Alan E Stewart & Janice Harris Lord. Handbook of Death and Dying. Editor: Clifton D Bryant. Volume 2. Thousand Oaks, CA: Sage Reference, 2003.
A person dies or is killed. Surviving family and friends must be notified. How people learn about the death of their loved one can have profound implications for coping (Leash 1994; Lord 2002; Stewart 1999). Yet few empirical studies of the death notification process exist. Resources for educating professionals on the best methods of performing notifications have only recently begun to emerge (Lord 1997).
Our purpose in this chapter is to explore existing research on death notification. We begin with examples that illustrate the emotional impact of death notification for different types of loss. Next, we offer recommendations for delivering a competent and supportive notification based on interviews with hundreds of surviving family members. We examine the widespread need for training and outline a model that has been used successfully to teach professionals and others in death notification. The chapter concludes with recommendations for additional research on the effects of death notification and the benefits of receiving competent, sensitive, and supportive notifications.
Emotional Significance of the Death Notification Process
The death notification process touches thousands of families every day. In addition, professionals including law enforcement officers, firefighters, paramedics, coroners, physicians, the clergy, and others are affected by notification duties. When sudden death occurs, the news that a notifier must convey often represents the survivors’ first information about an unexpected and often violent death. It is more than a “loss.” It is a traumatic, life-changing event. Stress and crisis theory suggests that people generally feel powerless in the aftermath of trauma (Bard and Sangrey 1986; Thompson 1992). They are distraught and in a state of disequilibrium, unable to cope using customary methods of problem solving. They suddenly realize they were unable to prevent the death and often feel overwhelmed. The goal of stress reduction is to relieve the psychological pain surrounding an event so that the event becomes manageable (Thompson 1992). This is not easy, especially when the survivors had no forewarning or time to psychologically prepare. If traumatized people are placed in a physically and emotionally safe environment where their needs are acknowledged and honored, they eventually are able to calm themselves. A sensitive and compassionate death notification followed by honest information about the circumstances surrounding the death may, therefore, be the first step in restoring a sense of efficacy and control to the survivors.
Poor death notifications can make lasting impressions on family members. Clinical experiences reveal that the most distressing components of a notification remain indelibly imprinted as conscious memories or unconscious trauma reactions for many survivors. One woman recalls the exact words of the military officer who notified her that her son had been killed by a drunk driver while on active duty: “I regret to inform you, on behalf of the United States Army, that your son, Mark, has been killed. The secretary extends his deepest sympathy to you and your family in this tragic loss.” This mother was shocked and enraged by the formality of the notification. She grabbed the papers in the notifier’s hand and demanded that he leave immediately.
Another woman said a sheriff’s deputy informed her through the screen door of her home that her daughter had been killed. She swayed, nearly fainting, and eventually responded that she didn’t know what she would do without her daughter. She said she will never forget the officer’s next words: “Ma’am, I guess God is just telling you that it’s time to stand on your own two feet.”
Death notification is daunting for the person providing notification, too. This is especially apparent if the notifier has had little or no training. Notifiers frequently rely on their instincts or personal perspectives. Usually, this strategy is inadequate. One officer prided himself in being “brutally honest” in delivering notifications. Finding no one at home when he attempted to notify a couple of their son’s death, he left a note on the door telling them that their son had hung himself in jail, with a phone number to call for more information.
Others make equally damaging mistakes by failing to ensure coordination among agencies. An employee of a medical examiner’s office, believing that law enforcement had notified a family of their adolescent son’s death when, in fact they had not, called the home to ask for dental records because the boy’s body had been burned beyond recognition. The father was home alone when he took the call. He suffered a heart attack and died. The father’s and son’s funerals were held simultaneously (Sanders and Stavish 1995).
Still others fail to identify natural reactions of survivors to a death notification and may respond inappropriately. Some family members may become verbally or physically abusive to the one bearing the news. This reaction is spontaneous and may represent the family member’s attempt to discount the tragic news. A physician, upon notifying a family that their son and brother had died, was struck by the boy’s teenage brother, who knocked off the doctor’s glasses. The physician filed assault charges against the boy rather than acknowledging that this may have been a natural reaction to the stress the notification initiated.
Contrast these hurtful notification practices with the supportive notification that an elderly woman received following the death of her husband. The notifying officer drove to the widow’s home, asked to come in, and invited her to be seated. He knelt in front of her, took her hands, looked directly into her eyes, and told her gently that her husband had been involved in a serious crash and that he had died shortly thereafter. He supported her reaction and was not ashamed when tears came to his eyes. He allowed her to regain composure in her own time, and he answered her questions honestly. Even though the notification occurred decades ago, this woman remembers nearly every word the officer said. She holds him and the entire law enforcement community in high esteem as a result of the compassion he showed.
The quality of the notification also can be affected when the survivors wish to view the body. Hospitals now routinely allow family members to spend time with their loved ones’ bodies after death, usually describing the condition of the body and the existence of any medical equipment not yet removed before viewing takes place. After this brief explanation, they then ask again which family members want to spend time with the body. Emergency personnel, such as law enforcement officers, firefighters, and emergency medical professionals are more reluctant to allow family members access to a body because of its condition following a suicide or homicide. They may believe it to be their duty to protect families from a potentially traumatizing experience.
One woman described her brother’s traumatizing experience after not being adequately prepared to view the body of their brother. The brother had been missing for several days, and the surviving brother actively engaged in the search with law enforcement. An officer found the body and relayed the message to an officer who was searching with the brother. The brother immediately wanted to go to his brother’s body. The officer, knowing how a body looks after three days in the hot sun, tried to restrain him but failed to describe what he would likely see. The brother broke away, ran to his brother’s body, and was shocked. He regrets having viewed the remains of his brother and says if the officer had described its condition, he may have chosen not to view the body.
In contrast, a woman expressed deep gratitude for being given the opportunity to view her son after he had been killed in a car crash. A police officer notified her at her home, and she desperately wanted to get to the body of her son. The officer, in a protective mode, attempted to discourage her. She would not take no for an answer. The officer agreed to drive the woman to the medical examiner’s office. The medical examiner met the woman at the office and asked for a few moments to prepare the body. Shortly thereafter, he brought the mother into the room and they stood at the door. Her son lay on a clean gurney on the other side of the room. The blood and debris had been washed from his body. A sheet covered the trunk of his body, and his arms were folded outside the sheet. His head was wrapped in a towel. The medical examiner described the nature of each of the young man’s wounds and asked the mother if she wanted to move closer. She did, eventually touching his arms and hands while softly crying. The medical examiner allowed her to react without attempting to interfere. In time, she stopped crying and said she wanted to see her son’s head, which had been badly injured. The medical examiner described what she would see if he removed the towel. He asked her to reconsider. The woman insisted she wanted to see his head, so the medical examiner removed the towel. She looked for just a moment and then turned away. She thanked the medical examiner for allowing her to do “what she needed to do.”
The Significance of the Death Notification Process for Different Kinds of Losses
As these examples convey, a wide range of death notification scenarios exist. These scenarios, in part, can be classified according to the extent to which they involve several loss-related variables. The first of these pertains to the degree to which the death was anticipated and expected versus the suddenness or unexpected nature of the death (Cleiren 1993; Parkes 1996; Stewart 1999). A second variable concerns the extent to which the death was timely or untimely, such as in the case of an elderly person or the untimely death of a child. It should be noted, however, that even the sudden death of an elderly parent could be traumatizing to the surviving family. Third, the degree to which the cause of death may have been frightening, painful, violent, or mutilating to the deceased carries significant implications for the survivors. Finally, the extent to which the death was preventable or avoidable, such as in the case of drunk-driving crashes or suicides, could affect how survivors assign responsibility for the death to themselves or others. We discuss these parameters in more detail below.
Approximately 78% of the annual deaths in the United States stem from causes that allow the survivors and those who are dying some measure of anticipation and preparation for the death, including cancers, AIDS, and other terminal illnesses (U.S. Bureau of the Census 2001). In these cases, both the dying person and the supporting family and friends begin to contemplate the death when a diagnosis is confirmed or as the disease progresses to its final stages. These preparations may involve saying good-bye, reviewing and reminiscing, developing or modifying legal papers, drafting health directives, and attending to many other personal and practical considerations. Both the dying person and his or her family and friends have some time to anticipate death and have the opportunity to spend precious moments together before it occurs.
For these reasons, the death notification does not produce the shocking trauma of the sudden notification of a tragic death. If the person’s last days or hours involved pain, discomfort, agony, or fear, the notification of the death might actually provide some measure of relief to survivors who know that their loved one’s suffering has ended. The death notification confirms the survivors’ expectations that death was imminent. Consequently, notifications for anticipated death may focus not so much on attending to the trauma reactions among the survivors as on providing support and specific information, such as reporting a person’s last words, the manner in which the death occurred, or the level of consciousness as the moment of death approached.
Approximately 22% of annual deaths stem from causes that can be considered traumatic in nature, such as vehicular crashes, homicides, suicides, accidents, or acute medical conditions such as heart attack or stroke (U.S. Bureau of the Census 2001). In this regard, the September 11, 2001, terror attacks in the United States represent an extreme form of traumatic death. These deaths involved all four of the aforementioned risk factors. They occurred suddenly, were untimely, involved noticeable physical injury or destruction of the body, and were preventable.
Reactions to notifications of trauma deaths range from shock or a form of dissociation that may resemble stoic acceptance to acting out intense feelings of despair, rage, or blame. Being unable to predict specific reactions and dealing with intense grief reactions has been cited by law enforcement officers, paramedics, military personnel, fire and rescue personnel, and the clergy as one of the most stressful aspects of the notification process (Bartone et al. 1989; Ender and Hermsen 1996; Hall 1982; Stewart, Lord, and Mercer 2000; Weiss et al. 1995).
Beyond providing appropriate emotional support following the notification, many notifiers are questioned by family members about the events that led up to the injury and death. The survivors may desire to be with the body of their loved one as soon as possible, perhaps because they did not have an opportunity to say good-bye in any form. If the death resulted from noticeable physical trauma or destruction of the body, the notification takes on the added dimension of assessing each family member’s readiness for viewing the body, preparing them for what they will see, and providing additional emotional support (Lord 2002). Furthermore, the suddenness of the loss, coupled with other risk factors, may make it especially difficult for survivors to assimilate and understand the details surrounding the death. Consequently, the postnotification process may extend to days or weeks after the actual death as survivors contact health care professionals, law enforcement personnel, the clergy, or others to ask questions or seek clarification of details.
Overall, the death notification process following a tragedy is vitally important in orienting survivors to their loss and in influencing their initial trauma and grief reaction. The death notification becomes a significant opportunity to provide secondary prevention of complicated bereavement or posttraumatic stress disorder, both of which are more likely in the aftermath of a traumatic death compared with an anticipated loss (Parkes 1996; Rando 1993; Stewart 1999). Notifications that function as a secondary preventive, however, must be performed in a competent and emotionally supportive manner. In the sections that follow, we describe the elements of sound death notification practice.
Core Elements of Supportive Death Notifications
A core set of tasks make up the death notification process regardless of who performs the notification or the setting in which the notification is delivered (Lord 2002; Stewart 1999). These components include (a) correctly identifying both the deceased and the survivors to be notified;
(b) initiating personal contact with the survivors; (c) providing information about the events leading to the death, the injuries that were sustained, and medical procedures administered, if any; (d) telling survivors that death has occurred; (e) supporting survivors’ natural reactions and providing immediate emotional or physical support; (f) honoring survivors’ choices about viewing the body shortly after the notification; and (g) providing assistance, information, and follow-up care. The ways that these tasks and events are managed will differ according to the death notification setting and the professionals involved.
Identifying the Deceased and Survivors
For deaths that occur in hospitals following illness or injury, the identification process may be relatively straightforward in that the deceased and his or her surviving family are already known (i.e., this information was gathered during admission to the hospital). If the patient is admitted and dies before the family is notified, the staff may need to seek identifying information among personal belongings, such as purses or billfolds. In other instances, such as sudden deaths in vehicular crashes or homicides, the identities of both the victim and the survivors may have to be determined indirectly through methods such as vehicle registration records or medical and dental records. Regardless of the manner in which the victim and survivor identities are established, it is vitally important to have accurate information to ensure that the correct survivors are notified and can be told exactly who has died. Notifications have occurred in which parents were notified that their “son” or “daughter” had been killed, but the notifying officer did not know the name of the deceased. It then became necessary for the parents to make numerous telephone calls to determine which of their children had died.
A second component of the identification process involves seeking information about the survivors that could make them vulnerable to the effects of the death notification. Older persons, those who have health concerns such as heart disease, persons with a history of psychological disorders, or those who have experienced other traumatic losses in the recent past may have a higher potential for additional physical or psychological problems or even death following the notification. Knowledge of these survivor characteristics can alert death notifiers to the need for additional medical or psychological services during and after the notification. Some law enforcement agencies have emergency medical services standing by when they notify of a sudden death.
The third component of the process involves identifying the circumstances surrounding the death that may make it especially traumatizing for the survivors. For instance, following homicides or multivehicle crash deaths in which there may be both innocent victims and offending or responsible victims, hospital staff should plan to take members of the respective families to separate rooms in the hospital to avoid confrontations or other negative outcomes (Leash 1994). If a family with small children is being notified of a sudden death, one staff member should plan to stay with the children while the parents are taken to a private area to be notified. Care should be taken to make sure that children do not witness the emotional collapse of their parents.
Contacting and Meeting the Survivors
Once the necessary identifying information has been accurately determined and planning has been accomplished, the survivors are contacted. If the person dies at the hospital and the family is not there, they usually are telephoned by a nurse, chaplain, or social worker and asked to come to the hospital. In cases of anticipated death, this is acceptable. However, when the illness or injury was unexpected, it is preferable for the hospital staff to ask police to contact family members and drive them to the hospital. This is especially important if death has occurred because it may help prevent vehicular crashes as distraught family members race to get to the hospital. If death is imminent, the hospital staff must weigh concerns of getting the family to the hospital quickly (phone call) with those of providing safe transportation that may take longer (law enforcement). In the latter case, the family may question the officer about the details of the events leading to injury. The notifying officer should be informed about the basic details of the case and that the patient’s condition is serious.
Most clinicians prefer to use the initial contact with survivors to summon them to the hospital (Collins 1989; Leash 1994). However, a majority of survivors in one study said they believed they should have been told their loved one was already dead when they were contacted, even though they said they understood the reasons for postponing the notification until they arrived (Leash 1994).
There are both process and content issues to consider in the initial contact, whether it is personal notification by an officer or a call from the hospital. At a process level, the initial contact allows the notifier to minimally evaluate the survivors’ potential strengths and social supports along with the aforementioned characteristics and liabilities that may increase the person’s risk for traumatization. At a content level, the contact informs the survivors that a family member has been severely injured and that the prognosis is not good. Short of telling the survivors of the death, this information helps to prepare the survivors for further sad news.
Survivors should be met by a member of the death notification team as they arrive at the hospital and should not be kept waiting or left to search for personnel in the emergency department (Collins 1989; Lipton and Coleman 1999). The survivors’ initial apprehension and anxiety levels may increase to panic or be transformed to anger or other intense reactions if they cannot quickly locate appropriate personnel in a large or busy hospital. Once the survivors have been met, they should be taken to a quiet and private room that is well lit, preferably with a window and furnished with a phone and comfortable furniture. The room should allow survivors privacy to vent their emotions and to comfort each other without exposure to other hospital stimuli that may add to their distress. The sight, sounds, smells, and emotionally charged atmosphere of a busy hospital may outstrip the abilities of vulnerable survivors to cope.
Anecdotally, some survivors have stated that they resented being taken to the hospital chapel because they did not see themselves as spiritual and concluded prematurely that their loved one was already dead.
When police make the initial contact at the family home, the notifying officers should approach the home without emergency lights or sirens. They should confirm they have correctly located the surviving family by using the name of the deceased: “Are you the parents of Johnny Smith?” Children and adolescents should never be notified of a death before their parents. Likewise, a child should not be used as a translator if the victim’s family speaks a foreign language. This places children in the position of notifier, a task far too overwhelming. Once the proper adults have been identified, notifiers should ask if they might come inside the home. Although the mere sight of uniformed officers increases a survivor’s level of anxiety, getting inside the home is highly preferable to talking on the front step or through a door because the notified person may faint or exhibit other characteristics requiring immediate support (Byers 1996). Once inside, the officers can determine which family members are present and make a quick assessment of their physical status and relationship dynamics by asking how many people are in the home. Elderly, ill, or young persons with one adult should be quickly identified. Asking family members to be seated can prevent physical injury and make it more difficult for those who tend to lash out physically. The officers should be seated as well.
Sometimes, family members are at the scene of a homicide, suicide, or vehicular crash. It is difficult to seek privacy when giving information in these cases, but other officers, firefighters, or emergency personnel may be able to form an outwardly facing circle around the family. This provides a semblance of privacy and protects family members from unwanted media attention. In these cases, family members and the informant should kneel or sit on the ground when possible.
Once immediate survivors have been seated, whether in the hospital, in the home, or at the scene, they should be given details of the person’s injuries and his or her current status if the person is receiving treatment. Clinicians and researchers agree that giving details in an accurate but piecemeal manner, referred to as “dosing” the information, gives survivors time to examine the implications of the news and to begin constructing a narrative of the unfolding events (Lipton and Coleman 1999). If the patient is still alive, survivors benefit from having updates on their loved one at short, regularly spaced intervals. In the hospital, for example, a team consisting of an attending physician, nurse, social worker, or chaplain may allow the physician to give crucial information and return to the patient while another professional remains to answer questions and support the family.
The time available for dosing information to survivors in the home setting is much shorter. In these instances, Hendricks (1984) and Leash (1994) suggest that police officers present details in a deliberate and stepwise manner, pausing after each significant unit of information to allow the survivors to process the implications or to ask for clarification. For example, “I’m afraid I’m coming with some information that will be difficult for you (slight pause). Your son Johnny was involved in a serious car crash this afternoon about 3:30 (slight pause). His injuries appeared to be serious, and he was treated by EMTs at the scene. He has been taken to Charity Hospital. The emergency staff there called us to offer to drive you to the hospital.” Notifying officers are cautioned, however, about drawing the process out too long. Although it is best that more than one family member go to the hospital where they can support each other, taking too much time to locate other members of the family can prevent them from getting to their loved one before he or she dies. If the victim dies while the officers are traveling to the home to notify family members, officers should deliver the death notification.
Delivering the Death Notification
At least two professionals should participate in the notification process. In hospital settings, the attending physician should be one of the team. The other can be a nurse, social worker, counselor, or a chaplain. An officer at the scene of an unexpected death should be accompanied to the family’s home by another officer or police chaplain, victim advocate, or the survivor’s pastor, priest, or rabbi (Wentink 1991). These additional persons assist the survivors after the notification and provide an important supportive presence for the primary notifier.
Medical personnel must decide whether to take extra time after the death to assemble appropriate supportive personnel and to prepare the body for viewing or to inform the family immediately. Most family members want to be informed as soon as possible but are understanding of the hospital staff’s request for a few moments to prepare the body for viewing, if desired. If the delay before the notification is too long, survivors may guess what has happened or ask outright about the occurrence of death. They should be told the truth even though the notification may be delivered with the personnel and resources on hand. Although some notifiers may be tempted to lie and indicate that death has not yet occurred, this otherwise well-intentioned strategy can backfire when family members note the time of death on the death-related documents and subsequently discover the deception. Survivors should have access to the full range of information, including their loved one’s body, as soon as it is possible. Notifiers should always strive to be open and honest during the notification process.
The notifier should use explicit language that involves some variation of the words died, dead, death, or killed rather than euphemisms such as “gone,” “passed on,” “now in a better place,” “fatally injured,” or “lost.” Hopeful survivors can misconstrue euphemisms. In the vehicular crash scenario noted above, if the victim has died, the officer might say, “I’m afraid I’m coming with some information that will be difficult for you (slight pause). Your son Johnny was involved in a serious car crash this afternoon about 3:30 (slight pause). His injuries appeared to be serious, and he was treated by EMTs at the scene. Although Johnny was alive immediately after the crash, he died en route to the hospital (pause for reaction). The doctors there have confirmed his death (pause for reaction). I am so very sorry.”
Comments of genuine concern may help family members begin their emotional reaction if it has not begun. Notifiers should allow plenty of time for them to react. Once family members have calmed themselves somewhat, notifiers can go on to say something like, “If you would like, I can drive you to the hospital so that you can talk to his doctors and see his body, if you wish.” Using direct language firmly establishes the reality of the death (Leash 1994; Worden 1991).
Responding to Survivors
Notifiers must be prepared to respond on both behavioral and verbal levels to a wide spectrum of reactions that can range from looks of stoic acceptance to confusion or outbursts in which survivors may attempt to hurt themselves or others. Survivors’ initial reactions, although intense, are usually short-lived (usually 10-15 minutes). Clinicians caution against the use of medications that sedate or physical restraints unless survivors attempts to harm themselves or others, including the notifier (Collins 1989). Sedating medications can keep survivors from experiencing the inevitable emotions that are part of the bereavement process.
Once the survivors’ initial reactions have been ventilated and they have regained some sense of control, the notifiers may supply additional information about the death, such as the person’s final words or condition at death if the information is assuring or comforting. Although tempting as a reassurance strategy, survivors should not be told the family member “felt no pain” or “never knew what hit him” unless the notifiers are absolutely sure this was the case (Lord 2002). Survivors will feel betrayed if they later learn this was not true. Survivors will benefit simply by having the notifiers listen to them and support their reactions. In this regard, notifier responses that facilitate survivors’ emotional processing of the loss (“It’s OK to be angry at God” or “You were obviously very, very close to him”) tend to produce better outcomes than giving advice or attempting to minimize the loss (“You have to be strong for your family now” or “You still have your daughter”) (Lord 2002). Survivors tend to respond more favorably to an empathic approach than to one that is sympathetic and distant (“I wish I could do something to make this easier for you” vs. “I can’t begin to imagine how hard this is for you right now”) (Leash 1994; Lord 2002; Wentink 1991). Survivors may be comforted somewhat to hear that the person who died also mattered to the notifier and that the notifier is willing to absorb a little of their pain rather than distance himself or herself (“When I saw him, I couldn’t help but think what a fine boy he must have been”).
Responding empathically to survivors, however, may place extraordinary pressures on physicians or officers who are asked to shift their professional role from a saver or protector of life to one that involves supporting someone in emotional pain (Swisher et al. 1993). It is not an easy transition to make. For some law enforcement or health care professionals, a death notification is tantamount to admitting defeat. Such feelings may contribute to a notifier’s discomfort and may interfere with his or her ability to respond properly to survivors. This possibility underscores the importance of selecting the notification team to include both the physician or officer present when the person died and another professional who may be more skilled in handling trauma reaction among the survivors.
Viewing the Body
As discussed in the examples presented earlier, survivors should be allowed to view the body after their initial response to the notification has subsided. Although most survivors will want some time with their family member, others will not. Certain ethnic or religious beliefs prohibit viewing dead bodies. Others may want the viewing opportunity but may appear hesitant. People who express reservations about viewing the body should be encouraged to discuss their concerns with the notifier. They should never be told that that they “must” see the body “for their own good.” In many cases, survivors are afraid of what they will see and of the memories that a viewing may create (Parrish et al. 1987). Notifiers may ask if survivors would like to be told how the body looks before deciding whether to view the deceased. A description of the body’s condition and a promise to accompany the survivors to the viewing may be sufficiently reassuring. In addition, survivors may be told that most people eventually remember their loved ones as they were in life, not in death. Ultimately, the survivor’s preference for not viewing must always be respected and supported. In these instances, permission may be sought to take a photo of the body in the event that a survivor wishes to view it at a later date.
Small children should not be present during viewing. Witnessing distraught family members can be frightening to children. No child, regardless of age, should be forced to view a body. Some people, particularly men, may feel protective of others, perhaps women, elders, and young people, and tell them they should not view the body. Although this may be a noble attempt to protect a loved one, each family member should be given the choice to view the deceased. Some family members have acquiesced while in a state of shock and then later regretted not viewing the body.
Older children and adults who want to view the body should first be told about its condition and what they will see. They should be told that the body may be pale in color and that there may be medical equipment attached. When equipment is attached, they should be told why the equipment couldn’t be removed, such as the need to await a coroner or investigator. Some professionals suggest that medical equipment always be left in place, even if it is not required, in an effort to show what was done for the person (Von Bloch 1996). The bed and surrounding area should be cleaned of blood spills and major wounds should be bandaged before viewing takes place.
The notifier or another professional should lead survivors who wish to view the deceased into the viewing room and wait for all to enter before approaching the body. At this point, unless there are legal reasons for not touching the body such as a criminal investigation, the professional can move toward the body and touch an arm, the hair, or the forehead to facilitate the survivors’ approach. Although the survivors may mourn visibly and audibly, they usually can be left with the deceased unless a criminal investigation requires that the body not be left unattended by professionals.
Clinicians and researchers have unequivocally observed that survivors should have as much time as they desire with the deceased (Awooner-Renner 1991; Lord 2002). In some cases, survivors may want to view the body several times at the hospital or morgue before it is taken to a funeral home. Parents whose child has died may need to spend an extended period of time with the child and may want to hold the child. In most cases, they will ask first. If not, the professional may offer the opportunity. The child may be wrapped in a warming blanket before being presented to the parents. Such interactions are critical to the bereavement process and should not be denied unless legal purposes warrant. Contact with the deceased allows the survivors an opportunity to say good-bye, to begin disconnecting from the victim’s physical presence, and to experience the reality of the death.
Immediate or short-term follow-up for the survivors should include offers to notify additional family or friends of the death and remaining with the survivors until other members of their support systems become available. In home notifications by the police, it is especially meaningful for an officer, victim advocate, or chaplain to remain with the survivors until others arrive. Police officers may also transport survivors or arrange transportation for survivors to the hospital or coroner’s office.
Family members should be offered a choice about when to receive the deceased’s personal belongings. They may want them immediately or wish to wait until later. When they are ready, they should be told exactly what personal items are in the box or container and the condition of the items. Placing these items in paper or plastic trash bags is discouraged because some family members may perceive this as disrespectful. Finally, survivors may need assistance in signing forms, consenting to an autopsy, or contacting a funeral home.
Follow-up in the days, weeks, and months after the death can take several forms. Before the survivors or the notifiers depart, the notifiers should leave a business card or other instructions on how to contact them for additional information. As the initial waves of shock and grief subside, survivors typically find that they want additional information about the death. They may seek additional details about the circumstances or inquire further about the victim’s appearance or facial expressions, last words, or medical treatments. A meeting with the hospital staff or the officers who performed the notification at a later time can be extraordinarily therapeutic for the survivors. In addition, these meetings can be satisfying for the notifiers, who typically see survivors only while they are in acute distress. Finally, survivors should be considered for grief counseling or psychotherapy if their acute emotional responses to the loss persist for months afterward or if they exhibit recurring symptoms of trauma (i.e., persisting arousal level, reexperiencing aspects of the loss or notification event, and avoidance of reminders of the loss). Grief counseling should be encouraged as a supportive experience with care given not to pathologize the survivors’ reactions.
Need for Death Notification Training
Although counselors, psychologists, social workers, and victim advocates recognize the need for competent and compassionate notifications that incorporate the principles discussed, a preponderance of frontline professionals who deal with death on a daily basis have not received systematic training in how to perform this task or how to respond to grieving or acutely traumatized persons. Bearing this important responsibility without the guidance and experience of formal training can be extraordinarily stressful for notifiers. As one officer said, “I would rather face a loaded gun than deliver a death notification.” Another officer, in reporting lack of support in his own department, said when he attempted to debrief after a notification, his supervisor asked, “Do you want your reputation to be that of a ‘snot slinger’ throughout your career?” (Lord 1997:13).
These anecdotes of the difficulties notifiers face are validated by results from empirical studies. A mail survey of 244 professionals who regularly encounter death (primarily police officers, victim advocates, chaplains, and mental health providers) revealed that although 70% of the respondents had performed at least one death notification, 41% of these persons had received neither classroom nor experiential training in death notification (Stewart et al. 2000). Chaplains and victim advocates were more likely than other professionals to have received at least informal training. Notifiers reported that it was particularly difficult for them to provide notification for deaths caused by violent crime, drunk-driving crashes, suicide, and the death of a child. Survivor reactions that were the most difficult for notifiers to manage included attempts to harm self or others, physical acting out, and intense anxiety.
A 1997 study (Violanti 2000) compared 256 surviving spouses of police officers with 63 spouses of police officers whose mates had not been killed. Only 39% of the 298 police departments involved reported any type of protocol for handling line-of-duty deaths. Only 32.8% of the surviving spouses were “very satisfied” with their notification. Furthermore, although 80% of the departments handled death notifications for the general population within their precincts, only 13% of them provided any training.
Another study of law enforcement investigators revealed that 67% of those interviewed said the duty of death notification was “very stressful or extremely stressful” (Eth, Baron, and Pynoos 1987). Their apprehensions stemmed from feeling untrained or unprepared, perceiving that they overidentified with the family being notified, fearing their own vulnerability (fear of verbal or physical aggression on the part of the notified), and fear of being labeled by colleagues if they had emotional difficulty with the task.
Within the military, Bartone et al. (1989) observed that casualty assistance officers (CAOs) who witnessed survivors’ acute distress generally experienced more negative affect, a diminished sense of well-being, and more somatic symptoms than those who did not directly witness the survivors’ distress. The negative effects of notification were moderated by the notifier’s level of dispositional hardiness and level of social support, especially at high levels of exposure to survivor distress. Ender and Hermsen (1996) observed that nontraditional family structures, such as single or divorced parents and blended families, and the associated issues about who should be notified and supported posed significant challenges for CAOs. The researchers also found that racial and ethnic differences between the CAOs and survivors made it difficult to offer support.
Our anecdotal experiences along with the results from the research literature emphasize the pressing need for death notifiers to receive both curricular and experiential training in how to effectively manage the death notification process. In response to these needs, Mothers Against Drunk Driving (MADD) developed a curriculum to educate death notification trainers. This project is described in the next section.
Development of the Madd Death Notification Training Seminars
MADD developed its death notification training curriculum based on case studies and the empirical literature as well as the resources of more than 400 local MADD chapters. In surveying these sources, a consensus was reached that death notification education should emphasize (a) how to select appropriate notifiers; (b) the importance of correctly identifying the deceased and the survivors to be notified; (c) how to initiate contact with survivors; (d) how to actually deliver the death notice; (e) how to respond to survivor reactions and provide immediate support; (f) how to respond to survivor requests, such as viewing the body; and (g) how to provide follow-up assistance. The first purpose in developing the death notification training curriculum was to educate persons from various professional groups about the need for clear, informed, and compassionate death notifications. The second purpose was to teach attendees methods and procedures for performing notifications as well as for self-care during the process. A final goal was to teach trainers how to educate other death notifiers.
Once the initial curriculum was developed, local chiefs of police, sheriffs, and highway patrol were helpful in cosponsoring the first death notification seminars. Based on the pilot seminars, MADD then refined its program with the support of the U.S. Department of Justice, Office for Victims of Crime and presented the material at four additional sites in 1995. In 1997, a more thorough curriculum was developed that included overheads, handouts, and an extensive annotated bibliography. Victim impact panels, composed of survivors who had received a death notification, were also used in the seminars to educate the trainees about the positive and negative aspects of notification. Separate curricula were developed for four professional groups that routinely deal with death notification, including law enforcement officers, mental health and victim advocates, chaplains and funeral directors, and health care professionals. MADD and the U.S. Department of Justice used the revised curriculum to conduct training seminars attended by nearly 700 notifiers in seven U.S. cities.
Effectiveness of the Seminars
Most of the 700 attendees at MADD’s piloting seminars were contacted a year later and asked to complete a questionnaire to further assess their needs for death notification education and to evaluate the effectiveness of the MADD curriculum and seminars (Stewart, Lord, and Mercer 2001). The respondents stated that their greatest unmet educational needs before attending the seminar were (a) specific detail on how to deliver a notification, (b) how to manage immediate reactions of the family, (c) how to manage their own emotional reactions, and (d) general aspects of death notification.
The respondents rated the seminars favorably in enhancing or improving their skills (M = 7.8 of 10 points) and stated that they were very likely to recommend the seminars to their colleagues (M = 8.6 of 10). Those who felt their specific educational needs had been met were most likely to recommend the seminar to others. Specifically, the more the respondents felt they had been helped in terms of learning the details on how to deliver a notification, the higher they rated the seminars as generally helpful. However, those who responded said they felt the need for even more assistance in learning to manage their own emotional reactions in performing a death notification.
Following the seminars, the number of respondents who began offering death notification education to others more than doubled, from 30 to 73 (55 of whom had never offered such training before). Those educated by MADD saw the number of notifiers they trained triple from 1,400 to 4,313 during the year following seminar attendance. Overall, this evaluation documented the pressing need for death notification training and identified the benefits of such training both in terms of notifiers who feel more informed about how to perform this task and in the increasing number of professionals who completed the training.
Recommendations for Research
The authors’ professional experiences with the death notification process have helped to identify a number of questions worthy of empirical research. As discussed previously, performing death notifications can be an emotionally exhausting task, even for notifiers who have received training and have experience with the process. We observe, however, that not all professionals who perform death notifications are personally well suited to this task. Research is needed that more clearly delineates the personality profile of people within the relevant professions who are both interested in providing notifications and who perform them in a competent and compassionate manner. This research may yield the dual benefit of identifying the professionals least likely to be significantly troubled by delivering notifications and may also ensure that the notifications are of a high quality for the benefit of the survivors. Further research is needed to examine the longitudinal effects of performing notifications on the notifiers’ coping and adjustment processes. A comparison of professionals who are able to deliver competent and compassionate notifications over a longer term with those who cease their involvement in death notifications relatively early would be informative in this regard.
Several lines of research should be pursued to examine the effects of the death notification and its components on the survivors. As of this writing, only one research project (Stillman 1985) has examined the effects of the manner and quality of death notification on the grief and bereavement process and outcomes. That study of survivors of law enforcement officers killed in the line of duty found that their level of stress was significantly related to the manner in which they were notified of the death, the amount of emotional support they received from the agency, and the amount of assistance they received from the agency in securing death benefits. Similar studies should be conducted of more general populations of survivors.
As scholarship on death notification has advanced, it has become progressively easier to identify the salient variables that distinguish a competent and compassionate death notification from one that was poorly coordinated or delivered. Consequently, it may be possible to use a retrospective design to reliably assess the quality of survivors’ death notification experiences and to relate this information to various process and outcome variables. In addition, it is possible to use prospective longitudinal methods to compare competent and supportive notifications with a kind of status quo “notification-as-usual” approach. An objective of both lines of inquiry would be to assess the relative importance of the death notification process among other variables, such as suddenness of death, in affecting the survivor’s trauma and grief responses.
Finally, within the death notification process itself, research is needed to inform the current practice heuristics. For instance, to what extent does letting a survivor view and spend time with the body of his or her loved one facilitate a successful bereavement process in the long term? Anecdotal evidence suggests that such time with the deceased, when survivors want it, is vitally important in coping with the loss. Yet these relationships have not been examined empirically. The death notification setting is also important. To what extent does it make a difference to deliver a notification in the family’s home, which is a known and perhaps comforting place, compared with notifications that occur at the hospital, the medical examiner’s office, or in a police car or ambulance? The existing bodies of anecdotal information in all these areas should be supplemented by findings from empirical studies.
Both trauma and complicated bereavement are unique among all the other psychological problems people can experience because the etiology is known for each one (i.e., the experience of a traumatic stressor or the death and loss of a friend or loved one). Given the causal role that a death or loss can occupy for each of these problems, it makes sense to inform families and other survivors of death in a manner that minimizes the likelihood that secondary traumatization and complicated bereavement will occur and that maximizes the survivors’ opportunities for successful coping. In this regard, we believe that efforts to enhance death notification research, training, and its practice are all extremely worthwhile endeavors.