Jill’s mother arrives at Rose’s house soon after the paramedics have discontinued resuscitation attempts. A sudden death, such as Rose”s, can have a profound impact on family and friends. Jill and her mother were very close to Rose and are distressed by her unexpected death. A police family liaison officer attends to provide the family with support and advice.
Practical advice
Rose’s family have not had to deal with a family death before. The following resources contain useful information to help them organise the practical issues involved in dealing with a death.
Grief is often defined as a deep sadness, most commonly associated with the death or loss of someone important to you. Grief is very individual and as a result Jill and her mother may experience their grief in different ways. There are people who find themselves tearful, feeling numb or crying openly. They may find their ability to sleep and concentrate affected. Individuals sometimes feel at a loss and not fully in control of their daily lives. Others may grieve in a quiet and controlled manner in which their emotions are kept private and outwardly they appear to be coping normally. The individual nature of grief is important to remember when you are with others who have also been affected. For all of us personal expressions of grief are influenced by our culture, beliefs, age, gender and the relationship we had with the person who died.
A person may not even know they are grieving; the feelings and effects may be subtle and unusual.
Mood swings – feeling low or having bursts of anger at unexpected times
Problems sleeping – waking early or sleeping for long periods
Vivid unpleasant dreams or dreams about the person they have lost that seem so real they feel huge disappointment when waking
Being generally irritable and annoyed at little things
Loss of appetite or comfort eating
Drinking more alcohol than usual
Feeling that there is no point in some things; other things no longer seem important
Crying for no specific reason or crying triggered by a memory or thought
Avoiding situations where they have to socialise, especially as others can seem awkward or nervous around them
An inability to function; feeling emotionally and physically shocked and stunned
The term Bereavement is associated with the process of grief following death. The individual may still have on going feelings of sadness, loss, despair and at times possibly anger, disappointment and anxiety. The important thing to remember is that both grief and the process of bereavement are absolutely normal. Most individuals, with support, can develop an understanding of what has happened and acknowledge the impact the death may have on them as an individual, as part of a family or friendship group. Support for an individual is often provided by their friends, families and colleagues, however, some individuals may benefit from a professional source of support; their GP, clergy, and /or counselling services.
Jill and her mother might find the following resources useful in helping them cope with their grief and bereavement:
When Rose was found by her niece, nobody knew when she had suffered her cardiac arrest. The longer the “down time” (time from cardiac arrest to beginning of CPR), the less likely it is that resuscitation attempts will be successful. A number of policy documents have been produced to support decisions around adult CPR:
As has been seen in the previous section, with an ageing population and increasing numbers of people with multiple conditions, anticipatory care plans with accompanying DNACPR forms are becoming more common. Had Jill known that Rose had completed a DNACPR form and had this information been recorded on Rose’s KIS, then emergency services would have been aware of the situation and CPR attempts may not have taken place.
Looking at the environment in which Rose was found, then it might have been suspected that she had multiple conditions, an anticipatory care plan and, possibly, a DNACPR form:
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Rose’s case highlights two issues:
the importance of all family members being aware that an individual has completed a DNACPR form
the importance of information being recorded in the KIS, so that all agencies are aware of a patient’s wishes should they experience a cardiac arrest
However, if there is any doubt about whether CPR should or should not be performed, commencing is considered to be is in the best interests of the patient. This should be continued until a paramedic or suitably trained professional informs the responders that treatment should be discontinued.
Clear discussion about wishes don’t always take place between health professionals with patients that may benefit from having them or between family members who may want to be informed of individual wishes.
Rose had decided that she wanted, as far as possible, to manage her multiple conditions with medications and that she did not wish to have any invasive treatments or interventions. She appreciated that her conditions were not curable and were liable to progress. In NHS Scotland, planning for the future is normally referred to as Advance Care Planning. It involves talking about what you do or do not want to happen to you in the future regarding any care that you might need. The Good Life, Good Death, Good Grief website suggests that issues to think about are:
granting power of attorney
thinking about an Anticipatory Care Plan
talking to your healthcare professional and those important to you about what you want in the future
thinking about organ donation
deciding on whether you want a DNACPR order implemented
any medical treatments that you may not want
Advance care planning
Advance care planning is the term most commonly referred to in end of life care, although it does incorporate the writing of wills or “Living Wills” now known as advance directives or advance decisions which can be done by the well person early on in life to plan for what may happen at the end of life. Anticipatory care planning is more commonly applied to support those living with a long term condition to plan for an expected change in health or social status. It also incorporates health improvement and staying well (Scottish Government, 2010. Anticipatory Care Planning: Frequently Asked Questions).
Rose and her community nurse had drawn up an Anticipatory Care Plan. She had read through the information on Advance and Anticipatory Care Planning provided by the nurse and knew what was involved.
Based on their conversation, the community nurse completed an anticipatory care plan for Rose, with a DNACPR form. The format for anticipatory care plans may vary slightly, depending on the health board or clinical area. Useful suggestions on how to develop a plan can be found at:
A paramedic team arrives. On their way to Rose’s house, they have accessed her Key Information Summary (KIS) from the Scottish Ambulance Service database and are aware that she has multiple, long-term conditions. (Information on KIS can be found at: NHS Scotland: What is a Key Information Summary (KIS)?)
The paramedics take a verbal history from the firefighters (see Pulse Point below for an example of a documented transfer form) and take over resuscitation attempts. Effective teamwork is essential when muliti-agency intervention is involved. The video below illustrates how the Scottish Ambulance Service and Fire & Rescue Scotland are working together to save lives:
By the time the paramedics arrive, firefighters have been doing CPR for 20 minutes. They continue resuscitation efforts for a further 20 minutes, as per protocol (JRACALC Clinical Practice Guidelines). Time of death is called at 11.40 hours.
Jill phones her mother to let her know that Rose has died. Her mother informs her that Rose had completed an Anticipatory Care Plan, several months ago, which included a Do Not Attempt Cardio-Pumonary Resuscitation form.
As they are the closest to Rose’s house, a team from Fire & Rescue are the first responders to arrive. Two of the team take over from Jill and begin to work with Rose, in the kitchen, while the Watch Manager takes Jill through to the living-room. She is shaking and visibly upset.
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Rose’s niece, Jill, arrives to help her aunt tidy up after breakfast and notices that the curtains are still drawn. She lets herself in through the keysafe and finds her aunt collapsed on the kitchen floor. She immediately calls 999 on her mobile phone and, following the call handler’s guidance, commences CPR.
Examples of how a call-handler guides the CPR process can be heard in the two audio-recordings below:
Rose is an 82 year old lady who lives alone. She has carers who visit twice a day, normally mid-morning and early evening, to assist her with meals and activities of daily living. She has a number of long term conditions for which she takes regular medication. She mobilizes with the aid of a zimmer frame. A District Nurse has been attending twice a week to care for a wound on her leg, sustained after a fall 2 weeks ago.
Bert hears through the village grapevine that Sean’s recovery has not been straightforward and that he is having behavioural problems.
Several months later, Bert is called to attend a domestic disturbance in the village. He realises that the aggressive teenager, threatening violence to all around him, is Sean. Seeing the way Sean is makes Jack question whether he and Ewen did the right thing in resuscitating him.
Although it is several months since Sean’s cardiac arrest, Bert becomes increasingly affected by what happened. His performance at work is noticeably poorer than normal. His immediate line manager suspects that Bert might be suffering from Post Traumatic Stress Disorder (PTSD).
The following web links contain information on:
what PTSD is
how to recognise PTSD
the impact PTSD can have on an individual
ways of self managing
how and where to refer for specialist help
NHS Lothian: Rivers Centre – a specialist, out patient service providing psychological therapies to people experiencing difficulty following adult trauma.
PTSD UK – a charity that aims to educate and raise awareness of PTSD.
In the following videos, Gill Moreton, of the Rivers Centre, provides a brief introduction to PTSD.
What is PTSD?
Who gets PTSD?
Recognising PTSD
PTSD: What to do
In an example of good practice, East Neuk First Responders have a post-OHCA support system in place. The process involved and the benefits are discussed in the audio-recording below:
The incidence of PTSD in lay responders is very low. However, Bert has not only had to cope with the actual cardiac arrest event but also had to deal with the very visible, negative consequences of resuscitating Sean.
With Bert’s permission, his line manager contacts the local Police Scotland Trauma Risk Management (TRiM) co-ordinator. TRiM is a programme which aims to identify those who are unable to cope after their direct involvement in a traumatic event and to offer them support. A useful summary of this is contained in the Police Federation of England and Wales document, below:
Bert attends for a number of one to one sessions with a trained TRiM practitioner. He finds these extremely helpful in helping him process what has happened and in moving forward with both his professional and his personal life.
Following a period of intensive rehabilitation, Sean is discharged home.
Sean and the family have to come to terms with the long-term impact of his brain injury. Prior to his OHCA, Sean had been a sociable teenager. He loved sports and was hoping to go to University to study Sports Science. Following his OHCA he has to leave school as he no longer has the cognitive ability to study. His brain injury also means that he is unable to compete in the sports that he loves. He is now prone to episodes of anger and can become violent at times. Since leaving school, he has been unable to find any form of suitable employment.
The implications for the family are extensive. Sean’s mother, Elaine, gives up her job to care for him and feels increasingly socially isolated. This change in family finances mean that they can no longer afford some of the luxuries they used to enjoy. The family notice that former friends now tend to avoid inviting them to social events due to Sean’s unpredictable behaviour. Sean’s brother is becoming resentful of all the attention focussing on Sean and his academic performance is beginning to suffer. Their stress is compounded by the fact that there is no access to support groups or services where they live. Feeling at the end of her tether, Sean’s mum makes an appointment with their GP.
The family GP is concerned about Elaine. He suggests that she might like to access the Community Chaplaincy Listening Scotland service that the local Health Board has signed up to:
Both Elaine and her husband use the service and find it extremely helpful to be able to talk through how they are feeling and think about ways in which they can deal with their changed situation.
