contact next of kin by telephone to let them know their relative is critically unwell or injured. If the patient has died before we have managed to speak to relatives, it is my personal practice to inform them during the telephone conversation as otherwise they can feel frantic in their efforts to reach the hospital and thus put themselves at risk during their journey. Though devastated at this news, feedback over many years from families confirms that this is the right approach. On numerous occasions, relatives have stated to me that having the death confirmed before they set out on their journey has enabled them to arrive with less haste and panic despite their devastation at the news. In some instances, families have delayed their journey until after being contacted by the Coroner’s Office.

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Patient Scenario G

A 59-year-old healthy man was working away from home with colleagues. On failing to arrive at work one morning, his employer found him face down and unresponsive in his lodgings. On arrival at ED, he had a Glasgow Coma Score (GCS) of 3/15 and a respiratory rate of four per minute requiring assisted ventilation. His heart rate was forty-four per minute and blood pressure 190/110, pupils were symmetrical and poorly reacting to light. CT confirmed catastrophic intracranial bleeding. Discussion with the neurosurgical team confirmed his prognosis to be extremely poor and that he would not benefit from surgical intervention. His wife had been contacted by his employer, and when she phoned, she was told of his critical condition. She lived hours away so made arrangements to travel immediately. We discussed the real possibility that he may not survive until her arrival and she agreed that a DNACPR form was appropriate. I advised her to have a companion travel with her which she readily agreed to. Over the next 2 h, there were calls from his mother, three siblings and two adult children all requesting details. By prior agreement, the patient’s wife would phone the ED hourly for updates, and all other callers were asked to contact her for updates. Sadly before any family had arrived, he went into cardiac arrest and was not resuscitated. At the next update approximately 10 min later, she was given the news of his death. It was not totally unexpected as his blood pressure had steadily reduced over the previous hours. She arrived several hours later, and following a face-to-face conversation with me, she sat with her husband until other family members arrived. She thanked us all for caring for her husband and for keeping her updated during her long and difficult journey. Clear comprehensive documentation is essential to ensure all relevant details are recorded with accurate timelines and decisions made including discussions with family and other teams both within and external to the hospital. The names and roles of those in attendance during the patient’s care are listed, and a copy of the clinical record is provided for the Coroner’s team. A report will often be requested by the Coroner from the most senior doctor involved in the patient’s care to aid understanding of the patient’s presentation including relevant investigation results. From these and post-mortem results, if one has been conducted, the Coroner will decide if the cause of death is clear and whether there is any evidence of an unnatural death. Where an inquest is held, the Coroner will make a decision regarding further reports required from other team members. The NHS legal team will provide support and guidance for staff who have been asked to assist the Coroner by providing either a report or statement or to appear in person as a witness in an inquest. Junior medical staffs are encouraged also to seek support from their clinical supervisor with nursing staff receiving support from senior medical staff in the department as well as their senior nursing colleagues and line manager. Though acute hospitals have well-established organ and tissue donor coordinators who will interact with families and have in-depth discussion of the potential for donation, it is often a member of the ED team who initially identifies this possibility (see Chap. 11 for further details). I truly learned the value of this while working in Ireland where it was common to meet again, families who had

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agreed to donation and who expressed their gratitude for being given the opportunity. They spoke of how it was sometimes several years before they really understood the power and impact that enabling another person to live well had on their acceptance of the loss. Children and young adult sudden deaths are especially hard to cope with. Working in a large inner-city department, a mother came screaming through the door with her three-month-old baby that she had been carrying through town in a baby sling when she noted that he looked grey and was not breathing. Sadly, we could not resuscitate him, and his death was ultimately due to ‘Sudden Unexplained Death in Infancy’ (SUDI). On another occasion, a pre-alert from the ambulance service informed us that the body of an eight-year-old boy was being brought to the department so that the paediatric team could carry out post-death examination and investigations as his death appeared unnatural. His parents had called for an emergency ambulance when he suddenly became unresponsive having apparently got up for school as usual and been sat eating breakfast. When the ambulance crew arrived, they found no signs of life, and he was cold with limb stiffness compatible with death some hours previous. Police were called, and the death was investigated as potentially non-accidental, so his family was not allowed to accompany him to the hospital. When he arrived, I was shocked at how emaciated he looked. After full post-mortem examination and investigation, the cause of death was given as diabetic ketoacidosis; he had not been known to have diabetes. This family’s tragic loss of their child was compounded by the manner in which they were initially assumed to be complicit in his death. It serves as a sad reminder to treat the bereaved with sensitivity and empathy pending full investigation of cause of death.

5.9

Conclusion

In almost three decades of working in emergency medicine, I estimate that I have been directly involved with the sudden deaths of more than three hundred patients. Each had their story having often lived long and full lives though some had hardly started their lives at all. The most heart-wrenching concerned those in whom death struck without warning as people were taken from their families with little or no time for preparation. Despite the ongoing pressures in emergency departments, dealing with death is an essential skill for all staff because families deserve our best support to be able to come to terms over time, with their loss. Support and training for staff will ensure they receive the best that we can possibly provide. Learning Points

• How might you assess the relatives’ knowledge of the event leading up to the death? • Think about how best to express genuine condolence to a distraught relative. • Identify the criteria for referral to a Coroner.

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References Bækgaard JS, Viereck S, Møller TP, Ersbøll AK, Lippert F, Folke F.  The effects of public access defibrillation on survival after out-of-hospital cardiac arrest: a systematic review of observational studies. Circulation. 2017;136(10):954–65. https://doi.org/10.1161/ CIRCULATIONAHA.117.029067. Epub 2017 Jul 7. https://www.ncbi.nlm.nih.gov/ pubmed/28687709. Accessed 26 Dec 2019. Baker M, Clancy M. Can mortality rates for patients who die within the emergency department, within 30 days of discharge from the emergency department, or within 30 days of admission from the emergency department be easily measured? Emerg Med J. 2006;23(8):601–3. https:// doi.org/10.1136/emj.2005.028134. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564158/. Barnard BG, Sandbach DD, Nicholls TL, Wilson AW, Ercole A. Prehospital determinants of successful resuscitation after traumatic and non-traumatic out-of-hospital cardiac arrest. Emerg Med J. 2019;36(6):333–9. https://emj.bmj.com/content/36/6/333.info. Accessed 26 Dec 2019. Brake the Road Safety Charity. 2019. Sudden bereavement: a traumatic and challenging experience. https://www.suddendeath.org/uncategorised/75-challenginggrief. Accessed 24 Dec 2019. Coster JE, Turner JK, Bradbury D, Cantrell A. Why do people choose emergency and urgent care services? A rapid review utilizing a systematic literature search and narrative synthesis. Acad Emerg Med. 2017;24(9):1137–49. GOV.UK. When a death is reported to a coroner. 2019. https://www.gov.uk/after-a-death/whenadeath-is-reported-to-a-coroner. Accessed 6 May 2019. Higginson I, Boyle A. What should we do about crowding in emergency departments? Br J Hosp Med (Lond). 2018;79(9):500–3. https://doi.org/10.12968/hmed.2018.79.9.500. Accessed 10 May 2019. Johnson C.  A literature review examining the barriers to the implementation of family witnessed resuscitation in the Emergency Department. Int Emerg Nurs. 2017;30:31–5. https:// doi.org/10.1016/j.ienj.2016.11.001. Epub 2016 Nov 30. https://www.ncbi.nlm.nih.gov/ pubmed/27915124. Accessed 26 Dec 2019. McGuinness S. Death rites. Nurs Times. 1986;82(12):29–31. Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: a systematic review of causes, consequences and solutions. PLoS One. 2018;13(8):e0203316. https://doi.org/10.1371/journal.pone.0203316. eCollection 2018. Office for National Statistics. Deaths registered in England and Wales: 2017. 2018a. https://www. ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregistrationsummarytables/2017. Accessed 5 May 2019. Office for National Statistics. Unexplained deaths in infancy, England and Wales: 2016. 2018b. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/ bulletins/unexplaineddeathsininfancyenglandandwales/2016. Accessed 5 May 2019. Office for National Statistics. Suicides in the UK: 2018 registrations. 2019. https://www.ons.gov. uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheu nitedkingdom/2018registrations#suicide-patterns-by-age. Accessed 23 Dec 2019. Ref: ISBN 978-1-78386-914-5. http://digital.nhs.uk/pubs/aande1516. https://digital.nhs. uk/data-andinformation/publications/statistical/hospital-accident%2D%2Demergencyactivity/2015-16. Royal College of Emergency Medicine. End of life care for adults in the Emergency Department. 2015a. https://www.rcem.ac.uk/docs/College%20Guidelines/5u.%20End%20of%20Life%20 Care%20for%20Adults%20in%20the%20ED%20(March%202015).pdf. Accessed 24 Dec 2019. Royal College of Emergency Medicine. End of life care for adults in the emergency department. Best Practice Guideline RCM, London. 2015b. https://www.rcem.ac.uk. Accessed 5 May 2019. Stang AS, Crotts J, Johnson DW, Hartling L, Guttmann A. Crowding measures associated with the quality of emergency department care: a systematic review. Acad Emerg Med. 2015;22(6):643– 56. https://doi.org/10.1111/acem.12682. Epub 2015 May 20

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The King’s Fund. What’s going on with A&E waiting times?. 2019. https://www.kingsfund.org. uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters. Accessed 23 Dec 2019. The Lullaby Trust. SIDS & SUDC facts and figures. 2018. https://www.lullabytrust.org.uk/ wp-content/uploads/Facts-and-Figures-for-2016-released-2018-revised-September-17.pdf. Accessed 24 Dec 2019.

6

Sudden Death: An Emergency Nurse Perspective Petra Brysiewicz, Amanda Klette, and Tricia Scott

Abstract

After a person dies in the emergency department, a series of activities form the procedural base to sudden death. The person is declared dead; the body must be identified, cleaned, wrapped and transported to a mortuary. Evidence relating the death must be documented, and property is to be packed carefully. The process has a temporal aspect in that each cannot occur out of sequence. Relatives may soon arrive, and they need to be supported by the emergency nurse, trauma counsellor or the hospital chaplain. This chapter considers the procedural base to sudden death work by emergency nurses.

6.1

Introduction

Sudden death is a frequent event in the emergency department (ED), which emergency nurses are required to handle with competence, confidence and sensitivity. Once a person has died, a range of care procedures and legal processes must take place though the highly charged ED milieu may not be the ideal location to carry out sensitive, compassionate care of the deceased and his or her relatives. Nevertheless, all efforts should be made to respect the wishes of the deceased and family as far as possible. It is especially complex for the emergency nurse when the deceased

P. Brysiewicz (*) University of KwaZulu-Natal, Durban, South Africa e-mail: [email protected] A. Klette Trauma Programme Manager, Private Hospital Group, Cape Town, South Africa T. Scott Healthcare Education and Research Consultant, Hertfordshire, UK © Springer Nature Switzerland AG 2020 T. Scott (ed.), Sudden Death: Intervention Skills for the Emergency Services, https://doi.org/10.1007/978-3-030-33140-5_6

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sustained mutilating injuries, the death is a suicide or the mode and timing of the death is considered unacceptable, e.g. the accidental death of a child, an older person being hit by a bus or murder. For some emergency nurses, whether we choose to admit it or not, we may experience a sense of guilt or failure when a patient dies, asking the question “What if…?” (Isaacs 2015). Handling these scenarios creates an emotional toll as emergency nurses struggle to do the right thing or express appropriate words of comfort, so cognisant of this, we try to support the grieving relatives and the emergency team. Consider a situation where a mother was driving her children to school and was involved in a motor vehicle collision. She is not injured, but one of her children has died on impact, the other child has minor injuries and the husband is on his way to the hospital. As the ED nurse, you are concerned first and foremost with your patients, the mother and her child, but who will look after the father? There may be reactions of anger, guilt and severe emotional distress. There will be questions of what if? We need to be prepared to listen and acknowledge their pain, however it is manifested. This chapter offers some guidelines to assist emergency nurses with managing the sudden death of a patient in the emergency department. Sudden death occurs usually following a sustained resuscitation which may take different trajectories, e.g. very fast and sudden or a gradual decline. Whatever the trajectory once death has been declared, a series of procedures are to be followed to prepare and transport the deceased to the mortuary. This chapter will try to deconstruct these activities.

6.2

Anticipation of Death

It is important to have a system in place whereby we can communicate with the emergency services on scene before the patient arrives. This affords the hospital time to prepare for the specific type of patient that will be arriving and their current life/death status. Many facilities have trauma activation systems, whereby a message is sent to the team indicating that a critically ill patient is en route. This message is sent to all who will be involved in the management of the patient including nursing staff, trauma surgeons, radiography staff, phlebotomists, theatre staff, ICU staff and anyone else required to manage the patient. The message system reduces the amount of time spent phoning all the areas and rather allows the staff to prepare for the patients’ arrival (de Lange 2016; Redley et al. 2018). All emergency teams require a knowledgeable and experienced leader to steer them through the resuscitation phase. Delegation of roles before the patient arrives is imperative to the prompt management of the patient on arrival (ATLS 2013; de Lange 2016; Redley et al. 2018). Emergency nurses perform an integral role in the process of caring for all patients coming through the resuscitation room, medicine and trauma specialities, and should therefore be involved in the development of care practices within their unit (Kamalizeni 2015).

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Death Declaration

Following recognition that no more can be done for the patient in terms of resuscitation, the emergency doctor with responsibility for the case will seek agreement from the resuscitation team and declare the patient dead (see Chap. 5). Confirmation of death is based on the following observations: • • • •

No palpable carotid pulse. No heart sounds heard. No breath sounds heard. Fixed and dilated pupils (it is important to remember that this cannot always be used as medication given as part of resuscitation efforts could affect this response). • No response to painful stimuli. • ECG strip shows no rhythm (ATLS 2013). A patient can however still have a heartbeat whilst being mechanically ventilated but be legally dead due to a lack of brain function. The ventilator may not be turned off until the legal criteria for death have been met (Harding 2015). Time of death is important to document as it assists in investigations should there be an inquest.

6.4

Identification

To preserve the identity of the person who has died, a formal continuous means of identification must be followed. Again, local variation exists, and some departments secure an identification band around the wrist, whilst other departments place it around the ankle. A further label is secured to the outer covering of the body, usually a white hospital sheet or a hospital shroud though increasingly body bags are easier to use. Information must include the person’s name, unless the person’s name is unknown in which case the sex of the person is written, i.e. male or female, followed by the hospital identification number, date, time of death and the location of the death, e.g. emergency department.

6.5

Preparing the Body

Performing the last offices can be an emotional and stressful procedure, and how this is approached can have a profound impact on the family/significant others who will carry this memory and associated images with them forever. It is therefore essential that the body is re-presented to the relatives in a calm and restful repose. When handled well, the deceased person would look as if they are asleep, and this is especially hard to achieve where there is significant trauma to camouflage. Every effort should be made to cover unsightly injuries with either gauze

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and tape or a wound dressing. During body handling, universal precautions should be observed which requires that the emergency nurse wears disposable non-sterile gloves, a plastic apron, a mask and protective eyewear (if there are large volumes of body fluids). In the case of unexpected or sudden death, washing the body and removing clothing are not always recommended, especially in a forensic case. Indeed, blood patterns may form a vital piece of forensic evidence if a murder is suspected. Similarly, endotracheal tubes and intravenous cannulae must remain in situ. The presence of such clinical apparatus may be distressing to the family, so gentle explanations about each device and supportive explanation and communication may be helpful. It is important to explain to relatives that you have not cleaned the body or removed medical devices as the police still need to gather evidence in order to investigate the death. Explaining what each device is used for should be in layman’s terms, in a manner that the relatives can understand. Be honest with the relatives as witnessing the body of a loved one is distressing, without the added trauma of seeing a possibly disfigured body. The following guidelines can be used, and in most situations, more than one person is required. The body should be laid supine and, if possible, the limbs should be straightened with arms placed by the sides of the body. Clothing should be gently removed from the body, neatly folded and placed with care into a bag or packet, which can then be returned to the relatives. Often, due to trauma, copious body fluids may be present, e.g. blood, vomit, sputum, urine or faeces which should be washed off using a bowl of water, soap, clinical paper rolls and a clean towel. The face and hands should be given special attention because these areas are most frequently exposed to relatives who may wish to kiss or caress their loved one. Many departments dress the body in death attire, usually a white cotton shroud, then cover the body with a clean sheet. If necessary, absorbent pads may be placed under the body to prevent seepage of body fluids and to avoid further distress to the relatives. The body should not be covered completely as relatives may wish to hold the deceased’s hand or touch them one last time. They cannot identify their loved one if the face is covered, and identification of the deceased is important for the relatives as they may not have accepted that it is their relative lying there until they see them. The body is left like this until the family has had an opportunity to spend time with their loved one if they wish and to say a final goodbye. The eyes tend to lose their lustre within minutes becoming quite dry, so as soon as possible, they should be gently closed using a sweep of the fingers, though it can be a source of frustration to find an eye has opened again, requiring repeated closure (Scott 2003). If corneal or eye donation is to take place, close the eyes with gauze moistened with normal saline to prevent them drying out. The mouth should be cleaned of any debris using suction and teeth cleaned using a toothbrush and toothpaste if possible. Dentures are best removed, cleaned with a toothbrush and toothpaste and then reinserted. If the mouth drops open, a rolled-up towel (some departments use soft sandbags) is sometimes helpful when placed under the chin for support.

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Performing last offices forms an essential emergency nursing role although this can generate apprehension, so much support is needed for less experienced members of the team. The experienced nurse will perform each procedure in quiet reverence, showing respect to the person who has died. Indeed, some nurses are known to engage in silent prayer as they carry out each aspect of their role, whilst others may talk to the body as if they were still alive. Special attention should be given to respect the various cultural and spiritual rites of passage in death, e.g. Muslim, Sikh, Judaism and Hindu. It is essential to protect modesty whilst preparing the body by ensuring that no area is unnecessarily exposed. Emergency nurses who have experience in carrying out this process should accompany more junior nurses to show them how to perform the role with dignity, and frank discussions prior, during and following the preparation of the body can help to alleviate anxiety.

6.6

Property

Any property on the patient (clothing, jewellery, artefacts, e.g. bicycle helmets) should be carefully removed and retained for return to the relatives if they so wish. Once again, the policy of the facility that you are working in must be followed. Frequently, to access the body for resuscitation, clothes may have been cut off. This situation should be gently explained to the relatives who should then be asked how they would like these items to be returned, if at all. The nurse can say things such as “I am very sorry, but when we tried to help your husband, we needed to quickly cut his clothing. I can either fold them into a container for you to take home or, if you prefer, I can dispose of them for you”. Some hospitals will arrange for special items to be washed/dry-cleaned so that relatives may be able to take them home. Frequently, relatives will ask the emergency nurse to dispose of some items especially if they are beyond cleaning or repair. This request should also be recorded in the patient’s notes, and the items should be disposed of in the appropriate container. Any property handed over to the relatives should be recorded in compliance with hospital policy, taking special care with any valuables, e.g. wallets and jewellery, which require the signature of a witness. Generally, all valuables should be clearly documented before handing them over to the next of kin. Valuables may be left on the body if the family requests this; however, ensure that this is documented (and possibly witnessed) on the nursing notes and any documentation accompanying the body to the mortuary. Clear and concise documentation is imperative as questions may be asked following the removal of the body.

6.7

Death Pause

At closure of body preparation, some emergency nurses may wish to take a moment’s silence to reflect upon and honour the persons’ life. In some countries, this is known as the death pause (Bartels 2015).

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6.8

Transportation

The emergency nurse is responsible for ensuring that the body is sent to the correct mortuary; most people who die suddenly will go to the same hospital mortuary, and an autopsy (post-mortem examination) may or may not be performed. Indeed, a doctor may report the death to a coroner in the following cases: • • • • • • • •

The cause of death is unknown. The death was violent or unnatural. The death was sudden and unexplained. The person who died was not visited by a medical practitioner during their final illness. The medical certificate is not available. The person who died was not seen by the doctor who signed the medical certificate within 14 days before death or after they died. The death occurred during an operation or before the person came out of anaesthetic. The medical certificate suggests the death may have been caused by an industrial disease or industrial poisoning (GOV.UK 2019).

In the case of a suspicious death, before transporting the body, ensure that your hospital policy has been followed. All tubes must be left in place; the body is not to be washed and should be handled as little as possible. Refer to local policy regarding jewellery and clothing and the donning of shrouds though generally nothing should be placed on the body. These restrictions are important elements in the chain of investigation, and emergency nurses are ideally placed to identify, preserve and collect evidence (Peel 2016). The body is labelled, and time of death must be correct. All documentation of procedures and communication must be accurately recorded. When the body is transported to the hospital mortuary by the hospital porters, an emergency nurse will often accompany the deceased. The family needs to be made aware of where their loved one is going. If the body has not already been identified in the resuscitation room, then the relative may be asked to identify the body at the mortuary. If possible, the emergency nurse who was working with the deceased will explain to the family where their relative has been moved to and why. They may have questions around the management of the patient or any last words uttered prior to death by the patient; the emergency nurse will be in the best position to answer these questions or concerns. In this instance, a nurse should be present to support the grieving relative. It is important to write down contact numbers, addresses, etc. for the relatives and to hand it to them as they frequently forget verbal information given due to this being an extremely emotional situation. Some emergency departments have special bereavement coordinators who then arrange to contact the relatives a few days later to offer support and to reflect on the happenings of that day.

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Relatives’ Reactions

Sudden unexpected death is always difficult and emotional, even when it is someone who has lived a full life. The relatives we interact with at this time have had no time to prepare themselves for this traumatic life-defining event and often express extreme anxiety and lack their usual control. Death due to suicide, road traffic collisions, drownings or murders have an impact on how the relatives react to the news of the death. It leaves them desperately grasping for understanding and meaning. Generally, the doctor with responsibility for the resuscitation will inform the relatives of the news of the death. It can also be difficult for the emergency nurses who have just spent time trying to resuscitate the deceased as they tell the waiting relatives that the resuscitation was unsuccessful and their loved one is dead. Indeed, some nurses prefer to spend time in the resuscitation room rather than face the waiting relatives (Scott 2003; Wright 1991). This is because they may harbour anticipatory fear about the intensity of the relatives’ reactions to the news of the death and feel ill-equipped as they struggle to find the right words of comfort. Relatives’ reactions vary from immediate denial of the death, screaming, anger, wailing, bargaining and silence. On one occasion, a child was brought to the ED, cold and not breathing; the baby had sudden unexpected death in infancy (SUDI) otherwise known as a cot death. The mother was hysterical and screaming and was taken to the counselling room, whilst the father sat silently next to the child’s bed, hand on the child’s chest with tears falling down his cheeks. On another occasion, a relative punched a hole in the door leading into the resuscitation area in pure anger over the death of a loved one. It is important to remember that there is no correct way to respond to this life-defining news, and as ED nurses, we must expect and be able to deal with any reaction displayed by families (Williams and Haley 2017). It is important that the nurse understands that all reactions are normal and generally none are personally targeted towards the nurse. To protect our own emotional well-­ being, it is recommended that emergency nurses find ways to understand their own grief and feelings about death when trying to support others. Personal emotions should be kept in check, and it should be remembered that the emergency nurse’s role is to provide support to the family and not for the family to console the nurse.

6.10 Support to Family/Significant Others Most departments offer a private quiet room away from the noisy, busy department so that relatives can be supported in a dignified way. Such rooms tend to be a peaceful, tidy and comfortable area where the relatives may digest the devastating news of the death of their loved one. Ensure that there are comfortable chairs for the family members to sit on if desired and that water and tissues are readily available. A range of spiritual texts may be made available which the relative may wish to refer to whilst they await news, e.g. the Bible, the Koran, the Guru Granth Sahib or the Torah respective to Christianity, Islam, Sikhism or Judaism. Additionally, it is

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helpful to be able to access a toilet, sink, mirror and telephone nearby. Most of all, try to be attentive but not intrusive, remaining calm, and remember that people react differently so there is no right or wrong way to mourn the loss of a loved one. During our nursing training, we devoted our time to learning practical aspects of nursing and doing observations, blood pressures, temperatures, etc. Lectures were attended on ethical and legal processes related to accurate documentation of our scope of practice. We practiced setting up intravenous lines and intubating patients, but few of us were taught how to tell a person that their loved one had died. Bob Wright (1991), a well-respected nursing colleague and counsellor, published the first book offering guidance on how to handle the sudden death event. Bob taught us to prepare a comfortable room to receive the relatives and offered ways to find words of comfort for those who are about to face the worst possible message about someone they love. It is questionable who should be the person to inform the relatives of the death of their loved one and whether this is solely the domain of the emergency doctor. Indeed, it is often the emergency nurse who sits in the relatives’ room and liaises between the resuscitation room, alerting relatives to how their loved one is progressing. Occasionally, a relative may pre-empt the death message by saying “She’s died hasn’t she?” This reaction can throw the emergency nurse who may not know what to say, and it is necessary to contemplate how best to respond to this question. There is little empirical evidence asking relatives what their wishes would be in this situation. What is undoubted is that emergency nurses are heavily depended upon at this time and our role is to provide comfort and support to people during one of the most difficult, vulnerable and life-defining moments in their life. Every family’s needs differ, so emergency nurses should intervene flexibly and anticipate their needs no matter how small or impractical those needs may be. Frequently, it is hard for emergency nurses to know what to say to relatives to ease their deep pain, so here are some suggestions that may be helpful. Try not to tell them that you know how they are feeling; you don’t, and even if you had a similar experience, it is not the same as what they are going through now. They need you to acknowledge their individual tragedy and how devastating it is. Talk openly with them by asking them to tell you about their loved one. It might help if you have had time to form a rapport with the family, which is often difficult in the emergency department setting. Only do this if you feel it is appropriate. Ask them to tell you what they need: “Do let me know if there is anything that you would like me to do or anyone that you would like me to contact….” At this time, it is extremely hard for the relatives to make sense of the devastating news, and often, they cannot tell you as they don’t know what they need. Offer options, e.g. a cup of tea especially because they may have a very dry mouth and have been rushing to get to the hospital. Offer to phone someone to come and support them, and ask their permission to say, e.g. “It’s nurse (name) at (hospital) emergency department. I have been asked by Mr (name) to contact you. He has given me permission to tell you that his wife was brought in by ambulance today and he is in need of support. Is it possible for you to come straight away please?” Sometimes,

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it may be the telephone connection that is required, and then, the relative can personally speak with the individual. The emergency nurse might also offer to contact someone to collect them from the hospital as it could be unsafe for them to drive and most people are very willing to help during these sad times. Clear instruction needs to be given regarding the correct location, where to park their vehicle and who to ask for on arrival to the department. Hospitals may be able to waiver the parking fee for relatives in this situation. It is preferable to write down addresses and contact numbers of the mortuary where they may visit to sit with their loved one. If you observe that they are totally overwhelmed, they should be given a little time to regain composure, telling them you will come back to check in on them in a short while. Be prepared to sit with them in silence for what may seem like quite lengthy periods until they gather their thoughts sufficiently to speak. Ask them if it would be helpful to talk with the doctor who attended their loved one, and ensure that the doctor will be available before you offer this. If you know that the doctor is busy, offer to schedule a date and time for them to meet the doctor, so that any unanswered questions may be answered. This helps relatives to understand more clearly the events of the day leading up to their relative’s death. You may offer the services of a counsellor where they are available or offer to contact a religious/faith leader at their request. Have a discussion with the relatives about whether they would like to spend some time with their loved one, making it clear to them that it is entirely their choice. It is essential that family members who wish to see the body have an explanation of what to expect prior. This is because they may never have seen a dead body before and after death the body rapidly undergoes physical changes. This is frequently such a stark contrast to the last time they saw them alive. Discuss any tubes that may be present and what they are for. In the case of a motor vehicle collision, there may be blood or disfigurement; they need to be prepared for this. It is important to be honest with the relatives; this will allow them to prepare for what they are about to see. As emergency nurses, we must remember that we see disfigured bodies every day, but for this family, it could be the first time, and added to that, it is a loved one. We must use layman’s terms instead of medical jargon, e.g. “…there is a large cut on the face,” rather than mentioning a …“8  cm laceration from the temporal aspect to the pinna of the ear.” Answer any questions about what happens next. Relatives may have no idea which funeral home to call or what to tell the funeral home. Explain which mortuary they will be transported to and that they will be handled very gently and looked after there.

6.11 Sensitive Conversations Some questions could be raised about, e.g. autopsy, organ and tissue donation, requesting medical records and documentation for life insurance so be prepared to answer as many of these questions as you can. It is okay to say to someone that you

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don’t know what to say. Relatives are usually aware that in that moment, nothing that anyone says will make any difference to the reality that they are now faced with. Make sure that contact numbers are given to the family before they leave the hospital. They may have questions later once the reality of the situation sinks in and they are not feeling so overwhelmed. Take your signals from the family, and allow them space as they may want to spend time sitting with the deceased or with other family members only. Most emergency departments now have an allocated room or, at the very least, a space to afford them this privacy and time. Allow them to express their grief in their own way, and withhold judgement if they do not conform to how we think people should grieve. Death is a cultural and spiritual experience, so there is no right or wrong here. They may laugh, weep, cuddle the deceased and wail over the deceased or may not even want to go near the room, preferring to remember the person as they were. These normal responses should be respected.

6.12 Supporting Colleagues Be aware of the impact a death can have on yourself and those that you work with. This is not only medical staff; remember, for example the emergency department cleaners who mopped the blood from the floor. They were all involved in the resuscitation yet may not have their emotional needs addressed. Occasionally, when an event is overwhelming, the emergency nurse may need to ask for help from another staff member and possibly seek support later from a counsellor or a senior colleague. Even though in an ED you will only have had contact with the patient and relatives for a short period of time, the impact can be profound. Discuss with your colleagues how you feel. These reactions are normal and a perpetual reality of being an emergency nurse. Sometimes the accumulative effect of dealing with multiple tragedies can incapacitate a person (Wright 1991), so if you feel that working with repeated sudden death is affecting your everyday home and working life, then you may consider seeking expert assistance. Discuss with your unit manager, human resources, independent counsellors or your hospital faith/spiritual leader about how you feel. Most hospitals offer employee assistance to facilitate staff to deal with the stressors of working life and to establish appropriate coping mechanisms. Indeed, in the United Kingdom, the recently established “Our Blue Light” website provides a supportive infrastructure to all emergency services at http://ourbluelight.com. As colleagues, handling the same kind of events on a daily basis, we need to become more observant and look out for each other, encouraging catharsis through conversation with one another, and to seek help to continue to contribute to emergency care as mentally healthy individuals (Ameritech 2015). It is also sometimes helpful to try to separate work from home by finding an outlet such as exercise, meditation or perhaps going for a long walk with a trusted companion to disclose feelings in a cathartic way and try to make sense of some of these happenings. Use an outlet that is specific for you.

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6.13 Reviewing the Events of the Day Holding a brief meeting following the resuscitation can also allow everyone to verbalise what went well and what they might do differently next time. When the team discuss their thoughts, tension can be reduced, and team members become less likely to carry the emotional baggage of the resuscitation home with them. It is however very important to note that there is no current evidence that psychological debriefing is a useful treatment after traumatic incidents, and compulsory debriefing is certainly not recommended (Rose et al. 2002).

6.14 Conclusion As members of the professional team dealing with sudden death, we must be prepared to put our own feelings and emotions aside for that moment, so that we can be present with those in crisis. Whilst it is acknowledged that death is part of our reality, it is not ‘normal’ to deal with these raw emotions and images on a daily basis. Once we accept this, we not only can find ways of developing coping mechanisms for ourselves but also can assist those new to our profession to find coping mechanisms that work for them. Sharing with others our experiences will allow them to understand that managing these traumatic situations is a process and it is okay to not be okay. Learning Points

• How might you perform last offices, and what lasting image will you try to create? • How would you respond if a relative pre-empts the death message? • Consider why you should contain your emotions when talking with relatives?

References Ameritech. How to cope with loss as a nurse. 2015. https://www.ameritech.edu/blog/dealing-withdeath-as-nurse/2018. Accessed 5 May 2018. ATLS S. and International ATLS Working Group 2013 Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg 74, 5:1363. Bartels J. The pause.me. 2015. https://thepause.me//. Accessed 5 May 2018. de Lange S.  Improving Patient Handover Practices from Emergency Care Practitioners to Healthcare Professionals. 2016. https://repository.up.ac.za/bitstream/handle/2263/56956/ DeLange_Improving_2016.pdf?sequence=1. Accessed 5 May 2018. GOV.UK. What to do when someone dies. 2019. www.gov.uk/when-someone-dies. Accessed 30 Oct 2019. Harding M. Death (Recognition and Certification). 2015. https://patient.info/doctor/death-recognition-and-certification. Accessed 5 May 2018.

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Isaacs E.  Grief Support in the ED. 2015. https://emedicine.medscape.com/article/806280-overview. Accessed 5 May 2018. Kamalizeni D. The lived experiences of nurses caring for burn victims at a burns unit of a public sector academic hospital in Johannesburg. 2015. http://wiredspace.wits.ac.za/jspui/bitstream/10539/19483/1/MSc_NURSING_KAMALIZENI_2015f.pdf Peel M.  Opportunities to preserve forensic evidence in emergency departments. Emerg Nurse. 2016;24(7):20–6. Redley B, Brysiewicz P, Heyns T. Effective communication with the acute care team. In: Wallis L, Reynolds T, editors. AFEM handbook of acute and emergency care. 2nd ed. Cape Town: Oxford University Press; 2018. Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2002;2:CD000560. Scott P. Sudden death processing: an ethnographic study of emergency care. PhD thesis, University of Durham, Durham. 2003. Williams L, and Haley E. What’s your grief. Supporting Grieving Families: tips for RNs and others on the front line. 2017. https://whatsyourgrief.com/supporting-grieving-families-tips-rnsnurses/. Accessed 12 April 2019. Wright B.  Sudden death. Intervention skills for the caring professions. Edinburgh: Churchill Livingstone; 1991.

7

Sudden Death: A Hospital Chaplaincy Perspective Imam Rizwan Rawat, Rachel Allen, John O’Neill, and Mary Porter

Abstract

Religion and spirituality often come into focus when people face emotional stress, physical illness or death, helping them to remain calm and peaceful even for those who do not believe in any God. The role of the Hospital Chaplain is to enable authentic conversations and committed presence with people who are dying which often includes prayer and ritual. This chapter considers the experiences of a team of Hospital Chaplains who each bring their individual Spiritual and Faith perspective and rites during the sudden death event.

7.1

Introduction

The British Social Attitudes Survey has been conducted annually since 1983 when three thousand people provide personal information about specific aspects of their life. Religion or belief in the workplace and in service delivery is of particular interest. As of September 2017, more than half (53%), a record proportion of people in Britain, described themselves as having no religion, the highest ever level (NatCen 2017). This figure has steadily increased since records began, i.e. 31% in 1983. Societal change has had an immense impact on the range of religions practised in the United Kingdom. Globalisation has significantly impacted on the health sector in recent years (Scott 2010) particularly concerning shifts in health legislation which encouraged health professional migration whereby

I. R. Rawat (*) · R. Allen · J. O’Neill · M. Porter Spiritual and Pastoral Care Team, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK e-mail: [email protected] © Springer Nature Switzerland AG 2020 T. Scott (ed.), Sudden Death: Intervention Skills for the Emergency Services, https://doi.org/10.1007/978-3-030-33140-5_7

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emergency personnel increasingly work in a country other than the country they were born in. Increased migration has also impacted on the range of backgrounds experienced by patients. When a patient enters the emergency department, they may be in physical and spiritual pain and may gain comfort when a practitioner speaks with them in a gentle and caring way. Health professionals in contact with patients are encouraged to be responsive to a diverse range of cultural, religious and faith (and no-faith) needs. It is at this point that the patients and their family should be asked if they might benefit from the presence and support of a Hospital Chaplain. In the sudden death situation, time is often extremely limited, so communication with the relevant Chaplain should not be delayed. Specific aspects of a person’s life and death are sacred and must be respected in the healthcare setting though the unique circumstances of the emergency setting limit available time to understand what the patient and the family may wish for their loved one should they die suddenly and also after death has occurred. Indeed, the liminal space between life and death is immensely sacred, and the images retained and the way it was handled by those involved will be remembered for a long time afterwards, so there is only one occasion to do the best possible for them. In this sense, the contribution of the Hospital Chaplain is essential and helps alleviate spiritual pain and suffering so that the dying person may depart from their life peacefully. This chapter was created by a team of Hospital Chaplains who represent a range of faiths and also no faith and who offer spiritual support to people in need in the imminent moments prior to death and following death in the emergency setting of a hospital in England. Consideration will be given to the spiritual needs of the patients and their immediate loved ones, and en route, the various authors will try to explain their own struggle as they provide just a little comfort through prayer, connectedness and religious community when providing pastoral care in emergencies. Of course, as mentioned earlier, some patients and families may have no religious affiliation, so an important Humanist section has been included.

7.2

Reflections on Spiritual and Pastoral Care

I have worked in the NHS for nearly ten years as a Mental Health Chaplain and for the last three years as team lead for a multifaith and belief team, many of whom are fairly recently recruited. For me, call-outs to the children’s emergency department have been among the hardest. In my experience, call-outs involving children are more likely to follow suicide or accidental death, such as drowning whilst swimming outdoors. In these situations, death intrudes unexpectedly into a family’s life. As duty Chaplain, you walk into the situation with a short briefing from one of the nursing staff, to meet the family who are often in shock, sometimes shaking, and unable to speak coherently or engage with you. They have requested a Chaplain. You’re not always given more information than this, so it is difficult to know whether the family practises a faith or is not religious or what they are looking for from you. I suspect they don’t always know themselves. I sometimes feel powerless.

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All my mental health experience and instinct mean that I want to give the family space to absorb the shock and not push them to say their goodbyes too swiftly by having an immediate blessing of whatever tradition, religious or non-religious, for their loved one before they are ready. I try to help them retain some control and agency in the midst of their loss and devastation and to show that I am there and will stand alongside them for as long as they need me. I do not wish to ‘fix’ their distress in a rush perhaps because of my own need to bring this to a resolution, by ‘saying a nice prayer’ and then leaving, never to see them again. Yet, perhaps for some who experience deep emotional pain, despair and disorganised thinking, there is a need to be led through this situation in some way. There may also be unspoken pressure from the hospital to free up an emergency bed for a patient still living and in need of it. When I walk into the room, I don’t know the family or the child who has died; I can sense at times the difficult family dynamics exacerbated by shock and grief. I can’t help with these at this moment, but can only observe and try to be sensitive and ensure everyone is included in what is offered. For those who don’t feel ready to mark this ending by entering the room to be with the person who has died, I make them aware that this isn’t the last opportunity. It is possible to go and spend a few last moments with their loved one later at the hospital mortuary or at the funeral house. I tend to ask the family what they would like from me and to wait and see if they ask for anything additional to a prayer. Often, if they are able to, they want to talk about the person who has died and to talk about what has just happened in detail, processing it. Grief overwhelms and subsides in waves, and eventually, this gives way to silence as they gather their thoughts. The rituals of faith, whether the family want traditional rites of passage or a more general sense of there being an afterlife, or simply of the value of this child’s life, can help. Ritual has a place at times of transition, and yet there are no set prayers for the suicide of a child. For me, as a Priest, as a Chaplain, all I have to fall back on is my humanity and a sense of suffering finding a place in the heart of God and of nothing being unreachable by love. There are no easy answers or platitudes, and in any case, to utter them would be an affront to grief. Prayer in these situations is not hard; I want to give honour to the life that has ended, and I want to offer the family solidarity in their grief. I want to be a channel of strength and consolation for them, if this is possible at this moment. So, I offer myself for these things and hope that the prayers within my heart will be a help, if not now, then at some point when they look back and remember. I commend the child into heaven, in full knowledge that their family want them to be on earth, and I struggle with my own sadness that this is not possible. The emergency department staff are also often distraught at the death, perhaps keeping their feelings at bay by offering practical support, cups of tea and quick acts of kindness as they go about their work, which needs them to stay focused. The play specialists have been particularly brilliant to work with in children’s emergency department; they have a sensitive way of supporting families following the death of a child and making referrals to the Chaplaincy service and have been one of the professional groups I have valued working with the most.

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Our team comprises people who in one way or another represent most of the world’s religions and non-religious belief. I deliberately recruited Chaplains and Honorary Chaplains in this way so that the whole patient population has access from the NHS to the comforts of their faith or belief, especially at end of life. The only group who needs external support is Roman Catholic patients needing a priest for end-of-life care. When a patient is Roman Catholic, our team contacts a local on-duty priest to ask him to come and say last rites. As NHS Chaplains, we will usually also be there, outside the relatives’ room door, available to support the Priest if needed, on behalf of the hospital trust. The hospital trust offers staff debriefs following traumatic death, though for some reason the Chaplains can sometimes be left off the list of those to be invited to attend. As a team, we try to give each other space after having been called into traumatic situations. As team lead, I offer my team the opportunity to talk to me individually or as a group if they feel they would benefit or to someone else outside the team and to take time away from work where desired. I ask what they would find most helpful as we are all strong characters and all quite different people. I can remember being quite zombie like following one 2  am call-out to the children’s emergency department. I got lost on the way out of the hospital to home, a drive I do twice a day. I then slept but was affected still the next day when I felt that I just wanted to talk to people who had also been there the night before. I appreciated not talking or thinking too much about it when I was with the team as it helped me to keep going despite the emotional display that I had witnessed. We now have a system of clinical supervision in place, and between sessions, the team can call the person who offers this if needed. Being there for each other is at least a small spark of kindness in the midst of loss and all the raw emotion of emergency work. I think good supervision is crucial for spiritual and pastoral care teams generally. Without it (in general terms and I characterise), I would worry about the potential risks of Chaplains and Pastoral Caregivers becoming so open to people’s pain that they become overwhelmed by it or being so used to the adrenaline rush that comes with an out-of-hours call that they become a junkie for the adrenaline of emergency work, dependent on other people’s suffering for their own sense of spiritual purpose, or so hardened to other people’s suffering that it becomes a normality and unremarkable. Emergency work could equally produce a level of bitterness and disillusion with the unfairness of life that may be a hindrance to living fully and happily. Most people’s normality includes emergency only very rarely, so those involved regularly in emergency care need to be especially attentive to maintaining a balance in life.

7.3

Islamic Spiritual Support

On occasions when emergency department doctors, nurses and general support services have tried their best to support a patient and they have died suddenly, there may be uncertainty about how to attend to the spiritual needs of the deceased and their family. Who do they call? The Chaplain! I have worked as a Hospital Chaplain

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for around six years, starting as a volunteer and now working in a full-time capacity in the NHS. I have had some of the happiest working days of my life in this great institution yet, paradoxically, some of the hardest and emotionally testing. Today, I would like to write briefly of the experience of being called out of hours to support a family who had lost their son. One night, I received a phone call from one of my colleagues asking for an Imam (Muslim Chaplain) to support a family whose baby had died in the emergency department. I rushed to the hospital as quick as I could only to find out that tragically, their baby was just six weeks old. I arrived at the emergency department where the doctor directed me towards a room where I met the baby’s distraught family. I then supported the parents and two other family members as we walked to the viewing room. This is where I saw their baby for the first time since he had died. To me, he looked a healthy weight for a 6 week-old, and he still had the intubation tube in his mouth. The family asked me to pray a blessing for their son. I recited certain verses from the Holy Quran and some prayers for compassion and kindness from the Hadith (traditions from the Prophet Muhammed), and then, I offered additional religious support to the family. On finishing, the Consultant Paediatrician spoke with the family about the next steps explaining how the death was classed as a ‘Coroner’s case’. There was no easy way to say this. The family asked for the intubation tube to be removed before their son was taken to the mortuary as it seemed important to them. However, the Consultant Paediatrician was unable to give the green light as the retention of clinical tubes is a legal requirement. Naturally, after hearing this, the family, specifically the mother and aunt, broke down, screaming and wailing uncontrollably. The Consultant and I, as staff, tried to maintain our own composure whilst witnessing their immense grief. The family did eventually regain composure, and I managed to keep on a brave face on for them; however inside, I was melting away and didn’t know how I would get back to my normal working life. Looking back at this day, I don’t know if I could have done anything better. It usually is so rewarding for families to receive a blessing from the Hospital Chaplain, but it seems that the situation escalated so quickly. Personally, I would never wish this on anyone. In this case as the baby was six weeks old, full funeral rites will be given for the baby. The family had made their own arrangements for the funeral and burial. Regarding Muslim death rites, the timing of the death is considered to be determined by Allah, so aggressive resuscitation may be considered an affront to Allah’s will. Relatives may wish to prepare the body of the deceased themselves though this does not mean that non-Muslims would be excluded though their contribution may be limited to straightening the limbs, closing the eyes, sealing wounds and attending to medical devices (Scott 2010). It is important that “…the body of the deceased faces the Kaaba, the black cube shaped building in the centre of the Masjid alHaram, the Sacred Grand Mosque in Mecca” (Dudhwala 2019), the birthplace of the Prophet Muhammed of much significance as a spiritual location. Issues of postmortem examination will likely be met with abhorrence as the body of the Muslim is considered sacred and should not be dissected but buried whole though the

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benevolence associated with helping another person through organ and tissue donation is evolving as NHS Blood and Transplant works with faith leaders so that religion is no barrier to donation (NHSBT 2019).

7.4

Humanist Spiritual Support

This section provides a Humanist response to sudden death; however, as a new member of the team, I have rarely been called in response to sudden death in the hospital. There are several possible reasons. In part, it is because I only work a few hours a week, so I am less well-known across the hospital, and I am only on-call once a month, although this does not mean that I would not come in if I was asked. I think perhaps more significant is that at the time of a sudden and unexpected death, the thoughts of those present tend to turn to whether there is a need for specific religious prayer or ritual. At present, there are still relatively few Humanist or nonreligious Chaplains or Pastoral Care Workers employed within the NHS, so we have much to do to demonstrate the support that we can offer. As a Humanist, I do not enact any commonly recognised rituals. For those who have no religious belief, there is no common culture in the way we respond to death; there is no agreed liturgy or any recognised tasks or rituals that we must undertake at the end of life. Moreover, we do not have shared beliefs in an afterlife as offered by religion, but what I have learned from the death of my own loved ones and what I am recognising in my work within the hospital is that whatever our beliefs, whether in a deity or not, in heaven or not or in an afterlife or not, there can be a need for something that marks the death event, something that acknowledges the sometimes awe-inspiring, sometimes deeply shocking and sometimes unbelievable or unreal moment or the almost unnoticed moment when the living breathing person takes no further breaths. This is when your own life as you have known it comes to an end and your relationship with the one you have loved begins to change. So what as a Humanist can I offer to someone who like me has no religious beliefs on the occasion of sudden death? I bring my experience as a Humanist Funeral Celebrant where we commit the body of the loved one to its end, and I commit their memory to the hearts and minds of their loved ones—and I am recognising how this applies at the time of death within the hospital. On one occasion, I was asked to help with the very sudden and totally unexpected death of one young man. He had died suddenly of an unrecognised disease and had been sufficiently resuscitated to be on life support. The brain stem and other tests indicated that this should be withdrawn. His partner, a non-believer herself, wanted him to have a blessing even though he was a non-believer because she knew this would bring his family comfort. At first, I felt somewhat at a loss. I had no such ‘blessing’ of my own to draw on, and I felt that I could not offer him a blessing that I could not wholeheartedly believe. So, I listened to her talking about their life together, their love, their hopes, the difficulties they had overcome and how she would be comforted by imagining him being with loved ones who had died before. So, I was able to turn this into

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her ‘blessing’ to him, telling him that he was going with all her love and her promise to go on loving him and knowing that his love would always be within her to give her strength. I was sending him off with her blessing to be with their loved ones. So whilst I have no faith in the religious sense, I do have faith in enduring love and enduring influence and in relationship that continues after death, albeit in a different form. So, I learned that as a Humanist, I have something significant to offer at the time of sudden and unexpected death.

7.5

Buddhist Spiritual Support

Death is sudden on many occasions, and it is a hard time for the family as well as the professionals involved in the situation. At the time of death, Buddhists consider it to be the most appropriate time to see a Buddhist Monk (or Chaplain). The dying person may either listen to spiritual chanting, e.g. via their mobile phone, or call a Buddhist Chaplain to discuss and contemplate their thoughts. So, the presence of a spiritual person is immensely beneficial in expressing their thoughts from the heart. The dying person’s family will certainly contact a temple to gain emotional support. However, because of the suddenness of some deaths in emergency department, the family may not be thinking clearly or from a position of strength enough to consider contacting a Buddhist Monk. It is always helpful, in these circumstances, if the staff could offer that support; the family will certainly appreciate it then and at a later point in the grief experience. On a practical note, the presence of a Buddhist Monk gives them an inner confidence as they worship with them at this difficult time. I will personally light a candle and say a chanting (prayer) to the person’s name. This would take place at the centre where the Chaplain is affiliated and the family derives comfort from knowing that the Chaplain is chanting and he is focusing his blessings on them. Then, the Chaplain will spend a few minutes reciting a chant of protection and merits transfer to the deceased life. The essence of the religion emphasises enlightenment and moral virtue, and merit transfer is enacted as a mental process whereby the people left behind may rejoice in the good things that the deceased had done. In this way, the relatives honour the dead. The Buddhist Chaplain will then share the blessings with the family to try to ease their emotional difficulties by practicing a few minutes chanting, listening to the words of the Lord Buddha and breathing meditation. After that, the Buddhist Chaplain will connect the family with relevant people to support with further guidance and to discuss future activities.

7.6

Catholic Spiritual Support

A mobile rings, and the conversation goes something like this: Wife Chaplain

Hi, lunch is ready! Okay. I’ve just finished, so I’ll be home within about twenty minutes.

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Wife Chaplain

Are you sure? What do you mean Am I sure? Of course I am darling. I’ve just finished, and I’m on my way out of the door. Do you need me to bring anything home? Wife No, only you. Chaplain Okay. I’ll see you soon…. I’ve got to go, a call coming in. Love you! Hello Chaplain here, how can I help? Switchboard This is switchboard, the emergency department is on the line. Can I put you through? Chaplain Of course. Doctor Hi, we need a Roman Catholic Chaplain urgently; how long will it be before you can get here? Chaplain One minute. I’m just outside the door. Doctor Shall I tell you what’s happening? Chaplain Just the name. Tell me the rest in a minute. I’m on my way now. As I approach the emergency department, both the doctor and I acknowledge each other and hang up. A 45 year-old man has been rushed in with heart failure. The emergency department team has tried relentlessly to keep him alive and now needs to remove the oxygen and assistance in anticipation of ‘nothing more to do care’ (Glaser and Strauss 1968). Before doing so, the family, including mother and teenagers, surround the bed and ask for the last sacraments which include anointing, absolution for all sins of the past and communion, but communion is not going to be an option. A Roman Catholic lay Chaplain working within the NHS, or a Deacon, cannot administer sacraments which are reserved for ordained priests only. Here is the dilemma: Should I call a Priest, but then, the compounding dilemma is that it’s Sunday so they are all busy with their respective services and pastoral support. I speak with the doctors who say they cannot prolong the process of life as they have already done so by extended waiting for family members to arrive. I am not a medical person, so I do not understand the reasons behind this. I offer an ancient prayer ‘Go forth Christian soul from this world ...’ before removal of the life support devices such as airway and ventilator machine. Sighs and cries pour forth from the family, but acceptance comes after pastoral care and having explained that God is merciful and present and the desire and intention will be heard by God. The shock of the patient dying does not sink in straight away as the emphasis is on ensuring the dying person is anointed; he must receive the ‘last rites’ of some kind if not actual anointing. I offer prayers including ‘Go forth Christian soul’, and each member of the family blesses their loved one on the forehead with holy water. It is so beautifully wrapped into a small service including a ‘Hail Mary’ and an ‘Our Father’ and ‘Glory Be’, followed by a hymn where all joined in that the family became calm, thankful and accepting of the situation. The tubes and drips were removed from the person’s body, relatives’ tears gently but silently flowed, and the doctor carried out the prescribed process to pronounce death. A final prayer for the dead pursued; then, I took my leave assuring them of my prayers and suggested they call if they needed me. They did not need to call.

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The essence here seems to be that ritual is important to some people. It brings the first part of preparation for emotion work. It, in some way, hands on, or over, the loved one into the care of another; here, it is a triune God and for others a different God or mother nature, and others still, in a word or two, hand on the memory to the universe itself. But it is ritual that leaves those behind the space and process of mourning. Chaplains are also touched by death probably more so unexpected and sudden deaths, and their mourning becomes part of them as professionals and is lived out in constant reflective practice, by which they learn and grow to compassionately approach the next call. The phone must have buzzed in my pocket without me realising: ‘…I thought you said 20  mins?…’. Life for Chaplains must often abruptly go on.

7.7

Judaism Spiritual Support

When a Jewish relative learns the news of the death of a close family member, they enter a state of intense mourning (aninut) which lasts until after the funeral. This is a time of immense shock and disorientation when the mourner is allowed to express their deep grief (Rich 2011). When dying, there may be a request to hear or recite special psalms, for example Number 23 (The Lord is my Shepherd) and the special prayer (The Shema) (Scott 2010). Following death, the body should be minimally handled (not at all if an Orthodox Jew) and covered with a plain white sheet, and the Chevra Kadisha (Holy Jewish Society) should be contacted via the Rabbi to attend and arrange purification by water and prepare the corpse. Wherever possible, a practitioner should remain with the patient until relatives or the Chevra Kadisha arrives; it is a matter of the greatest respect to watch over a person as he passes from this world to the next (Lamm 2000). The eyes of the deceased should be closed and the head covered with the sheet ideally by one of the deceased’s children or friends; the feet are to be in the direction of the door. When a death occurs on the Sabbath, the body should not be moved, so it is necessary for emergency practitioners to sensitively handle this dilemma. The Coroner’s Officer should be made aware that the body is that of a person of the Jewish faith in order to respond to the 24-h time frame for autopsy and burial. However, as with most faiths, interpretation on issues pertaining to the principle of preservation of life is changing, and the use of organs and tissues to help another is increasingly acceptable among Jewish people (Lamm 2000).

7.8

Hindu Spiritual Support

The belief in reincarnation brings comfort to the dying and their families as they are reborn into a new life and are not gone forever. Notably, enduring physical suffering may lead to spiritual growth and a more fortunate rebirth (Thrane 2010). Therefore, it may be important for the person to speak with loved ones and perhaps apologise

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for any wrong doing to balance karmic debt. If the resuscitation is prolonged, the Hindu may believe that the soul remains on earth longer than is natural. Further, when the Hindu is dying, they will be thinking of Brahman which elevates their state of consciousness to a higher plane when the soul leaves the body. Death in hospital is to be avoided as Hindus prefer to die at home. Where this is impossible, the dying Hindu patient may be comforted by reading Hindu prayer from their holy text or by hearing it quietly read by a family member into their right ear. Hindu boys may wear sacred threads, which wrap around the torso, and permission should be sought from the patient or next of kin to remove them if, for example the patient suffered abdominal trauma. In emergencies, where it may be necessary to cut the thread, it should be returned to the patient (Scott 2010). Following death, jewellery, sacred threads or religious objects should remain on the body (Ambulance Service Association 2005; North West Ambulance Service 2013). Emergency practitioners should wear gloves when handling the cadaver, avoid body washing and cover the body with a plain sheet. Prior to placing the sheet over the body, the palms should be brought together and the fingertips placed underneath the chin (Henley and Schott 1999). Holy rites involve tying a thread around the neck or wrist, applying holy ash to the forehead, sprinkling holy Ganges water over the dying person or placing a few drops of holy Ganges water in the patient’s mouth or placing a sacred ‘tulsi’ leaf in the patient’s mouth. Decisions regarding the deceased especially concerning legal issues of post-mortem donation will usually fall on the most senior family member or the eldest son.

7.9

Sikh Spiritual Support

The family of a dying Sikh may derive comfort from reciting the Sukhmani Sahib or hymn of peace, and the patient may wish to speak passages from the Guru Granth Sahib (Dudhwala 2019). At the time of death, it is important that the five Ks (kakkars) of the Sikh faith remain undisturbed as they are symbols which identify their membership of the Khalsa, a body of devout Sikhs. Specifically, the Kirpan (sword) represents a token of grace, and the Kangha (comb) represents purity through spiritual cleanliness, i.e. thoughts and hygiene through physical cleanliness (i.e. to keep the hair clean). The Kara (bangle) represents community strength with God, whilst the Kesh (uncut hair), including the beard, symbolises holiness. Finally, the Kacha (shorts worn as undergarments) symbolises modesty (Langley 2002). For men, the turban is a mark of respect which the Sikhs have inherited from the Muslims and Hindus which should be handled with care if it must be removed, e.g. to do a primary assessment following head injury. A request for removal of turban and/or breeches may cause embarrassment (Henley and Schott 1999). There are no religious restrictions to post-mortem examination though the time frame may be delayed, and Sikhs prefer to hold the funeral as soon as possible after death. Cremation within 24 h is not a requirement for Sikhs in the United Kingdom; it is considered good practice but not mandatory. If there is a delay in receiving the dead

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body due to the death being a Coroner’s case, then the cremation will likely be delayed. Sometimes cremation may be delayed if the immediate family lives abroad and would like to attend the funeral.

7.10 Conclusion The essence of spiritual care when someone dies suddenly in the emergency department is enabled by showing empathy, offering spiritual comfort and nourishment to bring relief from loneliness and suffering. The term ‘dying with dignity’ is often used though it not always clear what this means or how it is enacted to the benefit of the dying person and family. Essentially, this involves factors such as empowerment to make important choices at the time leading up to a person’s death and respecting the death rites associated with the faith or belief of the dying person so they may leave this world in a state of peace. Learning Points

• Individuals are a unique blend of their culture, religion and spirituality. How will you respect these diverse needs? • Consider specific death rites and rituals to be respected in your locality. • Think about various attitudes towards post-mortem and organ and tissue donation.

References Ambulance Service Association. Community handbook: A guide to understanding the diverse faith and ethnic communities in the UK. London: ASA; 2005. Dudhwala Y.  Cultural and religious issues professionals may encounter following a bereavement. Sudden: Supporting people after sudden death. 2019. http://www.suddendeath.org/ uncategorised/145-cultural-and-religious-issues-professionals-may-encounter-following-abereavement-yunus-dudhwala. Accessed 7 May 2019. Glaser BG, Strauss AL. A time for dying. Chicago: Aldine Publishing Co; 1968. Henley A, Schott J. Culture, religion and patient Care in a multi-ethnic society: a handbook for professionals. London: Age Concern; 1999. Lamm M. The jewish way in death and mourning. New York: Jonathan David Publishers; 2000. Langley M. Eyewitness: religion. London: Dorling Kindersley; 2002. NatCen. British Social Attitudes: Record number of Brits with no religion. 2017. http://natcen. ac.uk/news-media/press-releases/2017/september/british-social-attitudes-record-number-ofbrits-with-no-religion/. Accessed 28 May 2019. NHS Blood and Transplant. Faith and donation. 2019. https://www.nhsbt.nhs.uk/how-you-canhelp/get-involved/download-digital-materials/faith-and-donation/. Accessed 16 April 2019. North West Ambulance Service. Working with diverse communities: A useful reference guide to understating diverse faith and ethnic communities. 2013. https://www.nwas.nhs.uk/ media/325891/working_with_diverse_communities_pocket_guide_2013_v1bs.pdf. Accessed 6 May 2019.

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Rich TR.  Judaism 101: Life Death and Mourning. 2011. http://www.jewfaq.org/death.htm. Accessed 16 April 2019. Scott T. Religion in trauma care: grand narratives and sacred rituals. Trauma. 2010;12(3):183–92. https://doi.org/10.1177/1460408610376708. Thrane S.  Hindu end of life death, dying, suffering, and karma. J Hosp Palliat Nurs. 2010;12(6):337–42.

8

Sudden Death: A Military Perspective Gavin Carr, Tony Kyle, and Di Lamb

Abstract

Sudden death is an inevitable feature of modern-day conflict, and military personnel deal with the death of both civilians and army personnel whilst on tour. The extreme circumstances and conditions involved make sudden death much harder to cope with, especially when one’s own life or that of a colleague is threatened. The following chapter documents the narratives of two military medical personnel who coped admirably with sudden death scenarios whilst on tour in the austere environment of Afghanistan showing courage and fortitude in the face of danger.

8.1

Introduction

The biologists’ perception is that human evolution is defined by conflict (Wilson 2016); therefore, to follow that argument to its natural conclusion, war could be argued to be inevitable. Indeed, conflict and war has peppered history and is routinely brought into the consciousness of everyday life via the immediacy of news coverage. The most recent enduring warfighting campaign in Afghanistan witnessed the loss of 453 UK military and civilian personnel, 353 of those having been killed in action (MoD 2016). Modern warfare demands agile and highly skilled medical teams that are capable of deploying to the battlefield to increase a casualty’s chance of survival following major trauma (Davis et al. 2007). Warrant Officers Gavin Carr and Tony Kyle were members of a Medical Emergency Response Team (MERT) in

G. Carr · T. Kyle (*) · D. Lamb Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK e-mail: [email protected] © Springer Nature Switzerland AG 2020 T. Scott (ed.), Sudden Death: Intervention Skills for the Emergency Services, https://doi.org/10.1007/978-3-030-33140-5_8

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the role of paramedic and nurse, respectively. Their experiences of sudden death in a military context will now be described. I am a 42-year-old Royal Air Force (RAF) paramedic at the time of writing having served in the RAF for almost 22 years. A significant portion of that time was spent in helicopter retrieval in remote and hostile environments. Most of the vignettes presented here occurred during my operational tours in Afghanistan between 2006 and 2012 as part of a multidisciplinary MERT. This was the most significant conflict in which the United Kingdom (UK) military had been engaged for a generation, and as such, the medical workload was increasing tour by tour. An average tour length was around 3 months, and I deployed as a MERT paramedic a total of six times, which meant that I was repeatedly exposed to those that had sustained significant lifechanging kinetic injuries or who had died as a result of their wounds. This chapter highlights the tenets of military battlefield death drawing comparison with death as it might be experienced in the National Health Service (NHS). Sudden death within the non-military setting may be upsetting, shocking and untimely but does not include many of the characteristics of military death. Military death on the battlefield and within theatres of operations is the complete antithesis of expected death. It is loud, scary, chaotic and disorganised. An early personal observation of death in a military setting is the sheer violence and forces involved. This section will provide an insight into sudden military death through the eyes of a paramedic whose only frame of reference had been as a practitioner exposed to scenarios that had culminated in death within the UK NHS setting. Real-time case studies will help the reader to consider the impact that sudden death has on the individual, the team, non-­vocational medical personnel and even the military mission. The first vignette is from my first deployment to Helmand Province as part of Operation Herrick in 2006. We had been tasked as a four-person MERT to deploy to the Kajaki Dam. We were a helicopter-borne advanced trauma care retrieval team with dedicated force protection (FP). The original call described one casualty with a broken leg, and the flight time from our base at Camp Bastion was around 25 minutes. As we arrived at the location, it quickly became apparent that this tasking was more complex than a single fractured leg, although there was much confusion. The location of the initial casualty (with a broken leg) was in a precarious position on top of a ridge, and it was impossible for the Chinook to land. Concurrently, there was information being received about some more casualties in a nearby location. The first difficult decision was taken to relocate to the second incident, located in a river bed or ‘wadi’. As we approached the scene, it was difficult to see much due to the design and flight profile of the Chinook, but as we came overhead, I was able to see out of the rear ramp of the aircraft. We were approximately 50  ft. above the ground, and I could make out a group of soldiers and, soon after, an explosion, which I did not hear but was clear from the large plume of smoke. The Chinook continued to land but only placed the rear wheels onto the ground as they had now realised they were in a minefield, and the downdraught of the rotors had the potential to activate more mines.

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As panic ensued within the aircraft, I was in a position where I could see the aftermath of the explosion; the soldiers, approximately 100 yards from the aircraft, were gesticulating and calling us across to help them. I felt helpless, as did the rest of the team, as we had the capacity and capability to assist but were now in a potential minefield. The second difficult decision was taken to relocate to another helicopter landing site (HLS) effectively leaving the injured soldiers where they were. We then proceeded to land at a second HLS where the team left the aircraft and, escorted by paratroopers who had been based in Kajaki for several months, travelled initially by vehicle and then on foot to the observation point (OP) high above the dam. As the incident matured, our team split to start and treat casualties as they were extricated, and I found myself with the original casualty who was still at the OP on the ridgeline. On returning to Camp Bastion, this time in an American Black Hawk helicopter, I learned from the rest of my team that the soldier I witnessed close to the initial explosion had died from his wounds. This was my first experience of witnessing a battlefield death. The moral components of death within the military bring specific challenges. In multi-patient tasking, you very often find friends and colleagues of the deceased crammed into a helicopter in very close proximity. MERT is held in very high esteem amongst soldiers and their commanders in Helmand Province; however, excellent reputations are difficult to attain but are also easily lost. A specific example of where, as a team, we had to consider the moral component impacting on a person’s death was during a multi-patient mission where we had a patient described as a T1 (the most urgent category of patient) and several ‘walking wounded’ casualties from the same incident and unit. It was clear from an initial assessment of the T1 casualty that, despite the best efforts of the medical team on the ground, he had died from his wounds. As other team members had assessed the walking wounded who required no further treatment, it was decided that we (four MERT practitioners) would instigate advanced life support resuscitation. Despite the obvious futility, this was aimed at providing, in some small way, comfort to his friends and colleagues. Had we chosen to stop the resuscitation, remove all medical equipment and place him in a body bag, we felt this could have had a negative impact on both the walking wounded casualties’ processing of events and on their ability to grieve. During my MERT deployments, I often wondered how the non-vocational medics dealt with the often horrific medical situations they were involved in. The MERT aircraft was flown by two pilots with two other air loadmaster crew, and we had a FP team of up to six personnel. I considered that as medical personnel, and certainly military medical personnel, I would expect to see death and severe injury and be upset, but I wondered what it was like for these non-medics to have this thrust upon them. As RAF pilots and aircrew, I imagined they joined the RAF to fly, travel the world and move equipment and personnel. During missions with large numbers of patients, we would have very little spare medical capacity, so often, the loadmasters would become a surrogate MERT practitioner. It was troubling to learn anecdotally that several of these loadmasters described feeling helpless when they were not involved, but ultimately, their primary role was to keep us, the casualty and the aircraft safe and allow us to deliver the best care we could.

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It was also subsequently revealed to us (anecdotally), by the Chinook crews in particular, that following such intense periods of deployments several loadmasters experienced significant mental health issues as a combined result of the kinetic activity they were involved in and the death and dying scenarios they witnessed within the aircraft during medical missions. Whilst MERT personnel are also known to have suffered mental health problems, I wonder whether aircrew may have different trigger points, which are possibly linked to their expectations. These individuals simply did not expect the utter sensory overload of the sights, the intense noise or the proximity and contact with severely injured casualties. How a medical team deals with death in these circumstances can present certain personal and professional challenges. It is inevitable that in a four-person multidisciplinary team you will encounter differences of opinion and attitudes towards death. How this is then managed can have far-reaching consequences to all concerned. Having a mixture of doctors from both emergency medicine and anaesthetic specialties, emergency nurses and paramedics with varying ages, experience and opinions can all lead to potential tension. Whilst a patient death is upsetting and thought-provoking for a team, individual members can present very different emotions. Factors that affect these emotions can include differing personally held beliefs, stress, fatigue, team dynamics and an inherent rank structure. Consequently, a robust, transparent and effective debriefing system must be employed to allow individuals a platform to express their opinions and emotions. I personally found the debriefing an incredibly useful tool but only after I realised that they were an opportunity to strive for best practice as well as a very useful mental health screen. Barriers to the effective use of debriefing within pre-hospital medical teams following a traumatic incident can include inherent personality traits, preconceived ideas regarding debriefing, external stressors and system pressures. I have witnessed or even displayed some of these traits myself during debriefings. Termed ‘hot debriefs’, these inclusive meetings provided a platform to deconstruct a mission from beginning to end and to fill in gaps so that each team member and the FP had a greater understanding of the whole mission. With team members becoming task focussed and fully committed to their assigned patient, it was sometimes hard to develop an appreciation of the full casualty load and their respective clinical states. The debriefing then filled in any potential information gaps and allowed the team to appreciate the bigger picture. During the early introduction of debriefs, some teams used them as an opportunity to question individual clinical decision-making. I have also heard of teams who used these sessions as an opportunity to personally apportion blame, with potential to ostracise individuals. The entire deployed MERT capability comprised two 4-person teams. Each team completed 24 h shifts with a period of stand by and stand-down immediately following. An unanticipated consequence of a two-team system developed a competitive edge between them. It became the norm for the teams to compete for missions and casualty numbers. This competitive-style bravado was further enhanced by the fact that there were other medical evacuation teams provided by the North Atlantic Treaty Organization (NATO) allies at Camp Bastion also being tasked to missions. These were primarily US helicopters and personnel. I felt this level of so-called

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competition was unhealthy in many ways. It is now easy to see how this type of daily working routine, which involved heat, altered sleep patterns, personal danger, self-induced and system-­induced pressures and a subversive blame culture, could certainly impact quite heavily on both team cohesion and individual mental health. Host nation attitudes to death were somewhat surprising from a cultural perspective and particularly those deaths involving children. One thing I had not been prepared for was public displays of obvious stoicism and apathy from Afghan nationals regarding sudden death. What I noted were muted emotions, and this I guessed may be due to cultural and religious differences. In a rather selfish way, these allowed me to process sudden death incidents and accept them more readily. A lasting memory for me is that despite being hundreds of miles from home UK service personnel’s bodies were treated in a most dignified, peaceful, respectful and ceremonial manner with great care and thought being put into the repatriation process. This hopefully gave the families of loved ones some form of comfort after such devastating loss. Tony Kyle is a Military Nurse Research Fellow at The James Cook University Hospital and has been in the RAF for 23 years in numerous nursing and education specialties. He has experienced many conflicts in this time with his most recent deployment working as an emergency nurse on the MERT. Dealing with death is a very personal phenomenon, and from an early stage in the caring profession, we are taught about the theories surrounding this difficult subject, yet some people can deal with it and others find it harder to cope. A series of reflective accounts will be presented from a military nurse’s experiences of death, dying and critical injury whilst serving in a war zone. I am asked many times about how I was able to deal with some of the situations and injuries that I have seen; the simple answer to this is I genuinely do not know. Throughout the years working in both the military and NHS, I have observed health professions and non-health professions dealing with sudden death. These are my observations. My tours of Afghanistan were between 2009 and 2011, at the height of the conflict with hundreds of military and local civilians killed or seriously injured. It was a privilege and an honour to work as an emergency nurse on a MERT, but involvement also placed a massive emotional burden on everyone involved. The trauma team comprised doctors, nurses and paramedics, and there was also the FP element, predominantly made up of RAF Regiment personnel, helicopter pilots and crew who in most situations had not seen or been involved in serious trauma, dying or death.

8.2

First Encounter

This was my first tour as a MERT member deploying to Afghanistan, and to be honest, I did not know what to expect. I usually work in an NHS emergency department in the UK, so although I experienced the rigours of caring for patients at the roadside, nothing could prepare me for what I saw. My first day consisted of four missions to various parts of Afghanistan. Three of the patients had multiple limb amputations.

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We were accommodated in a tent for a 24 h period with a phone, TV and DVD player, and we played the ‘waiting game’. It was tense; the team were starting to get to know one another when the phone rang requesting that we moved to the helicopter site. Within minutes, we were on-board with rotor blades turning. It was time for the training to ‘kick in’. We were told that there were four patients involved in an improvised explosive device (IED) strike; they were in a critical condition with numerous amputations and severe blood loss. The landing site was classed as a ‘hot zone’ meaning that we could be attacked at any minute; the FP team prepared the weapons as did the helicopter crew, whilst we prepared the blood for transfusion and went through our treatment plan. I was the only member of the team in direct communication with the pilot, and therefore, I was kept up to date with the threat and condition of the casualties. We landed onto the sand in a deserted area of Afghanistan; the ramp at the rear of the Chinook disengaged, and dust sprayed everywhere as the UK soldiers on the ground, who had been administering life-saving treatment, stretchered their colleagues onto the helicopter. Thirty seconds later, we were airborne, and the helicopter trauma bay burst into action. Our team had defined standard operating procedures (SOPs) to treat one patient or multiple casualty situations. I was allocated to a patient that had suffered an arm amputation. The remaining members of the team were all busy preventing catastrophic blood loss and providing life-saving interventions. One of these patients unfortunately had sustained life-threatening injuries and went into cardiac arrest at the back of the helicopter. The team quickly repositioned to help the paramedic dealing with the cardiac arrest. The FP was also a vital part of this team, helping with control of bleeding and, in this case, cardio pulmonary resuscitation (CPR). We worked on the patient whilst also providing care for the remaining soldiers who were witnessing the resuscitation attempts first-­hand. CPR continued throughout the journey to Camp Bastion military treatment facility, but unfortunately, the soldier was pronounced dead. He was such a young man.

8.3

The Aftermath

This was a very difficult start to my tour both personally and for the extended team. I had to deal with my own emotions but also be cognisant of how others were feeling. Personally, I must have worked through Kϋbler-Ross’s (2009) stages of dying, time and time again. Anger was at the forefront of my emotions, angry at me for not being able to save him, angry at the Taliban for the needless death and even angry at the Ministry of Defence (MoD) for putting me in this situation. This was quickly followed by bargaining where I became intensely focused on what we as a team could have done differently. I was however acutely aware that there was a job still to be done; the helicopter, clinical equipment and the cabin had to be turned around and prepared in case we got another shout (mission), and consequently, my feelings and emotions, for now, had to wait. We had another four shouts that day with varying degrees of injury, and it was not until later that night that we were able to sit down and reflect on what had happened on my first day in Afghanistan.

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Reflection

It is a legal requirement for the team to complete debrief forms and patient report forms; these documents are attached to the patients’ medical records and stored in the hospital. It is at this point that we reflect on our practice with the view to improving care; it is a form of clinical supervision combined with debriefing. It can however become too intensely honest, affecting individuals in different ways. Some would accept it as a learning curve; however, I for one took it very personally and blamed myself for not having done enough. This I found to be one of the hardest parts of dealing with sudden death and dying in a military context; the ability to accept that in some situations the severity of injury was incompatible with life. I was very hard on myself, but I knew that if I allowed this emotion to continue I would not be able to function as a person. I developed what is classed in the healthcare world as a ‘thick skin’, as I went through the motions of rehearsing my clinical skills to hopefully stop myself from overthinking. Another coping strategy that I think most people adopted was to hit the gym, which helped immensely and allowed me the opportunity to balance my emotions. Another way was to provide training and emotional support for the nonmedics, and I think that helped everyone because it provided something to do whilst we were not working. The overthinking and negative reflection became very apparent at times of boredom; I would start to be self-critical, and it was only when I was active that this process dissipated. Another characteristic of my deployments was the decision to not follow-up with my patients. My previous experience of working in the emergency departments and for the ambulance service gave me a different perspective on how I interact with patients who survive to the next stage of the patient journey and those that unfortunately do not. In the early stages of my career, I worked in ward settings where patients died on a regular basis. I was instructed in my nurse training to provide last rites to these patients. I observed for the first-time nurses continuing to talk to the deceased, and this I found strange at first and to be honest a bit ‘weird’. It was suggested by my mentor that I ‘give it a go’. This changed the way that I viewed death, and it suddenly felt right to talk to the deceased; it was a cathartic moment, my way of saying goodbye. However, different situations provoke a different response, and working in the austere pre-hospital environment can be very challenging, balancing the environment with the respect needed for deceased patients. It is very unusual to provide last rites to patients in this environment, and I sometimes wonder what affect this has on healthcare workers. So, I decided not to go and see my patients whilst they were receiving care in the hospital in Afghanistan or ask for their progress reports, so that I could fully concentrate on doing the job to the best of my ability without, what I regarded at the time as, an unwanted distraction. This was not the case for everyone though; some nurses, doctors and paramedics did follow-up their patients to varying degrees, and I wonder to this day what added emotional stress that decision placed upon them.

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Paediatric Care

Looking after children became highly emotive to me especially when I found out halfway through my tour that my wife was pregnant. One situation of note was extremely challenging for me personally. The day started as normal with a debrief and preparation of the helicopter cabin; it was 11:00 h when the call came that there had been a mine strike approximately 20  minutes from our location. We quickly drove to the helicopter, donned our body armour and took off. En route, I was informed that there were three casualties, of approximately 6 years of age, two of whom unfortunately had been pronounced dead at the scene. As per SOPs, we communicated our loading plan so that the patient that was still alive was loaded first and the two remaining children were assessed for signs of life. When the patients were loaded, it became apparent that the mine strike had a significant impact with two of three children having evisceration injuries incompatible with life, the one remaining child died en route to hospital.

8.6

Reflection

These children had gone to visit relatives and were playing football, unaware that they were in a minefield. This had a significant effect on the entire team; the FP team had witnessed the severe injuries, and an innocuous sport that is played by children daily on the streets of the UK has resulted in such traumatic and devastating loss of life. To this day, I still see the glare of their eyes looking at me as if to say, ‘save me’. They had a significant effect on me and most of my team, but at that time, we had to be professional and deal with the bodies, respecting the family and local cultures. This was my first and only time that I felt the need to say ‘goodbye’ to my patients.

8.7

Distraction Therapy

Distraction therapy comes in many forms, and I believe that the environment and subsequent challenges faced by MERT personnel helped me to process the stresses and strains of dealing with dying and sudden death. Two situations on my second tour of Afghanistan demonstrate this. The first situation has been documented by the Discovery Channel, which had released a series about the Chinook helicopter. It involved us receiving a phone call detailing an incident, which seemed to be a reasonably safe and easy mission. A UK soldier had a gunshot injury to the arm and was to be medically evacuated to Camp Bastion. Once we arrived near to the location, we received instructions that there was a firefight and that we had to hold overhead. Throughout this period, I was receiving updates on the casualty numbers as it developed from a single patient lift

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to multiple casualties and that the firefight continued. It was decided that we had to land to retrieve these patients, and everyone on-board was briefed about the casualty numbers and threat. Pilots on all missions used tactical manoeuvres to safely extract the casualties, and this involved high-speed descent and an extremely quick extraction. This situation was no different, and we landed with the helicopter hovering and the rear ramp down. The soldiers on the ground tentatively but efficiently brought the patients to the helicopter, but as they started to load, the enemy opened fire. Soldiers were shot, and injured patients jumped from their stretchers and ran to the safer area inside the Chinook. We lifted as quickly as we had descended. We were all shaken, but we still had a job to do; there were now six patients on-board, some with minor flesh wounds, some with sucking chest wounds and two dead. As we moved out of the firing zone, the pilot communicated to me that he had been shot in the head and that the aircraft was severely damaged. I went to his aid, but luckily, the bullet had ricocheted off his night vision goggles, and he had sustained a minor flesh wound. Throughout all of this, patients were being treated, and the two soldiers that had unfortunately died were packaged appropriately with both sensitivity and dignity.

8.8

Reflection

I think this scenario, and many like it, provides the team with the opportunity to be distracted from what became the norm of suffering and death. The high-octane hostile situation somehow relieved some of the stresses normally associated with dealing with death and dying. This happened on numerous occasions, and whether it was a helicopter crashing and losing rotor blades, the team having to do CPR on a patient in a field with the possibility of being attacked or something less onerous like training FP teams to assist with intraosseous infusion; they all achieved the aim of distracting us from the reality of death.

8.9

Dealing with the Aftermath

An individual’s ability to cope with sudden death is a multifaceted, multidimensional phenomenon. The working environment can help or hinder that coping process. There are systems in place for civilian and military healthcare professionals, but the nature of coping is very different from one person to the next. Coping timelines can be broken down into immediate and future with numerous strategies employed to help the individual deal with a situation. In Afghanistan, I relied on my training to get me through the tough clinical environment, but no form of training exists to help with the emotional trauma and lasting imagery. This is when colleagues and friends play a significant part, in that, if it was not for those games of basketball, coffee and a chat or the many rants, I would not have survived.

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Once we returned from operations, we all dispersed to our units with some follow-up and some post tour debriefing, but in some situations (not all), the inner demons continue. I have grown from experiences since my deployments, and most of the feelings I experienced are normal, but one particularly significant lesson that helps me through is not to be too hard on myself or self-critical, and if you do need help, there are many military and civilian organisations that can provide support. The hardest part is recognising help is required and actually seeking it. Learning Points

• Consider how you maintain professionalism and self-composure to handle the death event when everything around you is falling apart. • Some practitioners overthink the role they play, apportioning self-blame when a sudden death occurs. What is your personal coping pattern? • Consider whether you would ask for help with the emotional trauma and lasting imagery of sudden death encounters. Who might you approach?

References Davis P, Rickards A, Ollerton J. Determining the composition and benefit of the pre-hospital medical response team in the conflict setting. J R Army Med Corps. 2007;153:269–73. Kϋbler-Ross E. On death and dying. 40th anniversary edition. Abingdon Oxon: Routledge; 2009. Ministry of Defence. Afghanistan casualty and fatality tables. 2016. https://assets.publishing. service.gov.uk/government/uploads/system/uploads/attachment_data/file/503022/20160222_ Op_Herrick_Casualty_Tables_Feb_16_REVISION.pdf. Accessed 20 Sept 2018. Wilson EO. Half-earth: our planet’s fight for life. New York: Liveright Publishing Corporation; 2016.

9

Sudden Death: A Humanitarian Disaster Worker Perspective Ivy Muya

Abstract

Humanitarian workers manage sudden death on a large scale, particularly where famine, disease, and man-made or natural disaster impact on a country’s infrastructure. Health services are minimal and human medical resource scarce, so establishing health care facilities is a matter of improvisation frequently compounded by massive migration patterns. Most humanitarian effort is focused on countries classified as eligible for Overseas Development Assistance though some situations impact on developed nations. This chapter focuses on how cultural and religious norms are upheld when working in sudden death scenarios.

9.1

Introduction

Emergency nurses work in humanitarian contexts such as natural and fabricated disasters involving wars, hurricanes, floods, earthquakes, and disease outbreaks. They treat patients presenting with medical and nonmedical emergencies involving, for example, cardiac arrests, respiratory disorders such as pneumonia, HIVrelated infections, trauma such as stab wounds, gunshot victims, road traffic collisions, etc., and these presentations can be difficult to predict. Four core principles guide humanitarian action: the humanitarian imperative, independence, impartiality and neutrality. Humanitarian aid provides material and logistic assistance to people who need help, usually this involves short-term help until longterm help by governments and other institutions intervene (European Union Humanitarian Action Partnership 2017). Humanitarian donation is “…to save lives, alleviate suffering and maintain human dignity during and in the aftermath I. Muya (*) African Federation of Emergency Medicine, Emergency Nurses Group, Cape Town, South Africa © Springer Nature Switzerland AG 2020 T. Scott (ed.), Sudden Death: Intervention Skills for the Emergency Services, https://doi.org/10.1007/978-3-030-33140-5_9

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of crises, as well as to prevent and strengthen preparedness” (OECD 2010, p. 4). It is often difficult to predict whether or not a person will survive, as this would depend on the availability of resources such as life-saving emergency drugs, personnel and equipment. During the set-up phase of a humanitarian response, the objective of the Mission Mandate is to save as many lives as possible. In some countries that have experienced ongoing conflict for more than 10 years, humanitarian workers are stationed within the local hospitals or in field hospitals that have been set up by external organisations. In 2017, 201 million people across 134 countries were in need of ‘last resort’ humanitarian support. Poverty, vulnerability and crisis are inseparably linked whilst conflict, violence and persecution drove ever more people from their homes (Development Initiatives 2018). Humanitarian crisis, natural and/or man-­ made disasters occur globally; consequently, a mass of humanitarian workers are based all over the world and as different countries have diverse environments, terrain, culture and socio-economic conditions, nurses’ experiences vary. Indeed, some nurses are deployed to environments with ideal resources and conditions, for example, hospitals that are fully equipped with surgical and diagnostic facilities (operating theatres and laboratory services). A typical nurse in the developed world is exposed to a comprehensive, training that equips him/her with all the tools required to competently carry out their profession; however, in the humanitarian context, the nurse may find it both challenging and difficult to perform at an optimum level. This is because the nurse is forced to step out of their ideal setting—a stable environment where all resources necessary to perform his/her skill are available. For example, if a trauma victim were brought into a fully resourced emergency department, it would be possible to conduct diagnostics such as X-rays. However, in the humanitarian sub-optimal environment, a fundamental resource such as electricity would probably be lacking let alone a full radiology department. Humanitarian nurses work in austere environments characterised by extreme weather conditions, remote locations and with limited and/or no natural resources, for example, water, so the setting is far from ideal to provide optimal care to those who are suddenly dying and the dead. Personnel with appropriate health care expertise, surgical and non-surgical supplies, equipment and logistical support such as transport and communications may be unavailable. This was common when I worked with a group of 30 nurses for a humanitarian organisation along the Kenya–Somalia border, a region suffering significant conflict involving skirmishes, violence and massacre. We provided health care in hostile conditions devoid of electricity, sources of running water, cold rooms and storage facilities for dead bodies. Clinical governance to ensure care reached quality standards was severely deficient. For example, field hospital structures are constructed using semi-­permanent design, that is, pre-fabricated canvas similar to a large tent. In such a setting, the sudden death experience was sub-optimal particularly because there were no facilities for storage of dead bodies and even if there were such facilities, they were

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invariably built to store single rather than multiple victims. So, rather than finding storage space, most of the time, the deceased would be immediately handed over to the care of the family to make their own arrangements. Disease outbreaks generate multiple sudden deaths with devastating effect on whole communities. Recommended infection control measures (World Health Organization 2016) require health care providers to follow the agreed-upon gold standard; therefore, in the event of an outbreak, for example, Ebola, a viral haemorrhagic disease, the dead would be buried in either mass graves or cremated. This implies that the humanitarian worker would not have the time or the resources to handle the dead in an ‘ideal’ way. The objective for every person who dies suddenly in humanitarian conditions is to provide effective, efficient and compassionate patient care. However, whether in a humanitarian field or a hospital setting, anticipation of the patient dying imminently and a subsequent need to manage their death sensitively and with dignity, remains the primary principle, though often subsumed by issues of infection control. The following section outlines some practical aspects of the humanitarian nurse’s role when a person dies suddenly in a local or field hospital. Consideration will then be given to the support of relatives and the team. In the event of a death whether witnessed or not, the process that follows is more or less the same in all settings. In the humanitarian setting, where there is no medical officer (doctor), the nurse may take responsibility for the death declaration in the presence of a witness. This is followed by the recording of the death or ‘notification of death certificate’, which involves an entry into a register. The field hospital administrator then records the death and notifies the family and/or next of kin. Family notification may be conveyed by a social worker who will visit the home of the deceased to speak with the next-of-kin. In rare cases where telecommunications are available, it can be helpful and, in very rare cases, it is a matter of simply waiting for the family to come and claim the body. In some communities, death is considered a very expensive affair and upholding the respect for cultural norms at the time of death can be expensive, so the family may not be able to pay for costs associated with the death. Rarely, for people who die in communities experiencing extreme financial poverty, families may not be prepared to claim the body of the deceased as they fear further financial burden if they are required to pay the hospital bill. However, in the humanitarian context, it is assumed that no payment is necessary and hence the situation described above is rare.

9.2

Respect for Local Culture and Religion

My humanitarian nursing role is practised amongst a predominantly Islamic culture and religion so I will highlight the religious and spiritual rites that I have personally repeatedly observed in this society. I practised among migrant populations in Daadab, a border town between Somalia and Kenya, the third largest refugee camp

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in the world (United Nations High Commissioner for Refugees 2019). Maternal mortality has always been a challenge in this location and it is not uncommon to receive mothers into the emergency department in difficult and/or prolonged labour. Since 1990, the world has seen a 44 per cent decline in the maternal death ratio—an enormous achievement. But in spite of these gains, some 830 women still die every day from causes related to pregnancy or childbirth. This is about one woman every two minutes. (United Nations Population Fund UNFPA 2019)

On one occasion I was faced with an emergency case where a 19-year-old female who had laboured for 26 h was transported over 200 km to the hospital. Her clinical history, presentation and observations indicated foetal and maternal distress. Consent to conduct an emergency caesarian section was sought from her husband who then was on the frontline of the civil war amongst the Somali people. Unfortunately, even with all the emergency medical interventions to keep her stable, the mother died from suspected respiratory arrest. As there was no mortuary and as she was Muslim, her body was tended by women only who came to the emergency room and handled her remains. They meticulously washed her body, as they recited scriptures from the Holy Quran; covered her in a white cloth and transported her to the nearest cemetery. Meanwhile, I carefully folded, wrapped and labelled her belongings and in the presence of a witness, recorded the items in the ‘Patient Belongings’ book. I requested one of the family members to check the items one-­ by-­one with me and sign below my signature. As there was no risk of infection a biohazard bag was unnecessary; indeed, following infection control practices totally is not always possible. The items were placed in a plastic bag and sealed to secure the contents. As an emergency nurse working in humanitarian zones it would be prudent to add a note on mass burials, a feature of this type of work. According to WHO/ WEDC (2013), more often than not in the humanitarian context, bodies begin to decompose from 12 to 48  h, hence storage in temperatures between 2 and 4° centigrade is essential. However, in austere environments, storage facilities such as mortuaries and cold rooms are usually unavailable. Therefore, mass graves are considered a viable option especially when infectious diseases place the local population at risk. I once witnessed a mass burial of victims following a terrorist act in Mali where official identification was confirmed by the families of the deceased. Identification was carried out using photographs matched to a unique reference number attached to the deceased. Where body parts were severed, they were treated as individual bodies rather than attempting to match them to a particular body. The clothing and belongings of the victims were kept with the bodies as this helped identification and having access to some of these items helped bring some degree of psychological closure for the family. The mass grave was then dug at least 1.5 m deep and the bodies were laid 0.4 m apart according to WEDC guidelines. During epidemics, such as the recent Ebola crisis in Sierra Leone, cholera in Haiti and other infectious diseases, mass graves are treated with full infection control guidelines as warranted by the WHO/WEDC guidelines (2013). Minimal

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handling of the bodies and time taken to bury them are key elements in controlling disease contamination. In such circumstances, the death-to-burial trajectory is very fast; thus, the family and the health care worker (nurse) have little or no time to commence grieving for the dead. In the event that a post-mortem is required, body identification marks, DNA testing and dental formulations are methods that have been used where possible. Indeed, austere environments may not have the local resources to conduct post-­mortem examination and this is an important problem in situations where there are medicolegal implications. In contrast to the field hospital, the urgency for body processing within what is often an extremely tight timeframe becomes more aligned to ‘clearing and forwarding’ hence the emotional effects could be more detrimental or profound some time afterwards simply because there has been no time to grieve a shortened period to absorb the shock of this life-defining event. What is experienced may literally be ‘buried emotions’.

9.3

Medico-Legal Implications

This chapter would not be complete without touching on the legal aspects of sudden death. The principle for dealing with the legal aspects of death remains the same throughout the world and there is not much difference in this setting. The role and function of a nurse working as a humanitarian is complex, dynamic and can not necessarily always follow a ‘textbook’ format. They have learned to be adaptable and versatile in order to cope with unpredictable presenting crises of what happens ‘on the street’. However, the guidelines, protocol and/or rules of handling the dead are defined by respective organisations including local hospitals and all other stakeholders during the humanitarian crisis context. The Medical Officer (MO) or physician, who is in the field working alongside the nurse, is authorised to declare death. This was apparent during the resuscitation effort resulting from a respiratory or cardiac arrest which I witnessed recently. Clinically, once nothing more could be done for the patient, the doctor ordered the resuscitation team to stop immediately. He/she is the only person who can formally certify the death. As mentioned earlier, the notification of death is recorded on a special form or in a record of deaths book. Confirmation of the deceased person’s identity usually occurs at the scene. When I worked in a controlled setting, for example, in a field hospital where the relatives were present, I would ask the doctor if we could invite the relatives to view the body. In a clinical setting where relatives were frequently absent, especially in refugee camps like Dadaab, Kenya, which had a nomadic population, we would notify the Camp Manager who would then contact the Social Worker in charge of the sector where the family of the deceased lived. At least one family member had to be notified and escorted to the field hospital in order to confirm the identity of the patient. I conclude this section on a specific population that is a ‘bi-product’ of natural or man-made disasters—that of Internally Displace Persons (IDPs) who are persons obliged to flee from their habitual residence. I am particularly familiar with the

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man-made disaster IDPs as they were specifically victims of conflict in Somalia, Kenya, Haiti and Mali. These are countries where populations are forced due to conflict, to move and live in camps. The sensitivity of death is worsened by the fact that more often than not, the IDPs have already lost at least one family member and once in a semi-stable setting, they may then have to deal with sudden death of an additional family member. No matter how difficult the conditions, the dead are still cared for with dignity and respect and they are afforded the same due legal process as they would receive were they still in their community. The medico-legal aspects in the humanitarian context are guided by international documents developed to affirm the importance that the humanitarian workers give to death, that is, identification, handling, and disposal in accordance with religious and cultural norms. These may differ from country-to-country; however, the basic principles remain the same.

9.4

Breaking Bad News

The way humanitarian nurses break bad news to relatives is quite similar to other clinically based locations. Invariably, humanitarian activities are carried out in less than ideal settings which mean that standard protocols and guidelines on breaking news of death may not be applicable. Humanitarian nurses are frequently called upon to directly confront relatives with the news as compared to the process within the hospital setting whereby the MD or most senior clinical provider usually communicates this news to the family. Humanitarian nurses often communicate the devastating news of the sudden death of a loved one almost immediately and sometimes the relatives will preempt the nurse. On one occasion in Kakuma Refugee Camp, Sudan, a relative begged the nurse to tell the truth about whether their relative was alive or dead. This can place the nurse between a ‘rock and a hard place’. Indeed, when the patient is confirmed dead nothing can change the situation, but the question of who is best skilled and available to tell the relative this news remains. Let us remember that medico-legal implications, specifically patient confidentiality, need to be adhered to in these instances. The personal patient information must be handled with utmost discretion.

9.5

Managing Property

Handing over patient belongings following a sudden death is yet another challenge for the humanitarian nurse. Instances such as disease outbreak may warrant complete incineration of the patient’s belongings and this may be a source of distress as relatives may wish to hold onto these precious items as a reminder of their relationship with the deceased. The key to handling belongings lies in the ability to correctly identify and label them and most importantly, have a witness to ensure transparency and accountability whilst the items are in the safe care of the team. Actually, both the

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family and the nurse must respect the integrity of the process. However, the dilemma that lies herein concerns whether or not the nurse and the family member who hand over and receive the belongings can be trusted enough to handle the process honestly and attention should be paid to ensure the security of all items.

9.6

Cultural Competence

When sudden death occurs different cultures handle the event differently, religion and spirituality playing an important part for both the nurse and the patient. The Multicultural Palliative Care Guidelines (1999) provides a brief description of different religions and their approach to death and dying, offering various examples of contexts which nurses in a humanitarian setting face. For example, at the time of death a Christian Minister prays with the family and offers them comfort; Buddhists believe that the dead are in transition to a happier place; Greek Orthodox priests may light a candle and say a prayer for 40 days as during these days the soul is believed to roam around the earth; and Hindu believers pray around the body but do not touch it as they consider the body to be unclean (see Chap. 7). Further, my own humanitarian nursing experience took me to three mainly Islamic countries, Syria, Yemen and South Sudan (Development Initiatives 2018), and in these locations, the predominantly Muslim people at time of death should have their eyes closed, their arms laid across their chest and their head or body should be tilted to face Mecca. The overarching point of this paragraph is that in a humanitarian context, the nurse needs to be aware of and sensitive to the particular setting and refrain from imparting their own belief frame onto the patient and family when dealing with sudden death.

9.7

Last Offices

In the humanitarian context, Last Offices or the laying out the body of the deceased is usually carried out by one or two nurses shortly after death has been confirmed. Practices vary between hospitals and cultures but always the central tenet of a dignified death is to be upheld. In Islamic societies, according to the teachings of the Quran, the family handles the dead and in this regard, deployed health care providers, including nurses, are not involved. A most important factor to consider is that the practice of preparing the body after death is gendered and religiously sensitive, that is, males handle male deaths and only Muslims handle a Muslim’s body, though it may be acceptable for a non-Muslim to do so if they don gloves. In non-Islamic cultures, the nurse is required to prepare the body for storage according to local institution protocol. The eyes are closed manually though gauze and adhesive tape may be applied in cases of orbital trauma. The mouth may be packed with cotton swabs or wool, then closed manually and supported under the chin where necessary.

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The mouth, nose, ear, vagina and anal orifices are packed with absorbent material to prevent oozing body fluids which may be contaminated. This is performed for infection control and also to prepare the body for transportation following referral to a forensic team. Forensic services are not commonly available in the humanitarian setting, again because these settings are not ideal and often resource limitations do not allow these examinations to take place.

9.8

Personal Reactions

An example of a real-life scenario will be used to clarify my personal reaction to the sudden death of a nurse working in a remote region in Bor, South Sudan. An adult male was brought to the field hospital emergency room early one evening with multiple gunshot wounds to the chest, lower limbs and arms, a usual occurrence in a volatile region where rebels fought on and off and attacked innocent civilians in their villages. At first, this was a clear case of multiple trauma resulting in severe external haemorrhage. As much as we had available equipment, personnel, drugs, surgical and non-surgical supplies, electricity and an operating room, etc., following respiratory arrest, the patient succumbed to death. There are huge implications arising from this scenario particularly because the person who died was a nurse who tragically ended life in traumatic circumstances. I found it helpful when my own sense of insight was derived by examining my grief reaction using specific elements proposed by Kübler-Ross (2014).

9.9

Denial

Soon after the death had occurred I could not believe that this had happened because the deceased was a nurse from my own professional community. I had taken a personal blow and self-doubted my competence. I began to check all possible things that could have gone wrong, questioning whether the equipment and drugs were up-to-date. I questioned if the resuscitation was carried out appropriately and for long enough for the patient to have responded or whether or not we had given up too soon. I then questioned whether we had enough manpower with the most appropriate skill sets to manage the situation.

9.10 Anger I became quite angry at the futility of the situation, the sheer lack of resources and why we did not have a flight on stand-by to medevac the patient immediately. My anger then diverted to the rebels who would not stop attacking innocent civilians before focusing on the practicalities of why we didn’t transfuse blood earlier than we did.

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9.11 Bargaining I started to accumulate a number of ‘what ifs’. Maybe if we (the team) had requested blood earlier, the death would never have happened. Maybe if there was six of us instead of four the outcome would have been better. Perhaps if we had submitted a request to logistics to station the aircraft in our field hospital, we would have had access to advanced cardiac life support. Maybe…Maybe…!

9.12 Depression I recall feelings of despair and recognising that I needed a break from the effects of handling deaths and at one point I even considered changing my profession to escape the emotional toll. I thought about asking the lead person if it would be possible to work in a different department so I did not have to face the consequences of these experiences. I questioned the purpose of my own life if I could not make a difference by saving another person’s life.

9.13 Acceptance After some time, I reached a turning point recognising with a more positive and practical attitude that we need to be better prepared next time. I decided to take active steps to do something positive by writing to the Procurement Department with a request to strengthen medevac facilities. I organised the set-up of a cold chain so that we could store blood supplies for transfusion in the emergency department. The above scenario frequently occurs in other humanitarian response units globally. In the humanitarian ‘world’, improvisation and crisis management is the order of the day. By default, one often finds oneself ill-equipped to cope and, in this regard, when nurses are struggling with sudden death their grief experience may evolve in similar way to that described by Elizabeth KüblerRoss (1926–2004).

9.14 Care and Support of the Team Debriefing as a structured coping mechanism has come to be effective in humanitarian settings and either group or individual counselling sessions have proved paramount in allowing nurses to ‘let go’ of their day; their experiences, tragedies and grievances. The more often this happens the more we can learn to adapt. It could be that the health care professional is viewed to be an emotionally and psychologically strong individual as often required by the profession, especially those who are deployed to humanitarian locations; however, we are not invincible. Nursing necessarily creates human connectedness and it is that very real appreciation of ‘caring’

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that renders us vulnerable as feeling human beings. Opportunities for catharsis are so helpful in helping us to untangle our understanding of an event and our reactions to some of the more intense moments in our work. Humanitarian work is a voluntary mission attracting practitioners who live by the principle of beneficence and who apply the deed of the ‘The Good Samaritan’ often, in quite difficult circumstances. Therefore, when humanitarian workers are faced with sudden death and all its sequelae, they tend to accept the magnitude of the event, the inevitability of the effects of disease coupled with the limited resources available. Despite extremely harsh conditions, the humanitarian worker enacts a moral duty to treat the dead with as much dignity as possible wherever reasonably possible. Moral duty creates difficulty in coping when the expectations of one’s role collide with the realities of practice especially when encounters with death are not handled in an ideal way, for example, during the recent Ebola crisis. These circumstances leave us with a feeling of incompleteness. Humanitarian nurses working in field hospitals have limited time to develop rapport with patients compared to nurses working in wards. This is because in the resuscitation room the quest to physically stabilise the patient is dominated by algorithms and procedural sequences sometimes within a high patient turnover. This leaves little time to manage the death and its aftermath. There is limited opportunity to develop an inter-personal relationship with the patient which nurses highly value and which contributes beneficially to the patient’s recovery. It is reasonable to assume that most emergency department sudden deaths would be considered easier to handle emotionally because a close relationship was never generated. Having said this, it seems apparent to me that all deaths are reflected upon later irrespective of whether they have a sudden or chronic trajectory. This is part of being human. As Head Nurse in Daadab, supporting a team of 30 nurses, I realise that each encounter with sudden death brings with it a unique set of circumstances and emotions, no matter how suppressed these may be at the time. Sudden death as the term suggests, is unexpected, raw, and often incapacitates the team due to the shock and horror of the event as it unfolds sometimes over a particularly lengthy timeframe. Caregivers and relatives may struggle with these traumatic circumstances and the images of trauma and devastation from the scene may recur in their minds. There is a need to monitor the emotional milieu and support the team as they tend to think about these people every day and there is a real risk that their minds become clogged with such overwhelming experiences. Some team members tell me they grieve by crying and screaming (inwardly and outwardly), others turn to their religion for strength, consoling themselves through faith and prayer. Some may find a quiet location, for example, the toilet cubicle in the changing room and sit in silence in an attempt to assimilate what has just happened. The need to reflect on the events of the day may linger for some time and I personally find myself thinking of what I could have done better, second-guessing myself over and over about what I did and how I behaved during the resuscitation and subsequent death. The event is not something that can be readily forgotten and the images may carry on in your mind at intervals. When these recollections become intrusive and disturbing or debilitating, we need to be alert to the possible

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development of posttraumatic stress disorder (PTSD). While many people think that nurses are made of stone, hardened to cope with the extreme things that we see in the course of our work, it is indeed far from the truth. We often find ourselves grieving in silence because other people depend on us for strength. One must appreciate that there is a huge difference in expectations between expected death and sudden death. Following an expected death, there is more time to emotionally prepare both relatives and humanitarian health care workers and the same process may be followed regarding the stages of grieving described above. In a previous deployment, I was involved in the resuscitation of a patient who sustained a gunshot wound to the chest after an exchange of fire with the militia in the remote city of Galkayo, Puntland State of Somalia. Medical knowledge alerted us to this emergency, a life or death situation. Indeed, my objectivity ‘kicked in’ and despite a resuscitation attempt unfortunately the patient swiftly died. In this case, due to the extent of injury, death can be expected, anticipated, hence, my reaction to his death was a little easier to handle as I knew what the two possible outcomes would be, life or death. In conclusion, death in humanitarian locations is often sudden and people die from a multitude of causes, dominated by disease and trauma, though often complicated by extreme malnourishment which renders the person unable to physically cope with additional health burdens. An extreme lack of resources features heavily in many locations where aid is offered around the global especially in countries receiving Official Development Assistance (OECD 2019). In these countries, the care and support of dying patients is paramount and the humanitarian nurse strives to meet the principle of Good Samaritan by resuscitating many and caring for those who die in a respectful and dignified way. Religion and cultural norms are respected among the community they serve and team is supported as fully as they can be, given the difficult milieu.

Learning Points

• Consider how poverty, conflict, violence and persecution may make sudden death work more difficult. • Following mass deaths, what are the main issues regarding infection control in your locality? • Consider your local policy for Last Offices.

References European Union Humanitarian Action Partnership. 2017. http://euhap.eu/. Accessed 9 May 2019. Development Initiatives. Global humanitarian assistance report. 2018. https://reliefweb.int/report/ world/global-humanitarian-assistance-report-2018. Accessed 19 June 2018. Kübler-Ross E. On death and dying: what the dying have to teach doctors, nurses, clergy and their own families. New York: Scribner; 2014.

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Multicultural Palliative Care Guidelines. Palliative Care Victoria: Living, dying and grieving well. 1999. https://www.pallcarevic.asn.au/library-media/multicultural-palliative-care-guidelines-1999/. Accessed 12 May 2019. Organisation for Economic Co-operation and Development. 2010. https://www.oecd.org/dac/peerreviews/12lessons.pdf. Accessed 9 May 2019 p 4. Organisation for Economic Co-operation and Development. 2019. http://www.oecd.org/dac/ financing-sustainable-development/development-finance-standards/daclist.htm. Accessed 12 May 2019. United Nations High Commissioner for Refugees. Figures at a glance. 2019. https://www.unhcr. org/uk/figures-at-a-glance.html. Accessed 8 May 2019. United Nations Population Fund UNFPA. Maternal health. 2019. https://www.unfpa.org/maternalhealth. Accessed 8 May 2019. World Health Organization. Clinical management of patients with viral haemorrhagic fever: A pocket guide for the front-line health worker. 2016. https://www.who.int/csr/resources/publications/clinical-management-patients/en/. Accessed 8 May 2019. World Health Organization/Water, Engineering and Development Centre Loughborough University. Technical notes on drinking water, sanitation and hand hygiene in emergencies: Disposal of dead bodies in emergency conditions. 2013. https://www.who.int/water_sanitation_health/emergencies/WHO_TN_08_Disposal_of_dead_bodies.pdf. Accessed 8 May 2019.

Sudden Death: A Disaster Mortuary Response—Practitioner Perspective

10

Mike Conway

Abstract

Man-made and natural disasters causing multiple casualties and fatalities pose particular difficulties for emergency service staff due to their infrequent occurrence; the normality of a response to large numbers of simultaneous casualties and fatalities can overwhelm the already burdened systems and facilities. This chapter discusses the set-up phase of mortuary services enabling identification, post-mortem examination and dispatch of bodies following mass fatalities for three major incidents.

10.1 Introduction A mass fatality event involving more than a handful of victims will, by its’ nature, have national, if not international, media, public and political focus. By definition, these are incidents that produce more fatalities than can be managed with locally available resources. The victims will be unidentified and, due to the diversity of the general public as a whole, may involve many nationalities and persons from different religious and cultural backgrounds. Local mortuaries that may deal with numerous single deaths in a year and occasionally two, three or four fatalities from a road traffic collision, for instance, will become instantly swamped by the potential numbers of victims. This may be due to the sheer volume of individual victims or by the numbers of fragmented bodies and body parts that can be encountered from high-velocity or momentum-­initiated

M. Conway (*) Derbyshire Pathology, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, UK e-mail: [email protected] © Springer Nature Switzerland AG 2020 T. Scott (ed.), Sudden Death: Intervention Skills for the Emergency Services, https://doi.org/10.1007/978-3-030-33140-5_10

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incidents, that is, vehicular incidents, plane or train crashes, and volatile force-initiated incidents from gas ignition or bomb explosion for instance. The response to these major incident and mass fatality events has two distinct phases: • Response Phase This is the initial activities by primary responders, ambulance, police and fire to triage, extricate, and save as many injured persons with a viability of life as possible. • Recovery Phase This is the post-response phase, carried out by specialist personnel, to document and safely remove any bodies, body parts, property and evidential material that may be relevant to the formal identification of each victim and subsequent criminal or legal investigation. The recovery phase has further sub-phases or processes that include not only recovery of bodies and evidence from the scene, but also responding hospitals/ clinic/surgeries, other mortuaries and the search and recovery from rubble removed from the site at a final clearing stage. Incidents are generally of two types: • Closed, where the provisional number and details of the deceased can be easily obtained, that is, manifest or passenger list (aircraft) (ante mortem data collection can be expedited). • Open, where the number and details of the deceased are unknown and not easily obtained, that is, city centre bomb blast (ante mortem data collection is reliant on missing person reports). There is also a ‘mixed’ type, which is a combination of both ‘Open’ and ‘Closed’ incidents, that is, aircraft crash onto shopping centre. Where a closed incident has occurred, ante mortem Investigators/Coordinators can be quickly dispatched to relatives in an effort to harvest as much information about the victim as possible; this ante mortem data, once collated, is used to match to post-mortem data retrieved from the victim in the response mortuary; should a ‘match’ be made a file is completed, which is forwarded to the Coroner and Identification Commission in an attempt to put a name to the unidentified body. Whatever incident faces the responders, it is important that pre-planning for many different scenarios takes place. The Civil Contingency Act (2004) establishes a coherent framework for emergency planning and response ranging from local to national level. Local Authority and police emergency planners in association with health authorities, HM Coroner and other specialists have an important role in determining the threshold for each response. Planning for where the response will

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take place, what facility will be used, where the equipment will come from and who will staff it all have to be taken into consideration.

10.2 Timescale of an Event and the Use of Normal Facilities 10.2.1 The Potters Bar Rail Crash The time of day and the day of the week an incident occurs can have a profound effect on the numbers of victims and the identification of a potential mortuary to deal with the response. The train derailment at Potters Bar Railway Station that occurred on Friday, 10th May, 2002 at 12:58 resulted in seven deaths; if the timing of this had been later, at rush hour, the platform would have been much busier with the potential for many more fatalities at the station as well as on the train. In this incident, the fourth carriage of an over-ground train became detached and crossed onto the adjacent line, it flipped into the air and continued into the station, mounted the platform and slid along before coming to rest under the platform canopy at 45°. Six passengers on the train died and one person passing under a railway bridge died from falling masonry. This incident was dealt with at a normal hospital mortuary; the number of deaths was not great, there was no fragmentation of the deceased and they were recovered in a timely manner. The mortuary was made operational by the Anatomical Pathology Technologists (APT) and ready to receive victims later the same day and because all normal operations within the mortuary were finished for the week, the deceased were processed to full Interpol1. DVI Standards2 (Interpol 2019) over the weekend without any disruption to the normal workings of the mortuary. Interpol is the world’s largest international police organisation, with 192 member countries. Many of the responding staff had trained together as a multidisciplinary team; this involved police and NHS workers forging links and good working relationships being built up over a number of years and although feelings were running high in order to get the job done, staff maintained their professionalism throughout the long hours of work; they supported each other during the process and lifelong relationships were built; some of these workers have been involved in further DVI work during other incidents, their relationships demonstrating the trust, accountability and professional attitude of those who respond to the DVI incident.

 Interpol – the world’s largest international police organisation, with 192 member countries.  DVI standards – the internationally accepted processes and procedures for recovering and identifying deceased people and human remains in multiple fatality incidents. 1 2

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10.3 Overwhelming of Normal Facilities 10.3.1 The London Bombings The terrorist bombings that occurred in London on the 7th of July, 2005 saw three simultaneous explosions on the London underground tube train network and one on a London double-decker bus, caused chaos for emergency services, halting of the underground system and gridlock of a number of surface streets. Communication in the initial stages of the response was problematic; this was also an issue for emergency service workers responding on the tube trains and in the tunnels. The explosions resulted in the death of 52 innocent members of the public and the four terrorist bombers; there was multiple fragmentation of the bombers and many of the victims who were close to the site of the detonation. No single mortuary within the metropolis had the capacity and capability to deal with such numbers and high fragmentation. The Mass Fatality Coordination Group3 in association with the Coroner decided to engage the Mass Fatality Plan for London; and a site was identified at the Honourable Artillery Company Barracks on City Road. A tented ‘village’ was erected (Fig. 10.1) to house the body reception area, body refrigeration areas, post-­ mortem suite, staff changing, toilet and shower facilities, operational offices and an evidence store. The tented village grew (Figs. 10.2 and 10.3) as demand on the facilities increased to include a larger staff changing area and boot store (Fig. 10.4) and personal protective equipment (PPE) collection point, staff rest facilities, canteen, catering facilities and a family reception centre with viewing facilities for those relatives who wished to attend following the official identification of the deceased and release to their funeral director. Many deceased were fragmented and not all the body parts from one individual were identified at the same time; the process took time, parts were reconciled and the deceased reconstructed. The police and technical staff (APTs) who responded to this incident were drafted in from many different areas; some of the technical staff were London-based local authority staff, others from further afield, some were locum (agency) staff, while others were NHS regular workers; many did not know each other and had not worked in this type of incident response before. Emotions were running high; some staff was unfamiliar with procedures and protocols, many were unsure where they were to stay that night or for how long they were expected or required to attend the incident response.

3  Mass Fatality Coordination Group—Chaired by HM Coroner attendees include, but not limited to, Police, Senior Identification Manager, Senior Investigating Officer, Local Authority, Local Resilience Forum Representative, Emergency Planning, Director/Budget Holder, LA/NHS Mortuary Management, Forensic Pathologist.

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Fig. 10.1  Thursday night

Fig. 10.2 Friday

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Fig. 10.3  Final stages

Fig. 10.4  Boot store

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A meeting was held with management staff from the Local Authority, London Resilience4 representatives and police emergency planners and accommodation arranged; a local mortuary manager was assigned as the lead for the response and he approached one of the staff who had been drafted in to assist him. The technologist he approached had dealt with the Potters Bar rail crash and had been deployed to Sri Lanka during the response to the Asian Tsunami; he was a trained body recovery and victim identification operative and helped with the continual training of police officers on DVI; he became the Technical Lead and the spokesperson for the responding APTs. The Mortuary Management Team5 met at the earliest opportunity and a game plan was drawn up for the forthcoming days; mortuary operations started in earnest on the Saturday. Victims were recovered from the three train scenes and one bus crime scene using standard body recovery protocol; body recovery booklets (Fig. 10.5) and unique reference numbers. The deceased from each scene had to be kept separate so four body reception areas and holding units were utilised, initial forensic harvest for trace evidence was carried out in these areas prior to each victim being brought through to the main mortuary area for the victim identification procedure(s). The deceased were collected from the refrigerated holding areas (Fig. 10.6) and brought through to the post-mortem suite (Figs. 10.7 and 10.8); this comprised a number of segregated areas fitted out with post-mortem table, dissection bench and sink, writing desk, exhibits area and all the associated equipment and consumables required. Within the main area was also situated a ‘C’ arm fluoroscope (Fig. 10.9) where the deceased could be scanned to highlight injury patterns, for early warning of potential hazards (glass, sharps, etc.) and evidential material such as bomb fragments. All deceased were initially scanned and some were returned to the scanner if items could not be found easily during the examination. Were staff emotions running high? I would say ‘no, not particularly’ because everyone was there to do their bit, each person had a specific task to conclude, the focus was on getting the job done and identifying these poor souls so they could be returned to their families. There were times when you could see various emotions boil to the surface; things like newspaper clippings of victims ‘in life’ being posted on the wall; although this can help to focus on the job at hand, it can also be a distraction as this can bring the deceased to life in the mind of the operatives; this is not always helpful. A professional counsellor was brought on site to assist any staff who might be having issues. One in particular became upset, not at what was being dealt with, but from the perception of a younger family member who thought they were not coming back from the event; this person was allowed a couple of days off to go and reassure their family. 4  London Resilience ensures London’s preparedness in the event of emergencies and coordinates the activities of a wide range of organisations. It provides a link between emergency preparedness and resilience at the local and national levels. 5  Mortuary Management Team comprises of HM Coroner/Coroner’s officer, Lead Pathologist, Lead APT, Facilities Manager, Police Operations Coordinator, Designated Individual, Documentation Officer, Ante Mortem Coordinator and other specialists as deemed necessary.

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Fig. 10.5 Recovery booklet

Mortuary processes continued for several days and the matching of ante mortem and post-mortem data began; following formal presentations of the findings to the identification commission and the identifications being established on some of the victims, a number of the relatives wished to view their loved one at the mortuary. A team of APTs was established to prepare the relevant deceased for viewing in the viewing suite at the response mortuary; some of the deceased required delicate reconstruction and cosmetic restoration while others were not in a physical state to be viewed; the relatives were given the option to sit with their loved one, but not see them if they were in a poor state. Careful handling of the relatives in association with the Family Liaison Officer from the police was required; in some instances, photographs were taken of the deceased and were made available for relatives to see if during the discussions the family was adamant to view. The use of the photograph would enable an idea of the extent of the injuries/damage to the deceased without fully exposing relatives to the physical trauma; if relatives still wished to view they were enabled by the technical staff. This is an emotive time for all persons involved, obviously from the relative’s point of view, but also from that of the staff; normally those involved with the

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Fig. 10.6  Refrigerated holding area

deceased in a DVI incident don’t see the families and those involved with the families don’t see the deceased, but the technologists who work in mortuaries span the two sides of this divide and interface with both. Staff can and will get involved with the emotion facing them, even the most stalwart of technologists can waver in the face of this emotion; after all we are all human. The modern-day approach is to offer the viewing of victims once the deceased is identified and released to the relevant funeral director and although this sounds a sensible approach and allows the relative to view in the surroundings of a ‘chapel of rest’ away from the hustle and bustle of the response mortuary, it is not always feasible. Some parts of a fragmented deceased may be identified, but not all of them; would it be right to delay a viewing, if the family so wishes until the rest of the deceased was found and/or identified? This would be a matter for discussion between the Coroner, Senior Identification Manager (SIM), Family Liaison Officer (FLO) and the family and would need to be carefully managed at all levels. During the second week of operations, some staff were given the opportunity to have a break from the work; a few went into London for a day; this was the 21st of July, when four further attempts were made to bomb London. The explosions occurred around midday at Shepherd’s Bush, Warren Street and Oval stations on the London Underground, and on London Buses route 26 in Bethnal Green. This caused

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Fig. 10.7  Post-mortem bay

Fig. 10.8  Post-mortem room

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Fig. 10.9  ‘C’ arm fluoroscope

emotions to run high at the response mortuary and within the APT staff as we did not know if there would be more fatalities, where our comrades were or if they were safe; we could not contact them as the mobile phone networks were not available. Metropolitan Police later said the intention was to cause large-scale loss of life, but only the detonators of the bombs exploded and only one minor injury was reported. The suspects fled the scenes after their bombs failed to explode. A fifth bomber dumped his device without attempting to set it off. We were all re-united later that day and thankfully no one was hurt; this gelled the team even more and this friendship enhanced the response and focused the determination to get the work done. Many of the responders remain friends to this day.

10.4 Adapting an Existing Facility 10.4.1 The Tunisian Shootings On 26th June, 2015, a mass shooting occurred at the tourist resort at Port El Kantaoui, about 10 km north of the city of Sousse in Tunisia. Thirty-eight people, 30 of whom were British, were killed when a gunman attacked a hotel.

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The deceased were due to be repatriated to the UK and a Coroner was appointed to look into these deaths. The Coroners Act 1988 states that Her Majesty’s Coroner has a duty to hold an inquest when informed “...that the body of a person is lying within his district” and that person has died a violent or unnatural death, or a sudden death of which the cause is unknown, irrespective of whether the death arose in their district or not. There was a proposition for this to be changed as part of the Coroners Reform Bill of 2006, but this essentially remains the same. On 1st July, the bodies of eight British nationals who were killed in the attacks were flown from Tunisia to RAF Brize Norton. On 2nd July, the bodies of a further nine were flown home. Eight more were repatriated on 3rd July; the final five bodies of the British victims were repatriated back to the United Kingdom on 4th July. These cases were due to be examined for confirmation of identity, cause of death and the potential harvesting of any evidential material at Hammersmith & Fulham Public Mortuary in London; the mortuary had been cleared of its day-to-day work in the preceding days. An extension was built to the outside courtyard by means of a temporary structure; this structure served to cover the mortuary entrances from press intrusion (Fig.  10.10) as the mortuary was overlooked by several high-rise buildings and a hotel (Fig. 10.11). The configuration of the mortuary was adapted so that the flow within the mortuary would be more conducive to the forthcoming processes and some simple signage erected for those less used to working in the mortuary environment. The wet and dry areas were marked out using high visibility tape and areas cordoned off to allow a one-way system to be adopted for the transport of exhibits and any potential specimens. All the deceased were brought back with military ceremonial detail from RAF Brize Norton and transported in convoy on the day of repatriation to the mortuary; the

Fig. 10.10  Covered entrance

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Fig. 10.11  Proximity to high rise

convoy of funereal hearses were held temporarily in a council compound behind the mortuary and one-by-one came round to the mortuary and unloaded their cargo. Each deceased was carried out of the hearse and brought into the reception area (Figs. 10.12 and 10.13) where the details of the coffin and associated body recovery booklet and Unique Referencing Number (URN) were booked in. The coffin was passed over a demarcation line (Fig. 10.14) and the de-coffining procedure began. Mortuary Teams rotated in shifts to complete the process of de-coffining the deceased as they were delivered from RAF Brize Norton. The mortuary teams opened each coffin in turn checking the paperwork against the labelling and URN; evidential photographs were taken at each stage so that there was an official record of each deceased. Each deceased was placed in a mortuary refrigerator (Fig. 10.15) until the post-mortem examination began. Prior to the commencement of any post-mortem examination, the mortuary teams were briefed on their role and responsibilities within the team and given a safety overview to remind them of the potential hazards and the precautions they needed to observe to avoid accidents; they had a dry walkthrough of the mortuary to familiarise themselves with the entrance, exits, workstations and general layout of the mortuary. There was a general tension or air of apprehension in the teams from both the unfamiliar environment, but also from the want to get started and enable the identification of the victims and the return to their loved ones; this was soon alleviated when they started to don their PPE and were able to muster for their first case. The post-mortem examinations each began with a CT scan of the deceased; this was facilitated via a mobile CT scanner situated in an area behind the mortuary; the scan enabled a quick understanding of what was contained in each body bag and what might be contained within each deceased. Once the PM process began, the deceased were each in turn brought into the post-mortem room through the

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Fig. 10.12  Inside structure

Fig. 10.13  Reception area

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Fig. 10.14 Demarcation

Fig. 10.15  Mortuary refrigerators

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Fig. 10.16  Post-mortem room (side view)

double-­ended refrigerators (Figs.  10.16 and 10.17). The post-mortem room was adapted by the technical staff to allow three examinations to be carried out simultaneously; for each deceased there was a PM table, a dissection area and an exhibit area for photography and exhibit packaging. Upon commencement of an examination, each case was identified by their URN from the recovery booklet and the labels attached to the outside of the body bag containing the deceased; they were brought into the examination area and with photographs at each stage, removed from the body bag then the labels attached to the body were also checked. The extent of each examination was determined by the Coroner in association with the Lead Pathologist, but every deceased was examined in line with the Interpol standard and pink DVI forms completed. At the end of the process, the deceased was reconstructed by the technical staff, washed, cleaned, shrouded, placed into a new body bag and returned to the refrigerated store (Fig. 10.18). Any exhibits removed were packaged by the exhibits officer and the DVI forms and exhibits removed for further scrutiny and safe keeping. The specialist staff who respond to these kind of incidents at both the scene and in the mortuary are privileged to be part of the process; many of them have the ‘Clarke Principles’6 (Clarke 2001).

 The following principles outlined by Lord Justice Clarke in his report in 2001 form the bedrock of DVI processes: ·  Provision of honest and, as far as possible, accurate information at all times and at every stage. ·  Respect for the deceased and the bereaved. ·  A sympathetic and caring approach throughout. ·  The avoidance of mistaken identification. 6

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Fig. 10.17  Double-ended refrigerators

Fig. 10.18  Post-mortem room (end view)

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There is no greater honour than to be part of the process of returning a lost loved one to their families. Learning Points

• Think about how the team protect the dignity and respect from public gaze for the deceased during mass retrieval. • Consider how individualised care is maintained throughout the body retrieval process. • Identify the stages of the post-mortem process.

References Clarke A.  Public inquiry into the identification of victims following major transport accidents: report of Lord justice Clarke, volume 1, CM 5012. London: TSO; 2001. p. 9. Interpol. DVI Standards. 2019. https://www.interpol.int/How-we-work/Forensics/Disaster-VictimIdentification-DVI. Accessed 20 December 2019 The Civil Contingency Act. 2004. https://www.legislation.gov.uk/ukpga/2004/36/contents. Accessed 12 May 2019. The Coroners Act. 1988. https://www.legislation.gov.uk/ukpga/1988/13/contents. Accessed 12 May 2019.

Sudden Death: An Organ and Tissue Retrieval Practitioner Perspective

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Lorraine Fahey and Anthony Clarkson

Abstract

The organ donation and transplant system has historically experienced a shortage in available organs. Recent legislative change has enhanced donation rates. This chapter considers donation and transplant statistics, offers guidance to practitioners involved in the organ donation process and explains the role and experiences of an experienced Senior Nurse-Organ Donation when in communication with the donation team and relatives of the deceased.

11.1 Background to Organ Donation in the UK At present, organ donation is the object of considerable media and public interest. The Organ Donation (Deemed Consent) Act 2019 received Royal Assent in March 2019, introducing an ‘Opt Out’ system for Organ Donation in England similar to that introduced in Wales by the Human Transplantation Wales Act (Welsh Assembly 2013) and similar legislative change is being considered in the Scottish Parliament and the Isle of Man and Channel Islands. These changes and the stories of the organ donors and recipients who have inspired them have highlighted the stark figures around this life-saving medical process. In 2016, there were 525,048 deaths in England and Wales (Office of National Statistics 2018); however, from this number organ donation can only take place where the potential donor has been mechanically ventilated; a fact which prevents most deaths from being considered to have the potential to donate. Consequently, only 5000 people die annually in circumstances where they could donate, just 1% of deaths in the UK. Three people die every day

L. Fahey (*) · A. Clarkson NHS Blood and Transplant, Watford, UK e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2020 T. Scott (ed.), Sudden Death: Intervention Skills for the Emergency Services, https://doi.org/10.1007/978-3-030-33140-5_11

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in the UK waiting for an organ transplant, and the attention of organ donation professionals, governments and the wider healthcare community has focused upon this 1% of deaths and how to ensure that every potential donor is referred, assessed and where possible supported through to donation. Organs for transplants: A report from the Organ Donation Taskforce (Department of Health 2008) sought to increase donation by 50% at year 5 with 14 key recommendations. One single Organ Donation Organisation, NHS Blood and Transplant (NHSBT) was set up to undertake the national management of the structure and personnel to facilitate organ donation. This change brought together locally employed donor transplant coordinators within a national service infrastructure with dedicated leadership across 12 regions staffed by Specialist Nurses for Organ Donation (SN-OD). Following this service re-design, the taskforce ambition to achieve a 50% increase in organ donation was validated with a landmark year five success in 2013. Both the Taskforce Report and the successor Taking Organ Transplantation to 2020 A UK Strategy (NHSBT 2013) sought to place organ donation within the parameters of normal end-of-life care in the UK, influencing clinicians to refer potential donors, to approach individuals collaboratively with the SN-OD and to change attitudes so the public are proud to donate when and where they have the opportunity to do so. Currently SN-ODs, hospital appointed Clinical Leads for Organ Donation and hospital Organ Donation Committee members work in partnership within the hospital to embed organ donation best practice, audit the potential for donation and train healthcare professionals to support the donation process when they have the opportunity. Concurrently, a comprehensive NHSBT Behaviour Change Strategy promotes pride in organ donation and most importantly seeks to persuade those UK citizens who support organ donation within the clinical guidance around gaining consent and authorisation from a donor family (NHSBT 2019) to ‘have the conversation’ with family and friends. Consent rates from families is over 90% where the donor was on the Organ Donor Register and had made their wishes known but slips to around 50% where those wishes were unknown. It is this proportion of the population who must be focused upon so that ‘attitudes to organ donation will change and people will be proud to donate, when and if they can’ (NHSBT 2013 p 6).

11.2 Donation in the United Kingdom The process through which organ donation is facilitated within the UK is determined by the diagnosis of the potential donor as either being confirmed as brainstem dead and proceeding to donate as a Donation after Brainstem Death (DBD) donor, or as a Donation after Circulatory Death (DCD) donor where they proceed to donate following the withdrawal of life-sustaining treatment in a hospital environment resulting in the cessation of their heartbeat and circulation.

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There has always been a prevalence of DBD donations in the UK, which allows the patient to be taken to theatre while still mechanically ventilated, allowing a planned retrieval and optimal perfusion of organs for transplant. However, in the past decade the number of donations by DCD has steadily increased as the potential for transplantable organs from these donors was recognised. In 2009/10, 35% of all donors in the UK were from a DCD source (623 DBD compared with 335 DCD); in 2017/18, there were 956 DBD donors in comparison to 619 DCD donors as highlighted in the Organ Donation and Transplantation Activity Report 2017/18 (NHSBT 2018a, b). The definitions of these donation criteria are broadly as follows.

11.3 Donation After Brainstem Death Donation after Brainstem Death (DBD) is the type of organ donation which may be undertaken from patients whose death has been confirmed using neurological criteria (also known as brainstem death or brain death). Neurological criteria for the diagnosis and confirmation of death applies where brain injury is suspected to have caused irreversible loss of the capacity for consciousness and respiration before terminal apnoea has resulted in hypoxic cardiac arrest and circulatory standstill. This diagnosis is only possible in patients who are on mechanical ventilation as cited in the Best Practice Guidance: Donation after Brainstem Death (NHSBT 2019a).

11.4 Donation after Circulatory Death Previously referred to as donation after cardiac death or non-heartbeating organ donation, DCD refers to the retrieval of organs for transplantation from patients whose death is diagnosed and confirmed using cardio-respiratory criteria. Controlled DCD takes place after death that follows the planned withdrawal of life-sustaining treatments which is of no overall benefit to a critically ill patient in an ICU or in the emergency department. Please see the Best Practice Guidance: Donation after Circulatory Death for further information (NHSBT 2019b). The UK had two years of unprecedented organ donation culminating in 2017/18 with the record number of 1575 organ donations which allowed 4035 deceased organ transplants. Consent rates among the UK population stood at 62%, but in some regions, notably the North West of England, this was considerably higher at 70.9% with a world class 80.6% for DBD. Organ donation is considered a routine part of the end-of-life process; however, that in no way mitigates the impact of a donation upon those healthcare professionals involved and particularly those who facilitate a donation, walking hand-in-hand with a recently bereaved family through to caring for the deceased donor during and after organ donation has occurred.

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11.5 U  K Legislative Framework and Consent/Authorisation to Organ Donation Consent/Authorisation for an individual to proceed to donate their organs is the Holy Grail of the organ donation and transplantation pathway. Without it there can be no organs for transplant, no lives saved and no hope for those who wait for an organ transplant. A superficial look at organ donation in the UK could cause the observer some confusion—polls regularly show that up to 90% of the population support donation, yet even in 2017/18, a record-breaking year for donation, the consent/authorisation rate was 65.5%. This ongoing dichotomy between public support and family consent/authorisation to organ donation has led NHSBT, the four National Health Departments of England, Scotland, Wales and Northern Ireland, and the wider donation and transplantation community to address this issue through a variety of implemented and planned interventions aimed at addressing both societal attitudes and maximising the opportunities for consent. The potential impact legislation has upon societal and personal donation decisions are constantly debated. From 2010, presumed consent (opt-out) was applied in varying forms in 24 European countries, with the most prominent opt-out systems in Spain, Austria, and Belgium, yielding high donor rates (Simpson 2012). This supported the conversation around whether in a nation with high levels of support for organ donation, such as the UK, a change to ‘opt-out’ legislation would improve donation rates by presuming that a decision NOT to donate would allow the presumption of consent to donate. In 2013, the Human Transplantation Wales Act (Welsh Assembly 2013) was introduced replacing the Human Tissue Act 2004, which had legislated for an ‘opt-in’ system in England, Wales and Northern Ireland. The Human Transplant Wales Act introduced presumed consent for legally capable adults over 18 years who have lived in Wales for over 12 months. The legislative changes in Wales, and early data following the introduction showing promising increases in consent, were undoubted influencers upon the decisions by England, Scotland, Isle of Man and the Channel Islands to explore the options for tailored Opt Out legislations for their citizens. In England, the law has been named ‘Max and Keira’s Law’ after the heart recipient Max Johnson and young organ donor Keira Ball whose stories provided a figurehead for those campaigning to bring about legislative change. Legislative changes may impact upon future organ availability; however, they may not alter the fact that currently three people die every day in the UK awaiting transplant. To address this ongoing organ shortage, there is a need to ensure that apart from societal changes every effort is made to optimise the approach to potential donor families. By providing high-quality care, support and information, consent/authorisation to organ donation can be maximised within different legislative frameworks. With an ongoing responsibility for organ donation across the UK, NHSBT educates and embeds best practice when approaching families. The Best Practice Guidance: Approaching the Families of Potential Organ Donors (NHSBT 2015) sets out the conflicting emotions and professional ideations that a healthcare professional faces when caring for a potential organ donor.

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The death of a potential donor is frequently sudden, unexpected and untimely, and when raising the question of organ donation, clinical staff face first hand the apparent tensions and conflicts between caring for a bereaved family and society’s need for more donor organs. Approaching the family of a potential organ donor can be a challenging prospect, which requires compassion and sensitivity, and yet it is an aspect of care for which few ICU clinicians have received any specific training. (p4)

The guidance offers advice to clinicians to help navigate the approach process. A vital part of the guidance is that the SN-OD should be involved and work collaboratively with the treating physician to plan and approach the potential donor’s family, recognising that in this delicate and specialised area of healthcare the bespoke training and experience of the SN-OD offers the family the optimal care experience as they make their donation decision. This is verified by the 70.4% consent rate when an SN-OD was present in 2017/18 compared to 20.5% where clinicians approached alone, as cited in the Organ Donation and Transplantation Activity Report 2017/18 (NHSBT 2018a, b). To effectively support donation, the organ donation and transplantation community need continued and increasing partnership working with healthcare professionals when caring for potential donors. Such a multi-professional approach offers the best chance to increase organ donor numbers within whichever legislative framework is chosen by each nation.

11.6 The Donation Process Every life-saving organ transplant begins with the referral of a patient who could possibly become an organ donor by a member of their healthcare team. In a nation where only 5000 people a year die in circumstances where donation is possible, every single potential donor is precious and consequently NHSBT has invested considerable resource into working in partnership with healthcare professionals to ensure that the reasons for, and process of, referral are understood and followed so no potential donor family misses the opportunity to choose to donate. The importance of referrals was emphasised, not just by NHSBT but also in the guidance document, General Medical Council (GMC) Treatment and Care Towards the End-of-Life: good practice in decision making (80/82) (General Medical Council 2010) and the National Institute for Health and Clinical Excellence Clinical Guidance on Organ Donation (NICE 2011). Both expressed the duty to explore the potential for organ donation and to follow national referral guidelines. The NICE guidance (NICE Clinical Guideline 135) states that organ donation should be considered as a usual part of end-of-life care planning and, while recognising that clinical situations vary, it sets out the criteria when the referral of a patient should be made: • defined clinical trigger factors in patients who have had a catastrophic brain injury, namely: –– the absence of one or more cranial nerve reflexes and, –– a Glasgow Coma Scale (GCS) score of 4 or less that is not explained by sedation unless there is a clear reason why the above clinical triggers are not met

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(for example because of sedation) and/or a decision has been made to perform brainstem death tests, whichever is the earlier the intention to withdraw lifesustaining treatment in patients with a life-threatening or life-­limiting condition which will, or is expected to, result in circulatory death.” (NICE 2011 updated December 2016). The guidelines set the point of referral early in the end-of-life pathway for the critically ill patient. To optimise the potential for a person to donate their organs it is vital that they are assessed and if that potential exists that they benefit from the input and expertise of a SN-OD who can work in partnership with the healthcare team to care for the patient and their family and guide them through their choices. A national referral number enables the same method of contact wherever a healthcare professional works. The necessary personal and clinical details of the potential donor are recorded, considered and a determination made as to whether the potential exists for that patient to donate their organs. Where it does not, the referring professional is thanked for their help and the reasons why donation is not possible are outlined. Where potential exists, the patient’s status is verified on the UK Organ Donor Register (ODR) and an SN-OD is mobilised to attend the unit. The SN-ODs across the 12 regional teams offer a 365, 24/7 service. The teams were designed to ensure that they are able to reach a potential donor within 3 hours. If an SN-OD is already working in the referring hospital, they will attend the unit immediately to offer support until the on-call SN-OD for the region arrives. The SN-OD mobilising to the unit will use their travel time to consider patient details and begin to think about how they can best work with the unit to support the patient and their family. The majority of organ donor referrals come from an intensive care unit or neurosurgical critical care unit with a significant minority from an emergency department. The SN-OD is a professional guest, there at the invitation of that unit to support the potential donor and family and to offer specialist advice to ensure the care and treatment provided for the potential donor maximises the potential for any donation to be successful. Upon arrival, the SN-OD will learn more about the patient and family and collaboratively determine with medical and nursing colleagues how best to approach the family to discuss the possibility of consent/authorisation to organ donation. NHSBT Best Practice Guidance: Approaching the Families of Potential Organ Donors 2015 (NHSBT 2015) clarifies that the best care for families involves the SN-OD in all three stages of the family approach as follows: • Planning •  Confirming understanding and acceptance of loss •  Discussing donation There can be no movement from one stage to another until the previous stage is completed, so a family cannot be expected to begin to consider the possibility of organ donation until they have a clear understanding of the fact that their loved one has died or cannot be saved. The healthcare team caring for the potential donor have considerable experience of dealing with sudden loss and breaking bad news to

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families; however, organ donation is still a relatively rare event on many units and the presence of the SN-OD brings knowledge and experience to the conversations that ensure that family questions, views and concerns about donation can be confidently and correctly addressed. The benefits of organ donation both for the donor family and any recipients are placed before the family and if the potential donor had joined the ODR, their decision to donate will be shared and the family’s role to honour their decision explained. Despite family and social dynamics impacting upon a donation decision, none have the impact of knowing that a loved one has actively determined that they want to be an organ donor. The organ donation conversation with relatives is highly sensitive, so the SN-OD must be prepared for this unique intellectually and emotionally challenging work. SN-ODs complete extensive training and mentoring. As experienced nurses they complete six months of training, including simulation sessions and bespoke communication skills training as well as time on-call with experienced SN-ODs to prepare them to approach a family. Working with a recently bereaved family during and after a donation/authorisation approach offers individualised care to meet that family’s needs, be that long or short contact, the needs of children in the family, or any worries about other relatives or pets. Anything that concerns that family and could reduce their ability to have the best possible end-of-life experience with their loved one and make the best donation decision is the concern of the SN-OD. Once a family has agreed to donation/authorisation, the formal paperwork must be completed and signed and medical and behavioural information about the donor gathered. The SN-OD splits their time between the family, potential donor and the necessary paperwork, ordering of clinical tests and undertaking the complex and multi-faceted organisation of the donation itself, a process which combines pastoral, medical, logistical, organisational and management skills into a process that will frequently require lengthy working and can take 20 or more hours. If there are no medical barriers to donation, the SN-OD can begin planning for the donation. Organs for transplant are allocated to citizens on the Organ Transplant Waiting List according to medical need and their match to the available organ. Because the factors impacting upon the success of a transplant vary from organ to organ, the process by which each organ is offered differs to ensure every organ is given to the person who needs it most. All organs are offered to the transplant centres by the central hub. Transplant centres consider the offers and accept or reject organs based on clinical assessment and suitability of the organ for their patient considering amongst other criteria, the circumstance of the potential recipient, the age and function of the organ. The decision to transplant an offered organ is for that patient and the team that is managing their treatment. Once organs have been accepted for transplant the donation operation itself is planned. Operating theatre time is arranged at the hospital in which the donor is being cared for and one of the National Organ Retrieval Service (NORS) teams is contacted to arrange their attendance. NORS teams are split between cardiothoracic and abdominal teams with the cardiothoracic teams retrieving hearts and lungs whilst abdominal teams retrieve kidneys, livers, pancreas and multi-visceral donations. A multi-organ donor could therefore require the simultaneous presence

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of two teams which requires considerable logistical organisation. The SN-OD works closely with the hub to ensure the arrangements for teams and theatres synchronise and that the donors’ healthcare team and family are kept fully informed. All members of NORS teams are highly experienced surgeons who join the teams because of a personal commitment to organ donation. The operation is conducted with the same care, respect and consideration for the donor as any patient and as with any other surgery, and the SN-OD assists the process and cares for the donor. Following surgery, any requests from the family are carried out and if the family wish to see their loved one afterwards, this is arranged. Retrieved organs are then securely transported to the hospitals where the potential recipients wait for their lives to be transformed by an organ transplant. The UK organ donation process is a complex one. With high demand for transplant, and a limited pool of UK citizens dying in a manner that could allow organ donation, every opportunity is precious. Legal and medical processes influencing the organ donation pathway optimise the potential for donation to occur, prioritise recipient safety and ensure dignified end-of-life care for the donor and their family. For the SN-OD, the process can be intense even with a wealth of professional training and experience but validated by the lives saved and the knowledge that the act of organ donation can offer immense comfort to those families whose loved ones save lives in this incredible manner.

11.7 Organ Donation: A Reflective Account As an experienced paediatric nurse and SN-OD, the sad reality is that dealing with child deaths has been a regular part of professional practice. Each is different and in its own way, challenging and sad. That children die is an unfortunate reality and it still feels like it is against nature so the old adage ‘parents should not bury their children’ is as striking as ever. It is a professional reality that over time, memories of most experiences fade; however, there are some cases that years later, are as clear as if they had happened yesterday and which still engender emotion. This is one such case. The referral for organ donation from the paediatric unit was for a five-year-old normal, healthy young girl with no significant medical history who collapsed suddenly and was admitted to the paediatric intensive care unit. Her scan revealed arteriovenous malformation pursuant to a malignant brain tumour and she deteriorated quickly so the plan was to test for brainstem death. This referral was very much within my professional comfort zone as I knew the unit and professionals therein very well and was accustomed to attending paediatric organ donation referrals; for my trainee colleague it was totally opposite. As nurses we are professional healthcare providers and are proud to be the voice of the patient in all scenarios; however, like any human being we need confidence in our ability to exercise our duties properly—my duty was to ensure that this family had the best support possible during this awful time. My colleague learned from the experience and understood the vital nature of our work and its benefit to patients.

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We arrived in time to meet with our healthcare colleagues and were introduced to the family in time to support them as they agonisingly witnessed their daughters’ brainstem death tests. The tests confirmed she had sadly died and in the conversation after the tests both parents made clear that they understood that their daughter had died. Every bereaved person’s reaction is different especially for bereaved parents. Her father was talkative, sharing memories of his girl and was adamant that organ donation was something his generous and loving little girl would love to do. Her mother agreed but was quieter, struggling to find the strength to articulate her loss. The healthcare team often react very differently when caring for a child, the natural quest to protect children makes them passionate defenders of these patients and their needs. I felt truly grateful that the team on the unit saw the benefit to bereaved families from donating their child’s organs and consequently were supportive, a fact that made the atmosphere in that room, whilst deeply sad, determined to uphold what their daughter’s family wanted and believed she would want too. The formal consent process for a small child is always difficult, fraught with emotion for everyone. As we went through her details her mother and my trainee colleague became quite emotional, so a short break offered some fresh air and quiet tears. As a professional nurse your role is to be caring and strong for the family, but it is impossible to deal with small children at the end of their life and not be affected by it. Sometimes the child is a similar age to your own, has the same hair colour or name or just is mad about the same television show as a child you love. The scale of the family’s loss is almost incomprehensible and in instances of sudden and acute illness like this, perhaps the biggest emotional hit is the comprehension of how a happy life can be suddenly turned upside down. This family was a happy unit of four a few days ago, now they are signing the consent form for organ donation and facing moving forward as a family of three. Their emotional trauma made caring for them, to do anything to help them cope and to ensure their daughter’s donation was a success, become a personal and professional commitment. As a previously happy and healthy young girl there was the potential for her to donate many organs for transplant, organs that would very likely save the lives of other children and hopefully spare their family from the grief that was enveloping her family. The SN-OD trainee found the experience emotionally draining in a way that he had not experienced during adult donations, so care extends to colleagues as well as the donor family. Dedicated time to support the trainee, encouraging him to share his thoughts and not be afraid to express his emotions. The offering process enabled cardiothoracic and abdominal organs to be accepted for transplant and the NORS were contacted and planned their arrival, working together to ensure their little donor was treated in theatre with all the care and respect she deserved and to maximise the chance that her precious gifts had the best possible chance of working. The entire process was explained to her family and they were gently walked through the steps, any wishes around mementoes such as hand and footprints were arranged, and they selected the clothes to be worn after theatre, something I promised to personally undertake on their behalf. The girl’s younger sibling was struggling so the parents made the incredibly tough decision to go home before she went to surgery, so they could comfort their remaining child. As they left

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her mother turned to me and asked to me to promise that she would not be left alone as she could not bear that thought. It is a request that I can still see in my mind’s eye as clearly as when she said it. It was an assurance I took very seriously and in partnership with the whole ICU team we honoured this. The operation to retrieve the girls’ organs resulted in her heart, lungs, kidneys and liver being successfully transplanted, saving children’s lives as the family had so hoped it would. Reflecting on why this girl and her family remain so clear in my mind years after my last interaction with them I can only conclude that the combination of a clearly devastated yet incredibly generous family and the dual pressure of providing excellent patient and family care and professional mentoring to a junior colleague make this donation very special.

11.8 Support for the Organ Donation Professional Organ Donation is a distinct and numerically small area of clinical practice. As such, there is relatively little documented evidence around the risks of psychological burnout amongst the SN-ODs whose professional life is spent supporting acutely bereaved families as they make their donation decision. NHSBT recognises the unique pressures that the organ donation workforce face and seek to put in place a series of measures to ensure acute and ongoing accessible support for their nurses. Organ Donation and Transplantation fosters a strong collegiate spirit amongst its workforce with every SN-OD working as part of a specific Regional Organ Donation Services Team. Teams comprise regional team managers, who are highly experienced senior nurses with management responsibility for eight to ten SN-ODs. This allows them to offer regular one-to-one meetings, shadow and support their direct reports both in terms of their ongoing clinical practice and psychological support and provide accessible resources to discuss any issues that may affect them. Teams support shared practice sessions, confidential meetings where individual cases are discussed, shared learning and shared feelings in a supportive atmosphere with colleagues. The opportunity to improve the service through sharing professional experience extends through a weekly ‘open door’ session in confidence with the Chief Nurse for Organ Donation and Transplantation. Recognising that the unique pressures of the SN-OD role may make off-the-shelf support programmes less impactful, a tailored support and well-being programme has been rolled out across the workforce by a team of internal trainers. The programme seeks to help colleagues recognise the signs of workplace pressures building up and help them develop resilience and the tools to deal with those symptoms through the setting and following of personal objectives. The objectives recognise the importance of physical health as a way of combating psychological pressures. The programme is the latest addition to the constantly evolving work to ensure that SN-ODs who spend their working lives supporting those facing acute bereavement scenarios are themselves supported to enjoy a fulfilling work environment and healthy personal life.

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Organ donation is a complex and multi-faceted healthcare environment but an ultimately rewarding and highly successful one. Organ donation and the transplants that result from donation offer the only chance of a healthy life to the thousands of men, women and children on the UK Transplant Waiting List. In 2017/18, the highest donation levels ever were recorded in the UK. However, if organ donation were all about the organ recipients, valued as they are, it is doubtful that this record would have been reached. Organ donor family feedback evidences that most families take great comfort from their loved one’s donation and are extremely proud that their last act on earth was the altruistic gift of life to strangers. Any work with families facing a death is difficult for the healthcare professionals involved, but perhaps uniquely organ donation professionals can save lives and bring hope even as the bereavement occurs; that is what makes working in organ donation and transplantation so fulfilling and what motivates the team every day to ensure every family who could donate is offered this special opportunity. Learning Points

• Explain the impact of recent legislation on donation statistics. • Explain the criteria for DBD and DCD. • How should the donation process commence?

References Department of Health. Organs for Transplants: A Report from the Organ Donation Taskforce. London. 2008. https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/4245/organsfortransplantstheorgandonortaskforce1streport.pdf. Accessed 12 May 2019. NHS Blood and Transplant. Taking Organ Donation to 2020 A National Strategy Taking Organ Donation to 2020. 2013. https://www.nhsbt.nhs.uk/tot2020/. Accessed 12 May 2019. NHS Blood and Transplant. Best practice guidance: approaching the families of potential organ donors. London: NHSBT; 2015. NHS Blood and Transplant. ODT Performance Report End of year—2017/18. 2018a. https:// nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/10358/odt-smt-monthly-performancereport-march-2018.pdf/. Accessed 12 May 2019. NHS Blood and Transplant. Organ Donation and Transplantation Activity Report 2017/18. 2018b. https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/12065/transplant-activityreport-2017-2018.pdf. Accessed 12 May 2019. NHS Blood and Transplant. Consent and authorisation: Clinical guidance around gaining consent and authorisation from a donor family. 2019. https://www.odt.nhs.uk/deceased-donation/bestpractice-guidance/consent-and-authorisation/. Accessed 7 July 2019. NHS Blood and Transplant. Best practice guidance: Donation after brainstem death. 2019a. https:// www.odt.nhs.uk/deceased-donation/best-practice-guidance/donation-after-brainstem-death//. Accessed 12 May 2019. NHS Blood and Transplant. Best practice guidance: Donation after circulatory death. 2019b. https://www.odt.nhs.uk/deceased-donation/best-practice-guidance/donation-after-circulatorydeath/. Accessed 12 May 2019. National Institute for Health and Clinical Excellence. updated in 2016. Clinical Guideline CG135: Organ donation for transplantation: improving donor identification and consent rates for deceased organ donation. 2011. https://www.nice.org.uk/guidance/CG135. Accessed 7 July 2019.

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Office of National Statistics. Deaths registered in England and Wales: 2017. 2018. https://www. ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregistrationsummarytables/201777. Accessed 12 May 2019. Simpson PJ. What are the issues in organ donation in 2012? Br J Anaesth. 2012;108:i3–6. https:// doi.org/10.1093/bja/aer352. Welsh Assembly. Human Transplantation (Wales) Act 2013. 2013. http://www.legislation.gov.uk/ anaw/2013/5/contents/enacted. Accessed 12 May 2019. General Medical Council. Treatment and care towards the end of life: good practice in decision making. 2010. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life. Accessed 12 May 2019.

Sudden Death: A Funeral Service Perspective

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Martin Jeffrey

Abstract

Following a sudden death, the family of the person who has died feels the loss intensely and this can have lasting effects. On many occasions, the body may have undergone significant change due to trauma or rapid post-mortem deterioration. The role of the funeral services is to prepare the body of the deceased according to their wishes. This chapter presents a detailed analysis of the funeral services, emphasising the reconstructive element of their role so that a closed coffin may be turned into an open coffin so that relatives may sit and view their loved one.

12.1 Introduction I became a qualified embalmer in 1995, endorsed by the British Institute of Embalmers (BIE), and I now have 28  years of experience working in the funeral profession at William Purves Funeral Directors, I am also a qualified Funeral Director and a Member of the National Association of Funeral Directors (NAFD). In my role, I have attended numerous courses in the United States on post-mortem reconstruction as I realised early on in my career I wanted to specialise in this field and eventually make post-mortem reconstruction training available in the United Kingdom. Turning a ‘closed coffin’ into an ‘open coffin’, is for me, what post-mortem reconstruction is all about. The term ‘closed coffin’ is used when the deceased is not in an acceptable condition to be viewed by their family or friends perhaps due to physical trauma at the point of a sudden death. In this case, the family are invited to come into the funeral home and sit by the closed coffin and are

M. Jeffrey (*) William Purves Funeral Directors, Edinburgh, UK e-mail: [email protected] © Springer Nature Switzerland AG 2020 T. Scott (ed.), Sudden Death: Intervention Skills for the Emergency Services, https://doi.org/10.1007/978-3-030-33140-5_12

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therefore unable to see or touch the body of the deceased. In contrast, open coffin viewing after a sudden traumatic death, turning a situation from unacceptable to acceptable, offers the family of the deceased the opportunity to view their loved one for the last time, an opportunity that previously would have been denied. Facilitating this final viewing is so important to some people because it offers the chance to say a final goodbye, the chance to have some degree of closure. In sudden traumatic death, there is no time to prepare and the sequence of events occurs at a time of great emotional turmoil. There is limited time to absorb what is happening and to say a final goodbye or apologise for the argument you may have had the night before. If viewing is not an option it can have lasting effects for the grieving process. I remember a very sad sudden death involving a young child. His mother had sent him out to play on his bike. A tragic accident on a beautiful sunny day was about to change lives forever. The young boy was knocked down by an articulated lorry and taken to the local mortuary. Everyone involved had said to the little boy’s mum and dad that there was no way they could see him as he was too badly damaged. The option to sit for a short period of time with their precious child in a peaceful state had already been taken away. This was likely to be devastating for his poor mum and dad. Mum feeling the enormous guilt of sending him out to play and always waiting on him coming back, whilst dad had unfortunately seen his young boy at the scene, under the lorry. This final image is likely to remain in his memory eternally. Both the mum and dad needed closure and a last chance to say goodbye, a last hug or kiss for their little boy. I was contacted by the Police Liaison Officer because of my reputation and skill set to ask if there was anything I could do to ease their deep pain. Of course, I wanted to help and, I would do everything I could to help them see him one last time. I arranged for the boy to come to our premises and spent two days carrying out his reconstruction. His mum brought some clothes and I personally dressed him and arranged for his mum and dad to come the following morning. Below is part of a thank you letter from the family to the funeral director who arranged the funeral. The family would like to thank you for your sensitivity and respect and for your skill with which you helped us at a very traumatic time. At every step you seemed to ease our way and this is very much appreciated. Please also thank Martin for his caring and skill, being able to see wee (name of child), peaceful and well looked after, was of such importance and comfort through the pain.

There is no doubt in my mind that the reconstruction of their boy’s body brought some closure to mum and dad and left a more peaceful last memory of their little boy, so post-mortem reconstruction is really important following sudden traumatic death. The last 5 years of embalming at this funeral directors comprised 7052 cases, covering all ages, genders and causes of death. Death in 75% (n = 5289) of cases was from natural causes, 22% (n  =  1551), I would say, are not straightforward

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cases because of a range of post-mortem presentations including decomposition, tissue gas, oedema, obesity, cancers. Although not needing reconstruction in most cases, there are specialist techniques involved to allow viewing to take place. Three per cent of cases (n = 212) died in traumatic circumstances, approximately 42 per year, ranging from road traffic accidents, suicides to murders. Injuries can be broken or detached limbs, badly crushed skull, broken ribs or spine, severe soft tissue injuries over the body and face, or missing tissue or bone which needs to be replaced. When charged with looking after someone who has died in a traumatic way it is very important to me that I remember the family and friends involved with the deceased, that they are well-aware of what can be achieved and that their expectations are achievable. These cases will never look like they did before the fatal event, but they will be restored to an acceptable level for viewing. My role is in looking after the deceased. I always remember that the person lying in front of me is someone’s granny, grandad, mother, father, son, daughter, brother, sister, aunt, uncle or cousin. I try not to forget that they are an individual that has been taken suddenly from the family. People ask, “How can you do what you do?” I want to be the best I can be and want to make a difference. I have the skills and passion for my job to make that difference between seeing and not seeing a loved one under such traumatic circumstances. It can be a very emotional, tiring role that can give such a feeling of achievement and satisfaction when families are pleased, relieved even, after the viewing takes place. There are many cases that have made a lasting emotional connection with me and I will never forget them. On one very sad occasion, I found myself called upon by my employer. His daughter and granddaughter were hit by a drink driver who had mounted the pavement and sadly his granddaughter died at the scene. There I was, with the man I have looked up to all my working life, the man who gave me a job, believed in me to train as an embalmer, paid for all my courses to America, relying on me to be there for his family but more importantly his granddaughter. The family were devastated and looking to me to help. I did the very best that I could do and, he thanked me later for everything I had done. I found this an emotional rollercoaster, sadness for the family I have known many years, not wanting to let any of them down, feeling good that I am able to do something to help, feeling sad about whether I could possibly have done more. The weekend after the incident I was attending a wedding, such a happy event but seeing the flower girls running about brought back all the sadness and the memories from events of the week before. These feelings will never go. I don’t want them to and it is what gives me the drive to help others when nobody else can. When looking after the deceased when they are brought into my care, I look beyond the trauma, the body being presented in an unnatural way, the blood and the smell... In Scotland, as a sudden death, there will have been a post-mortem carried out under the instruction of the Procurator Fiscal. This is not a problem; it just means I need to approach the embalming in a different way to that of a case that has

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had no post-mortem. This is a person who deserves to be treated with respect and dignity as they did in life. My first action is to wash and clean the body, placing modesty cloths over their genitals, and breasts if female. I assess the extent of the trauma and make a methodical plan as to how to best rebuild and restore the features. The deceased will be embalmed at this stage as it is important to slow down any deterioration as soon as possible. I use a waterless embalming solution as this is much stronger than what would be needed under normal circumstances. Depending on the trauma, I remove the trunk and scalp sutures and once complete the incision can be opened and the internal organs removed. The scalp sutures reveal the loose skull cap (calvarium), depending on the extent of the trauma whilst the trunk incisions will usually reveal the loose sternum (breast bone), with the internal organs underneath. The calvarium and the sternum are placed into a covered container and the viscera (internal organs) are removed and placed into viscera bags and treated with a preservative (cavity fluid). The hollow organs and intestine are cut with scissors to help the penetration of the cavity fluid and the trunk cavity is disinfected and cleaned. I then choose the arteries that will be used to inject the embalming fluid. For the head, if intact, I will use the common carotid arteries anatomically located at either side of the neck. For the upper limbs, the cut ends of the subclavian are usually easily located whilst for the lower limbs the common iliac arteries are usually easily located. When arterial injection is complete, the trunk and cranial cavities will be sealed by applying Dryene, a bleaching and cauterising agent; once dry the area is dusted with Viscerock, an absorbent powder to dry and firm any moist tissue, which will help minimise any leakages once the embalming is completed. When arterial injection is complete the trunk and cranial cavities will be disinfected. Any areas that are badly damaged, and where the flow of the embalming fluid is restricted, will need to be hypodermically injected with a syringe and needle to inject Dryene to the localised areas, this will cauterise, bleach and preserve the tissue. The trunk is dried and lined with an absorbent, preservative powder and then the viscera (internal organs) are placed back into the trunk cavity. The sternum is now placed back into position and all the main incisions can now be closed, usually with a close baseball suture. The body is then thoroughly washed with Dis-spray (disinfecting and deodorising embalming spray) once dried, the deceased is then placed in the refrigeration unit over night for the embalming fluid to saturate the tissues.

12.2 Reconstruction Once the above is completed I am ready to start the reconstruction. Post-mortem reconstruction falls into two categories comprising first, rebuilding the skull (frontal, parietal, temporal, occipital, ethmoid and sphenoid cranial bones), facial skull (maxilla, mandible, orbital, nasal and zygomatic) and second, bones along with soft tissue injuries to the torso, limbs, head and face.

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12.3 Focusing on the Skull and Facial Skull Access is a main feature of reconstruction. To see the extent of the damage I need to dissect any soft tissue past the damaged area to expose any bone or structure that has no damage and is in the original position in the skull. This is referred to as ‘the known’. All other broken or fractured bones need to be removed and cleaned. Placing them on a tray in order of front, back, upper left and right, lower left and right will help me when replacing them later. The simplest analogy to explain the next stage is to think of the reconstruction as a complicated jigsaw. Starting from the known at the back of the skull, I look through all the bone fragments laid out in front of me and find the first piece that matches the known, that is, any bone or structure in its original position in the skull and facial skull. Once I have located the first bone that matches, I will drill and wire them together. This is a time-consuming part of the process that takes many hours. I systematically find one piece at a time and drill and wire them together. The rationale behind this is that if you take the time to reconstruct and secure the deceased’s own skull then there is no guesswork involved, the shape and size will be correct. Once the skull and facial skull is complete I set it with plaster of Paris and remove all the wires. I then use non-drying clay to smooth out the skull surface prior to soft tissue repair. The next stage is to plan the reconstruction of the soft tissue injuries to the face. Some injuries such as small cuts or abrasions will be easily fixed and corrected with waxes and surface restorers; synthetic products, manufactured to mimic the look of soft tissue. Extensive injuries take a lot more planning especially if the eyes, nose and lips are out of alignment, so in this case I will use a range of techniques to achieve a good result. Intradermal suturing with dental floss is used for cuts and lacerations. This is inserted into the upper most layer of the skin and will bring the edges of the wound tightly together leaving no seam. Any deep, open wounds will be repaired with a basket weave suture soaked with glue and sprayed with an activating agent. This will make the ligature very hard and an ideal base for me to apply non-drying clay into the deep wound to pack it out and give a secure base for the waxes. I will finish off the soft tissue repair by using a wax surface restorer. I then thin out the edges onto the facial skin so that there are no lines between the skin and the wax. For features such as the nose, eyes or ears that are too badly damaged or missing, I will model them from non-drying clay and spray with a sealant before cosmetics are applied. Having now completed all the reconstruction of soft tissue injuries I am ready to apply the cosmetics. Airbrush cosmetics are for use in the mortuary. This is because the skin changes create pallor and cyanosis, which can create a painful last image to expose the family to. The makeup is sprayed onto the skin rather than being applied by brushes, sponges, fingers or any other method. It works by an adjustable airflow being passed through the airbrush system to distribute the cosmetics onto the skin in thin even layers. I apply a few layers of a neutral foundation cosmetic to conceal the clays and waxes and then apply warmer colours to give a more natural look using darker colours for shading around the eyes, ears, nose, and jaw line to create facial depth in specific areas. The technique is completed by the application of a lighter colour to

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highlight areas such as the forehead, cheeks, tip of the nose and chin. Once the cosmetics have dried the deceased is ready to be gowned; a white satin over garment with sleeves covering the deceased from the neck to the feet which is open at the back, making it very easy to put on or remove. The type of clothing donned varies greatly; some families will simply bring in clean pyjamas or a nightdress, nicely ironed and wrapped up in tissue inside a lovely bag. Others will bring in a carrier bag with shorts and a T-shirt simply put in the bag, not ironed. Mostly though there is a lot of time spent by the family picking out a special suit or dress, maybe the full highland kilt outfit that the person had worn recently or a wedding dress from many years ago. They will hand pick special jewellery that the person may have worn, the clothes will be meticulously ironed and shoes polished, it will be the last thing someone can do for the deceased and families feel the need to do their best for their relative. Families will bring in photographs of how they would like a lady’s hair done and typically the photograph will be from a wedding, party or a holiday from happier times. The hair will be washed and set as near to the photo as possible, although when the deceased is lying down in the coffin, it can be hard to make the hair look as natural as it was in life, gravity will play its part in how the hair will look. Makeup along with nail varnish that the deceased will have worn will also be brought; again, it is important for the family that the person looks as they did in life. We do not put makeup on the deceased unless requested. Not every woman or man wears makeup, and with children this can look strange to the family. Gentlemen will have their hair washed and trimmed, it is important we get the parting of the hair going the right way, whether or not their was a fringe, or the hair was swept back, again, getting the hair wrong will change the appearance to the family. Facial hair needs to be considered as to whether it is to be left on, trimmed or removed entirely. Nails will be cleaned and trimmed. When relatives enter the room where their loved one lies, lighting is so important, especially for trauma cases. The use of uplighters, down lighters, lamps, dimmer lights can make a real difference to all the hard work that has gone into making the deceased acceptable for viewing so I spend a lot of time preparing the room, even changing the room if things are not perfect. Flowers and religious texts are left on a side table for a more pleasant, comforting experience.

12.4 How Do I Know I Have Done My Job Well? I had a case where a young woman had been murdered and there had been several months delay from the time of death until the Procurator Fiscal authorised her body for removal from the local mortuary. As a sudden traumatic death, the family were devastated and were most distraught that they had not seen their daughter since before the attack had taken place. They were desperate to see her. When she was brought back to our premises, she was in an extremely bad way. The delay in being able to remove her along with the wounds from the attack made it impossible for her parents to view her in that state.

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With her parents’ permission I started restoring the body of their daughter to an acceptable level to allow them to view. This was a complex case with numerous complications involving decomposition, lack of hair and, wounds to the soft facial tissue. A few days later the mum and dad came in to see their daughter, for the last time. Dad was pleased with how his daughter looked, considering the circumstances whilst mum let out a scream at the viewing. At first, I felt I had let her down; she then apologised for screaming but said it was because she didn’t expect the make-up to be so pale. On reflection, my thoughts were, if the pale makeup was all that the mum and even the dad could see through the trauma and delay to them being able to view their daughter, then I have done a good job. I am constantly asked, “Where did you train to do your job” or, “How did you learn to specialise in post-mortem reconstruction?” It has been a long journey, and I have completed many courses to arrive at this level of competence. I feel that if you want to be the best at what you do then you need to keep challenging yourself, get out your comfort zone, try new experiences, maybe not even directly linked to your job. Constantly learning new skills generates so much personal satisfaction in being able to make a difference in your chosen career, especially a career of this sort, is priceless. • 1995 Qualified embalmer with the British Institute of Embalmers. • 1997 Qualified funeral director with the National Association of Funeral Directors. • 1997 Advanced Post-Mortem Reconstruction course, at Southern Illinois University, USA. • 2004 Academy of restoration and embalming, at University of San Juan, Puerto Rico. • 2010 Embalming and Post-Mortem Reconstruction at Springfield Missouri, USA. • 2010 Blake’s Emergency Services, international emergency mortuary support response team. • 2011 Start-up of the William Purves Embalming Academy. • 2011 Advanced post-mortem reconstructive surgery course. • Advanced 2 post-mortem reconstructive surgery course, both at Springfield Missouri USA. • 2013 Skin camouflage application techniques to post-mortem skin, British Association of Skin Camouflage, Liverpool Community Hospital. • 2015 Airbrush cosmetics course, Malmo, Sweden. • 2016 Start-up of William Purves Post-Mortem Reconstruction Course, the Old Medical School, University of Edinburgh. • 2017 Pearson BTEC Level 3 Award in Education and Training. • 2017 British Institute of Embalmers Tutors Course (ongoing). • 2018 Facial Anatomy, Dissection and Injection Course, Royal College of Surgeons, Edinburgh.

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As you can see, training here in the United Kingdom was limited. I knew early on in my career that bringing post-mortem reconstruction training to the UK was my vision. To be able to offer the opportunity of adding this specialist skill set to embalmers would be invaluable, enabling them to better serve the communities they work in. To gain the best possible training in embalming and reconstruction here in the UK, three of the main courses are as follows: • William Purves Introduction to Embalming Course. • British Institute of Embalmers Course. • William Purves Post-Mortem Reconstruction Course. These courses will provide a solid base from which to develop an embalming career. I have enjoyed every minute of my job as an embalmer; being able to make a difference and help people during such traumatic times makes all the hard work worthwhile. As an Embalmer, I have little or no contact with the family of the deceased. My experience of death and sudden traumatic death is purely located in my abilities as an embalmer and my skills in post-mortem reconstruction.

12.5 Funeral Arranging with the Families I felt it would be interesting to ask my colleague how his experiences of death and dealing with death on a very personal level with each family compare with that of an embalmer. He said, “The day I am no longer touched by the personal tragedy which comes knocking from time to time at my door as a Funeral Director, is the day I need to leave this profession.” Much of our work involves those strange bedfellows of sadness and relief. Sadness, or grief as we call it in our profession, is experienced as a great loss no matter how expected it is, even at the end of a long life well-lived. Yet, so often today in a world of dementia and dreary nursing homes, a deep sense of relief washes over in the awareness that their suffering is now ended, we trust. However, we all dread those 3 am phone-calls where through the tears we are told of sudden deaths, child or teenage losses or worst of all, suicides and all the ‘what-­ if’s’ they bring. The hurt and distress is palpable, the need for empathy is immediate and extreme. For every case our skill and satisfaction come from reaching out to the bereaved in their time of need, sharing something of ourselves as we journey beside them in their grief, that intensely emotional and real, yet often brief relationship of carer with ‘client’, all to ensure the one they love has the funeral they deserve—a funeral that is both appropriate for the one who has died and a comfort to those who mourn. As I have aged and gained experience in this uniquely challenging yet incredibly rewarding profession, I now find myself ever more open, ever more transparent and ever less afraid to be vulnerable in empathising with clients. The language

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becomes so authentic and highly emotional at times. Families are sharing very real emotions and sometimes very intimate and intense feelings or facts, so we must be ready to enter as much as we can into their grief journey whilst remaining professional but never distant or aloof. We do say things like “that’s awful”, “that’s so wrong” or “that’s so very hard”, so we do tend to comment on their loss, but we also recognise that we never totally understand and respect that the grief is uniquely theirs not ours. Our greatest challenge or dare I say ‘skill’, is in interpreting what they need from us in this their time of need. In all honesty, there is frequently the sound of laughter, the ironic smiles as often as tears as we share with bereaved families. Amongst colleagues we know we can be very real, by admitting to a tear on the way home as we struggle with a particularly testing circumstance. However, much remains unsaid, amidst the undercurrent of tension whenever there is that tragically small coffin in the room or bereft parents to support, it is that knowing look or touch or, when the need arises, hug, that says so much without speaking. But for us all it is our spouses or partners who see the real cost as we go over ‘our day at work’. The cereal spilt at the supermarket seems suddenly trivial next to witnessing a mother stand beside the open coffin of her child, a young dad widowed and trying to ‘be brave’ for his children. So yes, for me at least there are sometimes tears. We learn to share, we learn to cope, we keep reminding ourselves that tragedies are much rarer than the many we are touched by and we learn to save our deepest resources for those few occasions when there is no escaping or stepping back from the enormity of the loss and tragedy that do come our way but which are thankfully the exception not the rule. The following poignant message is an abstract from a thank you letter from a family following a sudden traumatic death of a loved one which demonstrates how important it is for viewing to be made possible in all these cases. There are three people in our lives who will always hold a special place, the man who married us, the midwife who delivered our girls, and you. Thank you!

These are strong powerful words from a grieving wife and mother. For me, it is such a privilege to be able to make a difference and help others at such a traumatic time in their lives. Death affects us all, no matter what age, gender or religion but sudden traumatic death can be such an emotional rollercoaster for everyone involved, from the professionals in contact with the deceased, the professionals in contact with the family of the deceased and for the family and friends ‘left behind’. Closure for the family and friends is so important, having the opportunity to say a last goodbye, to touch a hand for the last time, or a gentle kiss on the forehead offers a peaceful final memory. These moments are priceless. Nowadays, our lives are so busy, people travel more, drive fast cars, motorbikes, boats, and go on adventure holidays. We should all live our lives to the full and enjoy having our family and friends around us. When a sudden traumatic death occurs, it is essential that there are many allied professionals with the

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specialist knowledge experience and the sensitivity needed who are ready to help guide us through this traumatic time. For me, as an embalmer, post-mortem reconstruction is about turning a closed coffin into an open coffin for viewing. Making a difference.

Learning Points

• What do you think is the benefit of making a closed coffin into an open coffin? • How might you prepare a room so that relative’s may sit with their loved one? • What might you say to a relative who wishes to see their loved one following mutilating injury?

Sudden Death: A Multidisciplinary Emergency Service Perspective

13

Tricia Scott

Abstract

Sudden death has a distinct procedural base and a profound effect on those emergency personnel who are involved in the management of the scene. In addition, the attention given to relatives who are devastated by their sudden loss must be sensitive as they are steered through the process. This chapter considers concepts central to sudden death work, the procedural base to death work and illuminates the management of the sudden death process and impact on the emergency team and the relatives who are left behind to grieve.

13.1 Introduction Embryonic ideas about this book emerged following doctoral study which sought to explore sudden death work carried out by emergency personnel (Scott 2007). The research focused on three emergency departments in the North of England where sudden death practices and perceptions of emergency personnel were revealed using thick description from focus groups, narrative and informant accounts. Three emergency disciplines: emergency nurses, police traffic officers and paramedics provided the backdrop to sudden death trajectories, which explained how a person was processed through a state of collapse as a live person to a mortuary as a dead cadaver. The patient underwent a change in status as he/she journeyed through the life/death space. The representation of the often disfigured body to relatives was discussed within a dramaturgical frame (Goffman 1959), which raises questions about what is appropriate, indeed, achievable in the emergency context. This book builds on the

T. Scott (*) Healthcare Education and Research Consultant, Hertfordshire, UK © Springer Nature Switzerland AG 2020 T. Scott (ed.), Sudden Death: Intervention Skills for the Emergency Services, https://doi.org/10.1007/978-3-030-33140-5_13

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previous research providing authentic accounts of sudden death work from a wider range of emergency personnel and allied disciplines who are involved in the sudden death event. Sudden death is an unexpected death which includes: • • • • • •

Suicide Road crash or other transport disaster Drowning, falling, fire or other tragedy Undiagnosed advanced terminal illness, such as advanced cancer Sudden natural causes, such as heart attack, brain haemorrhage, or cot death Sudden death from a serious illness that was known about, but where death wasn’t expected, for example epilepsy • Murder • War or terrorism Relatives are usually ill-prepared to cope with the devastating news that their loved one has died (Brake: The Road Safety Charity 2019). Compounding this, people can die in the most compromised of situations and locations making the work of emergency and allied personnel, including body retrieval and management, more difficult. Unfortunately, trauma is the leading cause of death in the first four decades of life in the United States and has a trimodal distribution. The first peak of death occurs within seconds to minutes of injury usually due to lacerations to the brain, brain stem, high spinal cord, heart, aorta or other large vessels. The second peak occurs in the ‘golden hour’ within minutes to a few hours after injury usually due to subdural and epidural haematomas, haemopneumothorax, ruptured spleen, lacerations of the liver, pelvic fractures, or multiple injuries associated with significant blood loss. The third death peak occurs several days or weeks after the initial injury almost always due to sepsis and organ failure (ATLS 2013). So some of the cases that emergency personnel deal with are quite physically damaged and naturally, the traumatic way that some die has consequences for the management of the grieving family and the emergency personnel involved. Various seminal sociological texts have shaped our understanding of sudden death, which challenges the taken-for-granted ‘business as usual’ attitude of everyday life (Berger 1969), having the capacity to create an existential problem due to societal fear of decay and decomposition. The body politic (Douglas 2002) provides a metaphor for social order because bodily seepage such as blood, milk, urine, faeces, vomit, sweat, and tears represents dirt, disgust and horror and the impossibility of clean, pure and proper (Grosz 1994). The concept of ‘dirty work’ (Hughes 1981) can be applied to the activities which emergency personnel and allied death workers perform to manage a dead body, which in some situations may be ‘physically disgusting’, for example, following a death by drowning and which makes us question our moral conceptions. In identifying, cleaning, reconstructing, wrapping and dispatching a body to a mortuary swiftly, bodily order is maintained and in this way we balance the sacred and the profane, purity and danger, risk and taboo, and order and chaos (Douglas 2002). By maintaining ontological security following death, the

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potentially ‘polluting body’ may be controlled and emergency and allied personnel are adept in creating these conditions and representing the body to relatives as if they were ‘asleep’. For the emergency team, living through the resuscitation sequence and subsequent death of a patient, one thing is for certain: specific images never leave us but remain engrained, almost on the retina—the scenario, actors, sounds and smells associated with utter tragedy. Hard to forget are the “raw, almost feral” responses of a grieving relative as described in Chap. 2, an indication of their immense sense of loss as the relative tries to absorb the gut-wrenching death message. Or, in the military context concerning the death of innocent young children who were simply playing a game of football, we will not forget “The glare of their eyes looking at me as if to say, ‘save me’” (Chap. 8). Some emergency personnel will begin to experience stress symptoms and find it hard to control their anxiety after what they have witnessed and dealt with. Death becomes physical. Emergency medicine is a field in which time-sensitive algorithms help sustain life but which paradoxically also requires emergency personnel to offer emotional support to those who grieve, witnesses present and the emergency team. A fine balance is achieved as members of the team may oscillate between clinical objectivity and emotional involvement, most challenging when the dead person bears some characteristic attachment to the professional, that is, a child who is the same age as theirs or a very old person who perhaps resembles a grandparent. To feel anything less connected must surely compromise the caring human values to which the emergency and allied professions aspire. The process of contacting relatives and explaining the sudden death of a loved family member is a formidable, indeed dreaded, message to convey and requires a period of time sitting with them explaining the sequence of events and listening to the relative’s story. What type and intensity of support should be given by emergency personnel begs questions about how formalised the care of relatives should be especially when acute reactions demonstrate their extreme distress. When does caring begin and when does it end?

13.2 Human Tragedy Human tragedy is witnessed by emergency personnel and allied death professionals on a repetitive, daily basis and proximity to these events can emotionally incapacitate even the hardiest and most experienced emergency personnel (Wright, 1991). The procedural base and coping strategies during sudden death events is now presented in each chapter of this new teaching text providing accounts of emergency personnel and allied professionals contact with human suffering and emotional pain and walks the reader through the experiences and reflections of a range of emergency and allied emergency disciplines who are involved in the death processing industry. It is hoped that insight gained from reading about how the sudden death milieu operates may provide a sound teaching text, a reflective analysis, a catalyst to inform change where needed in service provision and enhance inter-professional working relationships.

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The narrative style of the authors reveals quite intimate personal reflections such as the relative in Chap. 1 who, when faced with her husband’s sudden physical decline, anticipated a positive outcome when in reality he died unexpectedly in the Catheter Lab. At times such as this, we search for meaning that something good will come from the sadness. Later, when sitting with her husband’s parents, it was with stoicism that they confronted the news of their son’s departure. But then, how is one supposed to respond? There is no right or wrong way. Losing one’s child, no matter how old the parent is against social order and though Jack’s parents may have been normalising to maintain some sense of order, it is likely that they were feeling the loss most intensely. We get through that day in the best way we can. What struck me as significant was the desire to keep the messages and cards of condolence in a file and to re-read the events of the past at a later time, when ready. This seemed to bring comfort to the grieving wife as she read through and I assume, re-connected with her husband, reflected on the events of the day and adjusted to her new status as widow. Treasured letters, photographs, cards and artefacts which connect the relative to the person they once knew tend to take on significant importance even many years later. Sudden death as a life-defining event is impossible to predict and even after years of practice as a Paramedic, Chap. 2 demonstrates how swiftly someone’s life can be turned upside down. It takes a split second, one enjoying a family breakfast, the next discovering your partner who has died. The complex range of deaths encountered in this book and the locations and circumstances vary immensely. In these situations emergency personnel do not have the luxury of time to gather their thoughts but must think of something constructive to say when they have no clear plan of what to say. The quest here is to try to do your professional best, to maintain composure when all around is flailing. The Paramedic recalled how “…in a handful of apologetic words he had taken them [relatives] from mild concern to abject horror “, faced “…an emotional tidal wave of raw grief” and had absolutely no idea of what to say next. It seems there is a feeling of impotence awareness from not knowing what to say for the best. Sudden death tests the mettle of even the hardiest of emergency personnel to reveal inner strengths as well as vulnerabilities and it seems they may on occasion take the death very personally, perhaps blaming themselves for not having done enough to save the person or persons. These feelings are an indicator of the value of human life. Here it is important to recognise this natural negative default and one should remember to pause, reflect and refrain from overthinking oneself into a state of negative reflection…you did all you could. The tendency is that we over-­ intellectualise the sudden death event and the part we played in the resuscitation and subsequent loss of life. It seems that somehow emergency personnel manage to remain objective about the sudden death activities that they are involved in but for some, participation can overwhelm. One Paramedic reported on how when he attended the scene of the death he could not remember seeing anyone else in the room and simply focused on the task in hand, the resuscitation. Though I am sure he had his moments, particularly well-explained when recalling the imagery of the event: on future occasions some years later, when he cam across the smell of cooked breakfast, it transported him back to the scene of the death.

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One thing that emergency personnel do seem to be concerned about is that most people who highlight bad experiences of healthcare or who go on to submit formal complaints, do not tend to object to technical aspects of care but show significant concern about how they were made to feel. The ability to recognise the deep pain that relatives experience is of primary concern and the need to update the relatives as to what is happening should be foremost. In a seminal survey, relatives expressed how they did not wish to remain uninformed and uninvolved at a time like this (Tye 1993); a tremendously difficult state. This issue is generating much concern lately as workforce deficits require emergency personnel and allied death professionals to do more with less time.

13.3 Anticipatory Fear Anticipatory fear of exposure to a dead body as a new recruit is an important area to focus on and should be foremost in the minds of experienced emergency personnel who mentor junior colleagues and trainees, for many have never experienced a sudden death event and, especially, been in close proximity to a dead body whatever state it is in. You may recall the Firefighter (Chap. 4) who, as a new recruit asked himself “What if I see a dead body?” and how his fears were brushed aside with a quick retort from his senior “You’ll deal with it, everyone does!” This response led to a reliance on mirroring the way in which his more experienced colleagues handled the encounter. Multiple images of horrific scenes are displayed on television and in films but nothing will prepare you when you face it for the first time; you just find a way to get through it. As a mentor supporting a junior colleague, the effects of exposure should be minimised as much as possible through an explanation of what to expect so new recruits are appropriately prepared for the actual event, the changes that the body undergoes: pallor, cyanosis, bloating, trauma and amputation, etc. Similarly, recruits need to receive formal training in how to deal with traumatic events such as sudden death in the course of their work and further, how to handle the quite debilitating effects of anxiety and for some, post-traumatic stress disorder (PTSD). Many emergency teams, because of a shared sense of purpose develop a strong camaraderie and team spirit and they get to know each other outside of their working lives. Sudden death work “…exposes emergency personnel to mutilation, death, bereavement, and constant contact with human suffering and pain, the expression of humour providing a primary coping mechanism to manage stress and prevent burnout” (Keller, 1990). The use of black humour (also known as dark, gallows or sick humour) is known to help emergency personnel cope (Rowe and Regehr 2010). Humour allows a stressful encounter to be normalised and therefore manageable (Charman 2013). Humour creates a powerful psychoendocrine release which increases camaraderie and solidarity and the ability to cope with annihilating situations that otherwise overwhelm, though its expression conflicts with codes of professional conduct.

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Hochschild (1983) published a seminal text entitled, ‘The Managed Heart’, which analysed service industries and, in particular, the act of displaying emotional behaviour through surface or deep acting compatible with the occasion, defining such an act as ‘emotional labour’. Surface acting refers to the expression of feelings in institutionally approved ways; the person is simply acting without emotional attachment. Deep acting focuses on inner feelings and demands greater psychological effort manifested in phrases like, ‘I psyched myself up’ or ‘I squashed my anger down’; typical indicators of a strong concern for one’s customers. There may be an acceptance that emergency personnel can deal with whatever is thrown in their direction, but not all emergency personnel have opportunity or inclination to talk about how they feel after an incident. Some teams may talk through an event during their break or with a senior colleague; however, the team needs to be alert to the signs of increased anxiety among our colleagues and ask the right questions of colleagues whom we think may be struggling (Scott 2007). We need to look after each other following repeated exposure to sudden deaths as any one of these repeated events can literally be the ‘straw that broke the camel’s back’ as someone begins to experience more debilitating anxiety symptoms. We should acknowledge that we are feeling these situations and outcomes too. Consider the humanitarian nurse who managed to keep on a brave face for the relatives when she was experiencing the pain of the loss of life too. We should learn not to be too hard on ourselves or self-critical as we are generally doing the best we can in quite often austere circumstances. As staff, we try to maintain our own composure whilst witnessing the relative’s immense grief. It should be remembered that an extreme reaction or even eruption will usually plateau at some point and then subside so it is best to sit through it and monitor the dynamics. Many patients will not make it to hospital alive, some will die in front of you and there may be more than one dying person; indeed, in a disaster situation there will be many and the scene may seem disorganised and traumatic to witness. In these situations it is important to think about how you will manage to remain composed and what you will say to the person who is taking a last breath. You will also need to plan what you are going to say to the relatives who may be in close proximity. Ask yourself whether you will be prepared for the injuries, the sheer explosive forces involved in some scenarios, the panic, and the emotion. The conditions that some emergency personnel work in can be extreme, indeed, austere. Noise, heat, poor vision, altitude can increase the difficulty in retrieving and resuscitating victims particularly following trauma and there is no harder situation than when you are exposed to risk of fire or when you are actually under fire and your own life is at risk as explained in the fire and rescue and military chapters. The following sudden death descriptors cited in the course of the book drive home the reality of working in conditions which annihilate the possibility of any sense of order, that is, loud, scary, chaotic, disorganised, sheer violence and forces involved, feeling helpless, the inner demons continue. Yet, despite these sometimes quite negative terms, order does exist testament to the steadfast commitment of our emergency services who day in and day out put their lives at risk for the benefit of the population.

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Worth considering is the question of ‘when is it OK to die? What seems legitimate and what is unacceptable? Age, characteristics and mode of death can prove hard to handle. It seems acceptable for a person to die when they have had a long and good life, when all business is finished, the family is around the bed and the person “... departs gently into the light” (Levine 1988). Death is considered unacceptable when the person is young or when death occurred in exceptionally traumatic circumstances such as the little girl who was ripped from the heart of her family in a traumatic and immediate way (Chap. 12). Individuals seem to gauge what is appropriate. The irony of luck profoundly determines whether a person will live or die such as the man at the roundabout who sustained fatal injuries from another vehicle (Chap. 4). Were the timing different; a split second earlier or a split second later, then that man would still be in the hub of his family enjoying life. Similarly, the woman who died following a large branch fall from a tree could not have been timed worse. This temporal dimension helps us to understand what has just happened and offers an existential explanation for our grief and a way to get through the sadness.

13.4 Supporting Relatives and Colleagues In the sudden death situation, people comprise a unique blend of religion, culture and raw emotion which shapes the way we handle the event and emergency personnel should attune to these various nuances when spending time with relatives. Rather than imposing your own religion or perspective onto the relatives, ask them what matters to them. Consider how you will select your words and also keep in mind what not to say as sometimes due to the tension of the scenario, we can occasionally be a bit clumsy and not quite express ourselves in the way we would prefer. Try to be genuine, authentic, speaking calmly and gently, avoiding clichés and platitude. When receiving the news of the death it is important to have an opportunity to discuss the events leading up to the death with the emergency doctor to aid understanding of how the death occurred. By turning medical jargon into layman’s terms, relatives who are in a state of shock are more likely to understand authentic conversation rather than medical jargon. Reactions vary, though the following emotional responses from relatives that emergency personnel may find difficulty in coping with comprise: withdrawal, denial, anger, isolation, bargaining, inappropriate responses, guilt, crying, sobbing and weeping and acceptance (Wright, 1991). The hospital chaplain offers spiritual comfort and community in the immediate life/death space, that liminal period where it becomes apparent that life will soon end and families will begin to mourn the loss of their loved one. These very special conversations create a lasting legacy which the grieving family will no doubt take with them for recall long after their loved one has died. Their comforting messages mark the event; the passing over to death of a person who holds immense social value, often irreplaceable. At this time, the all-­encompassing reach of humanity and love and the use of prayer and ritual to honour the deceased through acceptance of what cannot be reversed are a feature of their work.

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A common thread of objectivity is expressed across the emergency and allied professions, though it is acknowledged that on occasion, the accumulative effects of handling death either on a daily basis or in a mass death event has the potential to overwhelm. It is during these moments that emergency personnel consider the possibility that support may be desirable perhaps from a perceptive colleague, manager, counselling and welfare service, multi-faith advisor or chaplain. It is apparent that employers are responding to increasing concern about employees by providing optin welfare services to personnel who may wish to talk over the events of the day after a death has occurred. Uptake seems to vary and teams tend to rely heavily on camaraderie and understanding and a mutual trust and awareness regarding the harder aspects of their work.

13.5 Sudden Death Processing There is an intricate procedural base to sudden death work to be performed with competence, confidence and sensitivity; maintaining this milieu is critical to the lasting memories of the relatives who will recall the event years later. Procedures occur within a temporal path; one element cannot occur until the earlier aspect has been performed, that is, resuscitation, death declaration, last offices, body identification, property handover, certification, medico-legal aspects. This series of steps result in the making of a dead body as the layers of work unfold and henceforth emergency and allied personnel objectively refer to the once live person, as ‘deceased’, ‘body’, ‘cadaver’. Last Offices are carried out with utmost respect for the person who not long before was probably walking around and talking with absolutely no suspicion that a few moments later he/she would die. The emergency nurse and humanitarian nurse highlighted how each person is prepared after death; an intricate procedure involving washing to remove debris, donning death attire, positioning in a restful repose, having their hair brushed and styled and their face adjusted to look like they are asleep. These procedures help the representation of the body to grieving relatives whose last image will stay with them for a long time and some may never forget how their loved one looked. This one opportunity must be well-managed and attention should be given to the lighting, and arrangement of the room the deceased person is in. Often this is a clinical room, though generally a room is set aside in an emergency department for relatives to sit with their loved one. When death occurs suddenly in other settings external to the emergency department, for example, in the patient’s home or workplace, a restful repose is difficult to create and usually involves transportation and viewing at a mortuary. In these instances, emergency personnel do their best to (a) transport the deceased in a dignified way and (b) conceal the death from public gaze (Cromby and Phillips 2014). A very powerful reminder of this need is found in Chap. 10, where disaster mortuary, bereavement and post-­mortem examination services must literally construct a facility to accommodate and process a large number of bodies with laboratories, imaging facilities and cold storage whilst providing privacy from onlookers in the community.

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Clothing and items retrieved from the body such as a driving license or a bank card are very helpful in identifying who the person is where the body is unknown and will be treated with the utmost respect, as symbols of the person’s life. Although, handing over property in instances such as disease outbreaks may warrant complete incineration of the patients’ belongings, and this may be a source of distress as the relatives may wish to hold onto these precious items as a reminder of their relationship with the deceased. Yet again, the black plastic bag, featured as a means of taking home personal property. Over the last ten or so years alternative means of taking personal property home have been introduced, so some hospitals now offer a white plastic bag perhaps with ‘patient’s property’ written in large lettering on the side. Neither is a pleasant way of collecting a loved one’s items especially when the deceased is a baby. Perhaps in the latter instance it would be preferable to receive these precious items in a small, laminated pastel box, delicate enough to place in the child’s room or the parents’ bedside when they return home. When handling matters relating to the death, it is sometimes helpful to gauge the dynamics of the various people present to determine which relative seems to be able to maintain composure, frequently this may not be the next-of-kin. Permission should always be sought regarding who to hand the items over to or to be available for the official part of the process if they so wish. The practical aspects of body handling can sometimes be a source of frustration, for example, the eyes which will not close, the jaw that drops to create a gaping mouth, the hairstyle that is unknown, the disfigurement and the blood. Representation of the body is best carried out through dramaturgy, that is, the creation of a calm restful repose and as if the deceased person is merely asleep. This analogy is assumed to be of some comfort to those who grieve. The deceased body is sacred and should be protected and treated with dignity and respect and, in my experience, family members wish to continue to protect the body after the death. Relatives need to be made aware of where the body of their loved one is going, for example, the hospital mortuary and its location similarly, explain who people are who are present and near their loved one, why they are there, and what they are doing, such as clinicians, legal representatives, spiritual providers, receptionists, porters. I recall the wife of a man who had died suddenly quite late in life. Before she left the resuscitation room she asked me to “Look after him”. Her son was also concerned and sought reassurance from me that the hospital porters would handle his father gently when they moved his body for transport to the mortuary. He was a serving policeman who had multiple experiences of dealing with this situation. I told him that I would personally make sure that his wishes were carried out and went to the mortuary when his father was transferred. For emergency nurses, the entire process is characterised by dignity and respect for the uniqueness of the people whom they care for and they will make sure that the processing of the deceased body is dignified. Some emergency nurses will say a prayer as they carry out Last Offices; not necessarily out loud but by reciting it in their head as they wash and position the body. This is harder to achieve when there is mutilating injury to camouflage so that relatives do not see the damage to their loved one’s body arising from, for example,

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a road traffic incident. Such instances need improvisation and here, emergency nurses are adept.

13.6 Viewing the Body Saying a final goodbye is frequently requested and if it is not then an opportunity should be offered. It may be helpful to steer relatives through this process by entering the room with them, offering them a chair alongside the person who has died. When viewing the body timing is especially important, because the body undergoes rapid discolouration and loss of tone particularly visible in the face and lips so relatives should be made aware of what to expect when they go to sit with their loved one. Any disfigurement should be explained so they are prepared for what they are about to see. You might demonstrate that it is alright to touch the body as many relatives may wish to kiss or caress their loved one but feel they need permission to do so. Stay with the relative in silence and speak quietly and gently about the person they love and if they appear to be near to tears or even in floods of tears, as many are, let them know that it is natural to want to cry.

13.7 Medico-legal Following a sudden death it is essential to preserve forensic evidence. This is frequently because the death may meet the criteria for a Coroner’s case, which may lead to a post-mortem examination to establish cause of death. It may be helpful to refer to the eligibility criteria cited on the government website which explains what to do after a death and when a Coroner’s case is required (GOV.UK 2019). Forensic requirements should be upheld when caring for the dying/ deceased. It is important to ensure that a dying declaration is entered into the patient report form. When performing last offices, note any unusual physical changes, for example, bruising or marks on the body. Generally, items such as endotracheal tubes, chest drains and other invasive clinical apparatus would be kept in situ, though this can be upsetting to the family. Where relatives are near to the deceased body it is important that they do not touch these items. Collecting the death certificate can be a source of distress for relatives; however, most hospitals now have a well-trained and experienced bereavement specialist service at the hospital to process the legal aspects of the death. If the death is referred to the Coroner, the cause of death may be clear and post-mortem unnecessary. Where post-mortem is necessary to establish cause of death, one cannot object to the post-mortem procedure; however, the next-of-kin will be informed when and where the post-mortem will take place (GOV.UK 2019). Changing societal demographics and the changed composition of religion in society influences how we approach death and dying rites and rituals according to faith. Compared to 50 years ago, it seems quite remarkable that 50% of the

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population now declares no particular religious affiliation, yet few humanist or non-­ religious chaplains or pastoral care workers are employed within the NHS. Much needs to change to reflect this in terms of healthcare and spiritual support offered. When called to support a dying patient and their family, hospital chaplains can develop a sense of the family dynamics and consider the importance of agency when supporting the family; which relative is the supporter, the mediator, the advocate and the various roles people play in family life. Quite why chaplains don’t tend to be invited to debrief is difficult to understand. Perhaps it is because staff assume chaplains have some kind of diplomatic immunity from grief or more realistically, they consider it impractical because of their remote location in another section of the hospital or even another hospital in the same Trust. It should be remembered that hospital chaplains are part of the team offering a unique and significant contribution to healing and, their own emotional needs should also be given attention if they too are to maintain a life balance. For hospital chaplains dealing with death and dying, moral dilemmas may exist, for example, when the family wishes to hear a prayer yet the dying/dead person is areligious or in the situation of the Catholic Lay Priest who could not perform specific rituals, especially on a Sunday (Chap. 7). Overall, their role is to share their blessings with the family and to try to ease their emotional burden. The essence of spiritual care concerns a multitude of factors, for example, listening with empathy, spiritual comfort and relief from suffering. At the time leading up to a person’s death no matter how anticipated or not, death with dignity is sought and steps are taken to bring peace, relieve the dying person from loneliness and empower them to make choices about what is important to them and their loved ones. By respecting death rites associated with the religion/faith or indeed, nofaith of the dying person, hope in afterlife, peace from suffering, hope that their spouse, partner and children will be comforted and protected are paramount concerns for people who are dying.

13.8 Objectifying the Death There may be an assumption that specific emergency disciplines may remain totally objective but that is not necessarily the case. More likely, they are exposed to a continuum of objectivity and subjectivity. Consider the role of the funeral director (Chap. 11), who as guardian of the body, has close proximity to the corpse, and who finds ways to perform what is known as distasteful ‘dirty work’ (Howarth 2017). Emergency and allied personnel find ways to absorb their shock when handling sudden death events and doing so can sometimes accumulate to the point where it affects their mental health. Consider the soldier who was repeatedly exposed to images of his colleagues who had sustained significant life-changing kinetic injuries or who had died as a result of their wounds. We find ourselves in precarious locations and contexts and the notion

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of putting one’s own life at risk in order to retrieve others even when all that remains is a cadaver is very real for some and at a costly price. These situations provide good examples of shifting dimensions as we oscillate between objectivity and subjectivity in sudden death work whereby emergency personnel must stay focused whilst also feeling the loss. For some authors in this book who declared their most honest and authentic accounts of human suffering and emotional pain, nothing could prepare them for what they saw. Reactions may often be stoic but some situations escalate quickly and exhaust their capacity to deal with the screaming people in an uncontrollable scene. For some it becomes hard to articulate how they feel. For others, personal characteristics connect emergency personnel with the person who had died. Personal analogy can take many forms such as age, physical features, relationships and interests so it is understandable that the author of Chap. 8 identified acutely with his news of his wife’s pregnancy following the death of the child in Afghanistan. Indeed, referring to a baby being placed in the mortuary refrigerator, I recall a nurse colleague saying to me once how, “I could not bear to leave my child alone and in that fridge…it would just tear me in two” (Scott 2007). The concept of an ideal death in which the person slips back into their pillow with all business finished and with family and friends at their side (Levine 1988) is hard enough to achieve in the controlled environment of the emergency department, so consider how impossible this might be during disease outbreak, for example, the haemorrhagic disease Ebola. One interesting feature unique to the mass fatality event is its chaotic nature and sometimes the sheer volume of individual victims, fragmented bodies and body parts, which can overwhelm a community, especially those with limited resource. This is where a well-coordinated mortuary and bereavement services response team can alleviate some of the aftermath of disaster. After some disasters, the dead are often buried in mass graves or cremated. What this would imply is that the humanitarian worker in this context would not have the time or the resources to handle the dead in an ‘ideal’ way. We will always ask ourselves, whether or not we did enough as in the case of the humanitarian nurse and military nurse (Chaps. 8 and 9).

13.9 Educational Focus The need for a stronger educational focus on how to manage the physical aspects of dealing with bodies is a feature of all the emergency and allied disciplines. First exposure to death is daunting and there is little preparation for this inevitable aspect of their work. It seems that there is an overreliance on the good will of senior personnel who have witnessed and managed sudden deaths many times and who are prepared to patiently walk through what is required. However, personnel would certainly benefit from greater investment in how to cope with sudden deaths within their educational and training programmes.

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13.10 Conclusion This book is essentially a teaching text; one which I hope has provided some insight and direction from those who have been immersed in the liminal space between life and death through their various professional roles. Sudden death work is necessarily multi-disciplinary and emergency and allied personnel experience these events in a range of ways and have varying responsibilities according to their profession. There are a number of professional groups who have not yet been considered in this book. To date, little attention has been paid to the involvement of hospital porters yet they have a unique and significant contribution to the handling and transportation of the suddenly deceased and come in contact with emergency personnel and grieving relatives in the aftermath of the sudden death event. It is important that their experiences be captured. Similarly, midwives are central to the sudden death process when a baby dies in utero or is born dead following an emergency situation; their experiences and emotions and those of the mother and father provide powerful reminders of the fragility of life and use unique ways to process the event. We come to understand sudden death when we are exposed to its untimeliness, its rawness, as heard from those who practise the various emergency professions and have described the anguish that accompanies the death of a loved one. It is most apparent from learning how it is approached, and how we practically manage tricky scenarios involving, for example, rescue as well as through witnessing the last breath, death declaration, identification, body handling and reconstruction, responding to, indeed ‘coping’ with, extreme behaviours of relatives and our own exposure to suffering and pain. I hope these words offer a sense of calm in an otherwise turbulent world of emergency and allied health services and if the book has raised more questions than it has answered, then it has proved an effective learning tool. Learning Points

• Which emotional responses from relatives might you find difficult? • How do you prepare yourself to support relatives? • What kind of education/training is needed for your team to cope with sudden death events?

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