DEATH IN THE ICU
Whilst this does happen relatively frequently in ICU, every death has an impact on staff.
This impact can be somewhat mitigated by:
> Trying our best to provide a “good death” to our patient
> Making the experience as good as possible for the families
> Recognising our own distress and using established coping strategies
Dealing with the loss of a patient is one of the most demanding and challenging encounters in intensive care.
It is not uncommon to feel emotional and psychological distress when working with dying patients and their family, as well as when encountering repeated exposure to death.
The following coping strategies are employed to reduce distress as well as burnout and compassion fatigue:
> Reflective and spiritual practices
> Accepting your emotional responses to death
> Incorporating healthy routines (exercise, reading, television, relaxation, listening to music, family and pet interactions)
> Utilising external resources of support
> Debriefing – both hot and cold. Must be done well or can be detrimental.
All families are offered the opportunity to create memories with their loved one to cherish as keep sakes.
Offering photos, handprints, locks of hair, aromatherapy essential oils, hand moulds and any other requests that may be meaningful for that family are considered.
Quilts and bereavement bags may be provided for families to take home.
Here’s an example of one project that involved volunteers making bereavement bags for families to take their deceased relatives passions home after they have died in ICU:
Examples of some ways families are supported in ICU
Volunteer made bags for families to take their relatives possessions home in.
Bedspread brought in by family
Volunteer made bags for families to take their relatives possessions home in.
Volunteer made bags for families to take their relatives possessions home in.
> Coroner’s brochure
> End-of life brochure
> Coping with grief novel
> Contact details to the ICU social work bereavement team
For families of patients that were organ donors there is specific follow up
This is the process in Australia:
The initial follow up call
> Of great importance to the majority of donor family members is the initial follow up phone call from Donation Specialist Nurse informing them of the outcome of donation (89% recall receiving this call and of those, 97% found it to be helpful).
> This conversation is often the release for families after a stressful and highly emotional time in hospital, culminating in donation surgery.
> Many families eagerly await this call to inform them of the outcome.
> When transplantation goes well, this information provides solace to families and often reinforces their donation decision.
Initial letter
> 95% of donor family members recall receiving a letter from DonateLife.
> Most of these family members (96%) found the content of the letter helpful.
Anniversary card
> 79% of donor family members recall receiving an anniversary card from DonateLife 12 months after the death of their loved one.
> The vast majority (89%) of those who received the anniversary card found it helpful and were grateful that their loved one had not been forgotten
Level of comfort with donation decision
> For 96% of donor families (including intended donor families), the donation decision made in 2016 and 2017 still sits well with them today; 85% very much so (Figure 50).
> Families who declined donation are significantly less likely to feel very comfortable with their decision (65%).
> The majority of donor families (89%) find comfort in donation; 46% finding a great deal of comfort and 43% finding some comfort
Follow up
> Most donor family members (77%) feel the contact they have had with DonateLife has been at the right level.
> One in five (20%) donor family members feel they’ve not had enough contact with DonateLife since their loved one dies’.
Recipient correspondence
> Sixty-two percent (62%) of unique donor families have received a letter, via DonateLife, from at least one transplant recipient.
> In almost all cases (99%), this letter provided comfort to the donor family.
> Overwhelmingly, families who receive correspondence from recipients are grateful.
> It makes them feel thankful that their loved one’s gift was meaningful and that it “changed a life”.
Resources: https://donatelife.gov.au/sites/default/files/ota_wave4_donorfamilystudy_201117.pdf
Practical Aspects
After a death it is important the right people are informed.
This includes:
> The family
> The admitting specialist
> The patient’s GP
> Always consider if Coronial referral is required
The rules for this vary slightly in different regions:
The commonest reason we refer from neurocritical care is in the context of trauma.
> In most states, deaths resulting from a trauma or accident in an elderly patient (greater than 72) which may be attributable to old age (such as a fall) do NOT need to be reported to the coroner.
The Medical Certificate of Cause of Death (the ‘death certificate’) is an important legal document.
> For legal purposes
> For statistical and public health purposes
> For family members
> Part 1—report sequence/chain of events leading to death> Part 2—other significant conditions contributing to death> A column to record the approximate interval between onset and death.
TIPS
> Use the form from your institution, which is region specific but follows an international template
> Don’t complete if you are referring to the Coroner (see section above)
> Avoid non-specific terms such as cardiac failure, respiratory failure or shock whenever possible. At the very least they should never be the underlying diagnosis
> Where sepsis is the underlying cause, always state the organism or write ‘organism unknown’ if truly unknown – e.g. methicillin sensitive staphylococcus aureus septicaemia
> Pneumonias should be differentiated between hypostatic and aspiration and are usually not the underlying diagnosis. For example, dementia may be the underlying cause for a hypostatic pneumonia caused by inactivity
> Pulmonary embolism usually has an inciting factor as the underlying cause. Where a fatal PE results as a post-operative complication, the underlying diagnosis is actually the reason for the operation (e.g. motor vehicle accident resulting in a tibial fracture)
> Avoid ‘old age’ unless there is evidence of a very gradual decline in their ability to function over several months, and even then is usually a contributing factor rather than the primary mode of death
> Don’t forget tobacco smoking as a comorbidity!
Examples
TBI
1a: Traumatic brain injury 36 hours
1b: Pedestrian hit by truck 36 hours
1c: –
1d: –
2: –
ICH
1a: Intracerebral haemorrhage – 3 days
1b: Hypertension – 1 year
1c: Chronic pyelonephritis – 2 years
1d: Benign hypertrophy of the prostate – 5 years
2: –
aSAH
1a: Aneurysmal subarachnoid haemorrhage – 3 days
1b: Ruptured anterior communicating artery aneurysm – 3 days
1c: Hypertension – 6 years
1d: Renal artery stenosis – 6 years
2: Previous ischaemic stroke
Hypoxic Brain Injury after Cardiac Arrest
1a: Bilateral aspiration pneumonia – 2 days
1b: Hypoxic brain injury – 10 days
1c: Asystolic cardiac arrest – 10 days
1d: Myocardial infarction – 10 days
2: Type 2 diabetes mellitus
Use the form from your institution
TIPS
> Easiest if completed by the doctor who certifies death, as the body must be identified after death by the person completing the form
> Some cremation certificates require documenting that there is no pacemaker or other battery-powered device present in the body.
A cremation certificate must not be signed if:
> There is the possibility that further investigations into the cause of death are required
> You are aware that the deceased did not wish to be cremated
> You are aware that someone such as a personal representative or close family member of the deceased has objected to the cremation
Tissues can be retrieved up to 24 hours after death
Tissue only donation
> There are more opportunities for tissue donation than for organs because tissues can be retrieved up to 24 hours after cessation of circulation.
> Many families appreciate the opportunity to donate their family member’s tissues, including when organ donation is not possible.
> For families, donation of any type is of value, whether it be tissues or organs.
> It is therefore important that, when a patient dies in the hospital (whether in the ICU, emergency department or hospital ward), the possibility of tissue-only donation is considered and offered to families.
Tissues that can be donated include:
> Cornea and sclera (usually the whole eye is removed)
> Skin (split thickness from back, anterior and posterior thigh and posterior calf)
> Heart valves (aortic and pulmonary valves)
> Other cardiovascular tissues including pericardium, ascending or descending aorta, saphenous veins
> Bone: may include hip (iliac crest), long leg bones (femur, tibia), patella and humerus
> Other musculoskeletal tissue including tendon (may include achilles, patella, anterior and posterior tibialis, semitendinosus, quadriceps, peroneus longus and extensor hallicus longus; note that these are often retrieved with subjacent bone to aid the subsequent attachment surgery) and cartilage (knee meniscus).
For families of patients that were organ donors there is specific follow up
This is the process in Australia:
The initial follow up call
> Of great importance to the majority of donor family members is the initial follow up phone call from Donation Specialist Nurse informing them of the outcome of donation (89% recall receiving this call and of those, 97% found it to be helpful).
> This conversation is often the release for families after a stressful and highly emotional time in hospital, culminating in donation surgery.
> Many families eagerly await this call to inform them of the outcome.
> When transplantation goes well, this information provides solace to families and often reinforces their donation decision.
Initial letter
> 95% of donor family members recall receiving a letter from DonateLife.
> Most of these family members (96%) found the content of the letter helpful.
Anniversary card
> 79% of donor family members recall receiving an anniversary card from DonateLife 12 months after the death of their loved one.
> The vast majority (89%) of those who received the anniversary card found it helpful and were grateful that their loved one had not been forgotten
Level of comfort with donation decision
> For 96% of donor families (including intended donor families), the donation decision made in 2016 and 2017 still sits well with them today; 85% very much so (Figure 50).
> Families who declined donation are significantly less likely to feel very comfortable with their decision (65%).
> The majority of donor families (89%) find comfort in donation; 46% finding a great deal of comfort and 43% finding some comfort
Follow up
> Most donor family members (77%) feel the contact they have had with DonateLife has been at the right level.
> One in five (20%) donor family members feel they’ve not had enough contact with DonateLife since their loved one dies’.
Recipient correspondence
> Sixty-two percent (62%) of unique donor families have received a letter, via DonateLife, from at least one transplant recipient.
> In almost all cases (99%), this letter provided comfort to the donor family.
> Overwhelmingly, families who receive correspondence from recipients are grateful.
> It makes them feel thankful that their loved one’s gift was meaningful and that it “changed a life”.
Resources: https://donatelife.gov.au/sites/default/files/ota_wave4_donorfamilystudy_201117.pdf