Bearing Bad News: The Impact of Delivering and Receiving News of Sudden Bereavement

Abstract

First responders and care professionals are often required to convey the deeply distressing news to relatives of the sudden death of a loved one. Witnessing the extreme anguish and grief of those receiving such news can have a detrimental effect on the bearers, leading to peritraumatic distress and feelings of inadequacy and burnout. For the recipients of such news, how it is delivered will impact on their understanding, acceptance, and processing of the sudden loss and may be a precursor for complicated grief or mental health issues such as anxiety or depression. Through writing about her own experience, the author aims to illustrate how interaction with professionals supported or impacted adversely on her grief and is intended to maintain professionals’ awareness of the impact of their delivery on recipients. Ancillary professionals also have an important role in how they interact with the bereaved and in ameliorating their deep distress.

Introduction

The difficult task of bearing bad news to bereaved family members is frequently carried out by frontline professionals. Such a task requires sensitivity, compassion, skill, and ultimately experience to enable the task to be performed with competence, confidence, and above all, humanity. Although training is a vital component in developing the requisite skills, organizational support is essential in preparing and maintaining good mental health in those charged with carrying out this stressful duty. When either are lacking, personnel are at risk of suffering unprocessed emotional distress which may lead to diminished personal mental health and an inability to perform their role.

For those who receive news of sudden bereavement, how it is delivered will be remembered with a clarity embedded in the “before” when life was normal, and the “after” from which there is no return. The way the news is conveyed will affect their processing of the loss, assist or impede the grieving process, and may impact on future mental health. Aside from first responders, those who provide subsequent support to the recently bereaved also have a responsibility to exhibit kindness, patience, and compassion in their interaction with deeply distressed individuals.

In this paper, I explore the potential impact on the bearer and receiver of bad news and what might be done to mitigate that impact. I include my personal account of the sudden loss of my sibling to illustrate how contrasting widespread kindness and compassion from healthcare staff, and the negation of professional patient–family responsibilities by a staff member and her employing organization, impacted on my grief as I sought to recover from the devastating news. I do so as a reminder to all professionals who are involved in supporting the bereaved that what is said and done at a time of heightened emotional stress will leave a lasting imprint on the bereaved and may impinge on their partial or complete recovery from the unexpected loss with which they must live.

The Story Begins

I stand in front of the door, hopeful and semi-expectant even then that my brother will emerge when I knock again, searching for logical reasons why he is not there after two days of unanswered phone calls. Looking through the letterbox, all appears normal within my limited horizontal view—curtains open, daylight flooding in, jacket draped over the back of the sofa as usual. No reply. I stem a rising sense of panic and dread as I think “what now?” and walk towards his neighbour's door. She might know if he's away. I knock, she emerges unwelcoming and unsmiling, peering at me with annoyance as I disturb her Sunday morning. “I’m sorry to bother you but I was wondering if you might know where my brother is…”. She stares at me and delivers her cold, emotionless statement without preamble. “He died.”

Time stands still as I struggle to understand the enormity of the words I have just heard, as it does for every person informed of sudden bereavement. Every detail of that first moment will be indelibly etched in their mind—the words, the way they were delivered, the facial expressions, gestures, demeanour, nuances, and whether an indefinable sense of genuineness and empathy from the other is present. How that news has been imparted to the bereaved family member will have a lasting effect on their processing and assimilation of the news no-one wants to hear. This is especially the case where sudden death is involved (Reid et al., 2011). Leo et al. (2015) advise that the survivors’ “emotional reactions [are] significantly influenced by the manner in which the event is communicated. In fact, attitude and words used by the death notifier(s) not only impact survivors’ bereavement but also may turn into memories capable of accompanying them forever” (p. 703).

When death is sudden there is no time for the bereaved to emotionally or psychologically prepare for the irreversible loss. It is outside of their normal coping skills that may be drawn upon during other scenarios of loss such as a relationship breakdown, loss of employment, status, or financial security, all difficult events in themself and yet retaining the possibility that another relationship will be embarked upon, or another job found. The finality of death, especially sudden death, casts the bereaved into despair, disbelief, directionless grief, and hopefully, ultimately, into a search for meaning, and acceptance, leading to recovery of sorts.

Ancillary Bereavement Professionals

When faced with the difficult task of imparting news of death to family members, professionals play a pivotal part in determining how the bereaved person deals with and processes the loss. This continues throughout aftercare that may occur, and ongoing contact with professionals beyond the news itself, to the hospital bereavement officer, coroner's office, and mortuary and undertaker staff. Carlsson et al. (2020) reported that “Experiences of health care professionals as caring or uncaring toward the lost person or themselves were significant and influenced the transition toward coherence and meaning” (p. 8).

It is the next day and I am seated in front of the hospital's bereavement officer, or rather her stand-in, as I am informed the post holder is away on a month's overseas holiday in Australia. She was, however, in post when my brother died in mid-April. I ask why I wasn’t informed by the hospital of my brother's death. She says no next of kin details were listed in his records, but they did try to contact me on (an old) phone number provided by a staff member at his sheltered accommodation. Her stand-in hands me my brother's personal effects which consist of his wallet and ring. I open the familiar wallet and start to search through the few contents it contains. I find a piece of paper with my name and current landline and mobile numbers on it. My stomach churns and a flash of anger rips through me as uncomprehendingly, I move it across the desk to show the staff member.

“These are my numbers. Why wasn’t I contacted?”

She has no answer.

My ensuing cursory search through NHS Trusts’ websites reveals protocols and procedures for tracing a deceased's unknown next of kin in the United Kingdom. One such example offers clear guidance of “Where no next of kin is known, all reasonable attempts should be made to trace relatives by contacting any visitors the patient may have had, looking through the patient's property for any address books or other contact information, speaking to the deceased's GP, care home or sheltered accommodation provider, or by following any other leads which may be available.” (NHS Trust, Lincolnshire Community Health Services, July 2019, p. 8). In another example, a Bereavement Officer job description lists duties that include responsibility, “If required to, to carry out accompanied visits to the deceased property to seek information pertaining to unidentified next of kin and other relevant information.” (NHS Foundation Trust, Dorset County Hospital, n.d., p. 5). Inexplicably, the bereavement officer did none of these things in my brother's case.

I am searching for answers and enlist the help of the Patient Advice and Liaison Service (PALS) located adjacent to the hospital. The officer is compassionate and records my complaint, explaining that I will receive a written response. This arrives from the Chief Executive Officer's office six weeks later and does not address my questions. There follow three further exchanges of letters with the CEO during a period stretching over many months, the delay always on their part. Her final letter informs me I have now reached the end of the hospital's complaints procedure. None of her letters adequately address or answer the specific questions I have asked. I am reminded of the story of ‘The Emperor's New Clothes’ as I am seemingly the only one to see the obvious course of action that should have been followed by the bereavement officer who could have sought assistance from the police or contacted residents from my brother's sheltered accommodation to trace me, and most obvious of all, follow up on my details in his wallet. The CEO continues to deny any wrongdoing, lack of care, or dereliction of duty on the part of the bereavement officer, and the hospital. My request to meet with the bereavement officer is denied. I am ragingly angry, and deeply sad and the emotional toll is hard. My grief is compounded by the hospital's stance in not resolving my complaint. It is likely they think I’ll give up if they continue with their evasive smoke and mirrors responses to my questions.

Having experienced prior sudden bereavement of three members of my immediate family might suggest that I was practiced in receiving news of unexpected death when it occurred a fourth time with my brother's death and raises the interesting question of “whether individuals become inoculated to the adverse effects of a loved one's death after many experiences of loss” (Keyes et al., 2014, p. 2). Sadly not, for it is excoriating pain that picks away at a scab that covers but never properly heals.

Revisiting the Story: Searching for Meaning and Answers

“When a parent dies, you lose the past…when a sibling dies, however, you lose both the past and the future. That is the grief of a sibling—grief for what was past, and grief for what should have been the future” (Anamcara, n.d., p. 2).

My brother died suddenly and without warning of natural causes. Aged 69, he suffered a ruptured Abdominal Aortic Aneurism, otherwise known as a triple A, late at night while home alone. Feeling unwell for some hours with severe back pain, he had finally called for an ambulance at 23.20 which arrived 35 minutes later. When the paramedics arrived, he was conscious and coherent and well enough to be standing upright as he met them at the door. It was as the paramedics started their standard assessment and examination that he quickly deteriorated, falling to the floor and struggling to breathe. He had gone into cardiac arrest. The paramedics continued working on him for two hours, administering multiple shots of adrenaline and sodium chloride while performing repeated CPR. A second crew arrived to join the first and between them, they worked to do everything they could to save my brother's life. He rallied twice before going into cardiac arrest for a third time. He was comatose and hanging by a thread between life and death when they transported him to hospital by blue light, where following further attempts to revive him, he was pronounced dead shortly after 2 am in A & E.

My brother lived 20 minutes away from me and we would meet every two weeks or so, sometimes more often, to catch up during a drive to a local place of interest, garden centre, or favourite town, where we would enjoy a simple lunch and a relaxed familial bond. He was living with a cancer diagnosis and although it had spread from his bowel to his liver and lungs, the treatment had been keeping the cancer in check, and would not take him without warning. The last time I saw him was on my birthday. I did not expect it to be the last time.

I did not know that he had died until ten days after his passing. I had been trying to contact him to arrange our next get together but after two days of unanswered messages, I drove to his flat thinking that he might have been taken into hospital for tests, as had happened before, or might even be away on a spontaneous short break for pleasure. It did not occur to me even fleetingly that he might be dead. As the awfulness of his neighbour's cold words sunk in, I knew the finality of their meaning.

In shock and deeply distressed, I did not know where his body had been taken. I had contacted the hospital switchboard only days before to enquire whether he had been admitted for treatment but was informed there was no record of his admittance. Not knowing where to turn, I phoned the police on 101, initially calm as I spoke to the policewoman who answered, then sobbing uncontrollably and catching for breath, as I explained I had just discovered my brother had died but did not know where he was. She was wonderful—calm, compassionate, and efficient—and called me back within minutes after speaking with the coroner's office to inform me his body had been released to an undertaker by the same hospital I had contacted only days before.

As outlined above, I went there the following day to meet with the Bereavement Officer and to find out why I had not been informed of his death. What followed were months, that turned into years of seeking an explanation and apology from the hospital of why, when my contact details with the same surname were in his wallet, had I not been informed of his death. What I received from the CEO were carefully worded letters designed to placate with no hint of admittance of any form of negligence on the part of the Bereavement Officer, and therefore the hospital. This was a protracted and painful period wherein my grieving was delayed in part due to my quest in gaining satisfactory answers and feeling unheard and invisible. It culminated in taking my complaint firstly to my MP, then to the office of the Parliamentary and Health Service Ombudsman, whose intervention finally secured the apology I was seeking from the hospital.

Not all were as unfeeling. I learned details of the treatment administered by the attending paramedics by phoning the South Western Ambulance Service (SWAS) where my request for his notes was met with kindness and compassion and, following provision of my identity and his death certificate, were quickly despatched to me by post. I have read and reread the contents many times, matching the treatment actions described in the notes to viewing the medical paraphernalia of discarded plastic syringes scattered around his living room during those final hours when they battled to save his life. When I later gained access to his flat, I formed my own vision of the scene after seeing the living room furniture pushed back to accommodate his prone body while they administered CPR, his crumpled shirt left lying discarded on the floor as they urgently gained access to his chest. I see it all. I regret that I did not contact the SWAS information officer afterwards to tell him what a difference his kindness had made to me. It felt to me like a beacon of humanity in a dark storm of grief.

Although distressing to read the documented minute-by-minute progress of treatment administered on that night, I drew comfort and reassurance that my brother would have been unaware, for the most part, of what was happening as the paramedics fought to save his life. It helped me to gain acceptance and to process what I imagined had happened in that room during his final hours.

A meeting was also arranged at my request with the A & E doctor and my brother's cancer specialist, and I was able to ask questions and receive explanations and reassurance from these experienced medical professionals. Both showed kindness, compassion, and patience in their interaction with me as I dipped in and out of tearful distress. I appreciated the clarity they provided through discussing his cancer condition and prognosis, along with his medical record notes. This highlights the importance of Carlsson et al.'s (2020) assertion that “healthcare professionals have a unique opportunity to provide support and show compassion, both ‘here and now’ and over time. Through structural support such as follow-up meetings, professionals can provide family members with answers that facilitate a coherent narration of their loss” (p. 9).

The distress I experienced was exacerbated by the hospital's protracted lack of adequate answers to my unambiguous, straightforward questions. It is important to note however that, despite the lack of compassion exhibited in their handling of the situation, lessons were learned by the hospital and that as a result of my complaint and the involvement of the Health and Parliamentary Ombudsman's Office, the procedure for contacting next of kin was reviewed, leading to two failings being identified. The CEO also finally acknowledged errors had been made, most notably in saying “we acknowledge that there could have been more we could have done to contact you” (personal correspondence, June 2018). It is gratifying to know that if these revised policies and procedures are adhered to in future, no other bereaved individual or family will experience the same situation.

Potential Effects on the Bereaved

Sudden death impacts on the bereavement process and may determine the severity and complexity of grief reactions experienced by the bereaved. The shock of sudden bereavement is absolute, making the loss harder to grapple with, possibly leading to a slower, more incomplete, and longer lasting grief process (Kristensen et al., 2012). Complicated grief, also known as prolonged grief disorder (PGD), is grief without resolution because the depth and suddenness, unpreparedness of the suddenly bereaved, or lack of sufficient social and other support, have not made it possible to integrate and assimilate the reality of the loss.

The predictors for complicated grief following bereavement include relationship and attachment to the deceased, age, cause of death (unexpected or violent death), existing resilience, and social support. The potential for increased grief symptoms in survivors has been linked to the unexpectedness and unpreparedness of sudden death (Mowll, 2011). Aoun et al. (2015) studied low, moderate, and high-risk factors in the bereaved developing PGD and found it to be present in those suffering “out of time” or sudden bereavement and who do not receive adequate support. Although those in the high-risk group in the study were found to access informal and community support, as did the low and moderate risk groups, that level of support alone was not adequate for the high-risk group. They needed more, bereavement-related, specific support from mental health professionals, and/or greater support through internet and other educational sources.

Close relationships form a central role throughout our lives. They are intertwined with our sense of identity and reflect back to us who we are. When those relationships are lost through death, especially sudden death, a person's self-concept loses the reflective anchor which had been ever-present until then. This can have lasting psychological consequences for the bereaved, as reported by Keyes et al. (2014); “Population-based studies in the United States show that unexpected death of a loved one is the most frequently reported potentially traumatic experiences, making mental health consequences of unexpected death an important public health concern” (p. 864).

Anticipatory grief is enabled in situations where a person is suffering a terminal illness or admitted to an intensive care unit. Even admittance to a hospital Accident and Emergency department can afford some degree of anticipatory grief wherein a relative is surrounded by professionals and is assisted to prepare in some small way for the very real possibility that their loved one may soon die.

Sudden bereavement is an intensely stressful life event. Indeed, “unexpected death of a loved one is most frequently cited as the most severe potentially traumatic experience in one's life, even among individuals with a high burden of lifetime stressful experiences” (Keyes et al., 2014, p. 867). It is known that social support is an important factor in ameliorating the grieving process for many and the lack of it is associated with poor physical and psychological health, in particular, depression. The benefits of social support on mitigating a genetic or environmental predisposition to developing psychiatric disorders make it an essential component of good mental health and may play a large part in minimizing proclivity to stress.

Bearing bad News—Effects on Notifier

The ripples of sudden death affect not only the family members and friends (the survivors) but also the professionals assigned with delivering the news—first responders including paramedics and other health care professionals, police officers, clergy, and others (Hargrave, 2010).

Notifying bereaved relatives of death, in particular sudden death, of a loved person requires sensitivity, clear communication, allowing sufficient time, and consideration of a suitable setting in which to impart this most terrible of news. The shock of hearing the news, the accompanying flood of emotions, and the way it is conveyed, will stay with the bereaved person for months, years, and perhaps for the duration of their life. It is therefore essential that first responders, police officers, health care professionals, and others who may be involved in this task, receive adequate training to enable them to skilfully convey the information, be prepared for wide-ranging reactions from the bereaved, support them at this most difficult of times, and have awareness of their own humanness, discomfort, and reaction to the distress they may experience and witness in themselves and others (Parkes, 1998).

The term “peritraumatic stress” relates to the wide-ranging distress experienced during or closely following a traumatic event and may be a risk factor in developing PTSD and other psychological conditions (Bunnell et al., 2018; Vance et al., 2018). Police officers are involved in numerous stressful situations in their professional life and may employ dissociation as a defence mechanism in which thoughts and feelings about traumatic events are locked away to avoid painful memories. This is a maladaptive coping style and officers are to be encouraged to employ support where they can face their memories, thoughts, and feelings to enable psychological adjustment to the situations they encounter. While stress has not been found to be linked with psychological adjustment per se, increased stress may lead to heightened dissociation, which in turn may lead to poorer adjustment (Aaron, 2000).

Stressors will always be present in police work, but it is the way in which police officers cope with those stressors that shape psychological adjustment (Aaron, 2000). It follows then that the provision of training in the form of stress awareness, healthy coping strategies, and psychoeducation arms police with preventative tools to alleviate the impact of dealing with the cumulative toll of encounters with distressing situations such as breaking bad news of sudden death. Furthermore, a supportive organizational environment will encourage shared conversations with others about stressors and seeking support through attending critical incident debriefing, accessing peer support through trauma risk management (TRiM), or more formal channels such as the police psychologist.

However, it is not always easy to express emotions or seek support, for the culture of the police force, along with the professional standards required of them, lead many to feel they must maintain and exhibit control to do their jobs effectively. There are times when consciously processing or expressing “unspeakable emotion” is not utilized as to do so may be viewed by themselves or others as diminished professional competence (Howard et al., 2000). In Australia, Carpenter et al. (2016) report that for police dealing with death, suppressing emotions may enable a calm, controlled, professional approach to be employed but may impede sensitivity when interacting with relatives bereaved by sudden death.

Further research is needed and, in the United Kingdom, an ongoing research study, Breaking bad news: A qualitative study of frontline police work with the bereaved, is due for completion in January 2022. Its Principal Researcher, Lumsden, acknowledges that although breaking bad news to the bereaved is a task central to police work “there is both a lack of research into the ways in which officers break bad news to the bereaved, and on education and training for frontline officers” (College of Policing, 2020).

Police are advised to “be prepared to face raw emotion” when delivering bad news (Police Scotland, 2017, p. 2) and yet many officers across all forces, including new recruits, may not receive adequate training in assisting them to do so. Awareness and training have improved however since Henry reported in 1995 that “it is newly graduated police officers who appear to be the most likely officers to attend a [non-criminal] death scene…They are the least likely to have the requisite skills to cope” (Cited in Carpenter et al., 2016, p. 14). Police may employ black or gallows humor as a coping mechanism and to also push away feelings to keep functioning in their professional role, and in everyday life.

Training also plays a vital part in developing skills of medical staff in conveying bad news to the bereaved. Naik (2013) offers many common sense suggestions for delivering bad news such as ensuring that plain language is used to clearly state the person is dead, rather than euphemisms of “has left us” or “passed away.” He notes however that this subject is not included in doctors’ undergraduate training curriculum in Indian medical schools and relies upon their personal qualities to adequately carry out this demanding task.

Findings

Recovery from grief is not a linear process travelling in one direction from acute distress to recovery. Although there is continued acknowledgment of clearly defined stages of grief, there has developed over time a more complete and nuanced understanding of the complexities of bereavement and its effects on the person. The bereaved may feel as they plod through ensuing weeks and months that they are recovering, only to find themselves in deep distress at any time. This only serves to exacerbate their distress and sense of helplessness and hopelessness especially as society places unseen, and not always unspoken pressure on them to be “moving on” and “getting over it” by now. Although the aim in working through grief is to develop a healthy connection with the deceased loved one, it is not to attempt to eradicate the deceased from memory with no mention of them or no lasting recognition of the loss. For the bereaved person, the world as they knew it, has been irrevocably changed by the death of their loved one. This is compounded in sudden death and requires shattered assumptions about life, safety, security, and attachment to be reconstructed through new meaning-making of life and their place in it (Carlsson et al., 2020).

What happens during the minutes, hours, weeks, and months after learning of the sudden death of a loved one will remain with the bereaved forever. There are potentially many professionals involved in dealing with the suddenly bereaved and it is the responsibility and humanity of all to be compassionate and kind in their interactions, for what they do and say, and don’t do and say, make a marked difference to how the bereaved feels and processes their grief. All can make a difference in how the suddenly bereaved feel in that moment, and long afterwards, whether it is the first responder, bereavement officer, coroner, undertaker, morgue staff, or counselling professional.

Conclusion

This article grew organically from my own experience of sudden death, and the importance of how breaking such news to the bereaved can impact on their grief and long-term recovery. For the suddenly bereaved, not feeling heard or having their loss validated, inculcates a sense of abandonment, a lack of recognition of loss, and increased distress. It is intended to illustrate the need for compassion and for immediate and longer term support to the bereaved. It is also intended to “offer bereavement practitioners a broader understanding of the secondary losses that may be encountered when a person's grief is not recognized as legitimate or warranted” (Logan et al., 2018, p. 112).

Appropriate training and organizational support are essential in providing skills and instilling confidence in those tasked with delivering bad news of sudden bereavement to family members. Likewise, organizations, including hospitals, need to immediately acknowledge and act when an employees’ performance falls short of the standards required to fulfill their professional duties when working in a sensitive role.

Care practitioners are trained in employing self-care techniques for their own emotional and professional protection, without which they would be constantly vulnerable to emotional overload and burnout. They participate in supervision to ensure the demands of their role do not outstrip their capacity to psychologically accommodate the often-harrowing suffering they witness in clients. Although self-preservation is essential, it is imperative that frontline and supporting staff do not become desensitized to the distress presented by the bereaved. For the professional, imparting the news, or providing support to the bereaved may be a daily part of the job. For each newly bereaved person, it may be the first time they are faced with the irreversible loss of a loved one and may not have an armoury of self-care techniques or healthy coping mechanisms to support them through it. What is said and how it is said, matters.

Whether trained professionals or lay members of society, there is something we can all do to support those who are grieving not only in the immediate aftermath of the death but also in the ensuing months. A caring gesture, willingness to listen, and exuding genuine empathy can all go part ways to ameliorating grief and the sense of aloneness of the bereaved.