How to manage life and death outcomes
During a pandemic or mass casualty event we are faced with a potentially life threatening situation to some of the population with many others being unwell. This guidance is in response to this situation and may help mental health workers navigate the topics of dying, grief and bereavement when working in inpatient or community settings.
Conversations about death and dying can be very uncomfortable. During this event or crisis, these conversations will become more frequent and we need to respond in helpful ways, when we are working with someone who may be dying, knows someone who may be dying, or is bereaved.
So, why talk? It helps anxiety and distress. It helps people understand what is. It can sort out practical things and wishes for afterwards.
Common reactions to the news of death
- Shock and numbness.
- Overwhelming sadness.
- Tiredness or exhaustion.
- Anger.
- Guilt.
These feelings may not be there all of the time, and powerful feelings may appear unexpectedly and suddenly.
People who use mental health services may already have experienced adversities and have the experience and peer networks to cope with issues that the major incidents can raise. For some, however, it may appear to confirm their worst fears or create more hopelessness or despair. It may prompt intrusive memories of other threats and losses. If you know the person, you may know what may be triggered for them. Be mindful that people may not react as expected.
Consider these conversation starters:
- You know that you have … and that you are very unwell, is there something that’s on your mind?
- Do you know what is happening?
- If you were to become more unwell, what would be important to you?
How to tell someone that they are dying
This should only be done by a healthcare professional when it is clear that the end of life is near.
Time
Make sure you have enough time so that the conversation won’t be rushed.
Place
If possible, have the conversation in a place that’s comfortable for the person and where you won’t be interrupted.
Support
Ask the person if they would like anyone else to be with them or told. This could be a family member, carer or friend. They can support the person and help to check that they’ve understood what they’re being told.
Language
Use clear language. Avoid euphemisms such as ‘going to a better place’. Using the word ‘dying’ where appropriate can avoid confusion.
Communication difficulties
If someone has difficulty communicating, there are things you can do to support them. Speech and language therapists can help.
Understanding
Check that they’ve understood what you’ve told them.
Questions
Allow them to ask any questions. If you don’t know the answer, be honest and say you don’t know. You can try and find out and let them know as soon as possible.
They wish may to explore
- What will happen when they feel more unwell or the end draws near.
- Making the most of the time that they have left.
- What happens to their body after they die.
- Spiritual and religious practices that are important to them.
How to talk generally about someone’s death
- Avoid clichés that sound impersonal and not relevant to the person. Being genuine, concerned and empathic will convey a sense of comfort and support.
- It is okay to say ‘I don’t know what to say but I am here for you to listen and help’. Follow the lead of the service user so that they feel in control of the time you are with them.
- Ask what you can do to help the person. Ask what they would like if they were to become more unwell.
- Use your non-verbal communication skills (open body language, gentle smile and nod).
- Find a quiet, private place to talk.
- Give the person your full attention. Try to avoid distractions.
- Explore cues. Don’t assume you know what the person is trying to say.
- Don’t force them to talk.
- Show them you have listened by checking out you have understood what they have said
- Show them you have heard by summarising what they have told you.
- Provide information that is honest, accurate and appropriate for the person’s level of understanding.
- Try not to worry about ‘saying the wrong thing’. It is better to address the situation than ignore it. An apology is always possible!
- If you can’t think of something to say, offer your support, eye contact, and ask what you can do for the grieving person.
- You cannot and should not stop a person feeling sad or crying. but you can support them by listening and talking.
- Don’t feel guilty if you’re struggling. Ask for support from others.
- Consider your own wellbeing. You may be struggling with your own worries too.
- Stay grounded. Try to remain calm, gentle and present despite the chaos around us and them.
- Some people need an end to the conversation and doing something practical and physical can help such as cooking, exercise or TV.
- Allow the individual to talk to you about other people who have died if they want to. Such news will bring up memories of other deaths.
- A series of short conversations is often easier than a long conversation.
- Talk openly and honestly if they need to about pets left behind, funerals.
- Talk to colleagues too about these issues. We are all human.
- Make a record of people’s final wishes.
- Finally, use the chaplaincy as a resource of support for people who use our services and also for ourselves.
The interaction between home and work
One of the particularly difficult aspects of major incidents is that they may affect healthcare staff as well as the people who use our services. It does this all at the same time. In an epidemic or pandemic situation we may be worried about our colleagues if they are also ill. Departments may have fewer staff to manage demand or be staffed with people we are not used to working with. We may be concerned about bringing an infectious disease into units with vulnerable patients or scared we may take one home to our families, some of who may be in high risk groups. We ourselves may be deployed into roles or areas that are not in our usual skill set. Turning up for work during such time requires us to manage our fears and trust that our leaders will be making wise decisions about our safety and contamination.
Anxieties are normal during abnormal times. When everyone is under threat at the same time, it can be more stressful. The widespread nature of the problem might rally more people to collective positive action. Sometimes it can make people irritable, controlling, avoidant, needy or ‘hard’. The things that affect us the most may not make sense to us.
- Be aware of how you react.
- Stay grounded in your motivation to do a job well.
- Be forgiving of others.
- Keep well informed and well connected.
- Raise concerns and ideas for action.
- Informally support each other emotionally.
- Focus on the things you can control rather than those you can’t.
- Find safe people to talk through your worries.
Looking after yourself after you have broken bad news
- It is perfectly normal to experience feelings of shock, denial and frustration at the prospect of someone dying.
- Use the same resources and advice for yourselves that you give others.
- Stay connected with others. Rest. Smile when you can.
And BREATHE…
- Be kind to yourself.
- Respect your body by not overindulging alcohol, drugs, and bad food; by getting enough sleep, and by moving around at least a little every day.
- Engage with others in big and, or small ways. We’re not asking you to bloom into a social butterfly or anything. Just try not to isolate. Connect with colleagues, phone a friend, wave to your neighbours.
- Allow your emotions to ebb and flow. Don’t run from them. Expect that grief emotions will bubble up, their intensity will rise, and they will wash over you and recede.
- Take life one minute, hour, and day at a time. The enormity of what it means to live life without your loved one is overwhelming, but remember that coping with grief is something that happens bit-by-bit and day-by-day.
- Honour, remember and connect with your loved one’s memory and their continued impact on the world. Allow yourself space and time for this.
- Everyone copes in their own way and at their own pace. Your critical voice has a lot of expectations about what grief should be like and how you should cope. Remember, there are very few ‘shoulds’ when it comes to coping with grief. So give yourself a break.
(Based on Self-compassion in grief (opens in a new tab)
Things you can say when someone is told they are dangerously ill or injured
What they say: I’m scared.
What you say: This is such a tough situation. I think anyone would be scared. Could you share more with me?
What they say: I need some hope.
What you say: Tell me about the things you are hoping for? I want to understand more.
What they say: You people are incompetent!
What you say: I can see why you are not happy with things. I am willing to do what is in my power to improve things for you. What could I do that would help?
What they say: I want to talk to your boss.
What you say: I can see you are frustrated. I will ask my boss to come by as soon as they can. Please realise that they are juggling many things right now.
What they say: Do I need to say my goodbyes?
What you say: I’m hoping that’s not the case. And I worry time could indeed be short. What is most pressing on your mind?
Grieving when someone you cared for has died in a major incident
Examples of what people might think and what you can do.
What I’m thinking
- ‘I should have been able to save that person.’
What you can do
Notice. I am I talking to myself the way I would talk to a good friend? Could I step back and just feel? Maybe it’s sadness, or frustration, or just fatigue. Those feelings are normal. And these times are distinctly abnormal.
What I’m thinking
- ‘OMG I cannot believe we don’t have the right equipment.’ ‘How mean that person was to me.’
- ‘How everything I do seems like it’s blowing up.’
What you can do
Notice: am I letting everything get to me? Is all this analysing really about something else? Like how sad this is, how powerless I feel, how puny our efforts look? Under these conditions, such thoughts are to be expected. But we don’t have to let them suck us under. Can we notice them, and feel them, maybe share them?
And then ask ourselves: can I step into a less reactive, more balanced place even as I move into the next thing?
What I’m thinking
- ‘This makes it very real. This could happen to my mum, partner or child.’
- ‘What if I am carrying an infectious disease and take it home. This could be my family member.’
What you can do
Notice: Am I letting everything get to me? Is all this analysing really about something else? Like how sad this is, how powerless I feel, how puny our efforts look? Under these conditions, such thoughts are to be expected. But we don’t have to let them suck us under. Can we notice them, and feel them, maybe share them?
Common issues and conflicts for staff
You may have negative feelings about why one person dies and another lives and why one person is given life saving treatment and another is not.
You may witness deaths in a crisis situation and have dealings with families who may be particularly distressed if unable to be with their loved one.
The trauma of witnessing multiple deaths in stressful circumstances may not give you enough time process your thoughts or feelings.
You may have negative feelings about why one person dies and another lives and why one person is given lifesaving treatment and another is not.
You may be conflicted about someone ‘dying before their time’.
Working so closely with death raises questions or fears about our own mortality.
Anxiety levels can become heightened particularly when nursing patients of the same age as someone in our family.
Some staff may experience guilt about the possibility that they might pass the virus on to patients.
You might be angry at the workplace for not protecting you due to issues with personal protective equipment (PPE), conflicting advice about what they should do, for
example face-to-face or not.
Sometimes we are impacted by the death of one individual but not another and then feel guilty about that. This is a normal response.
You may be functioning on adrenaline initially but you may need ongoing support throughout this period is necessary to avoid the risk of crash and burnout later.
Managing your distress around witnessing deaths as a result of an serious event
- Your distress is normal in these abnormal times. Often it will go on its own with time and informal support.
- Seek out support if and when you get time to think and feel.
- Give yourself permission to take regular breaks during your shifts.
- It is important to try to eat, drink and sleep properly.
- Try to think about and use strategies that have helped you in the past to cope with stressful situations.
- Make sure that you try to take some time out between shifts, slow down and bring levels of arousal back to normal. It is being responsible, not selfish, to look after yourself.
- Stay in touch with your friends and family even if you can’t see them in person, you can have video and phone calls.
- Engage in physical activity. Maintain a routine as much as you can. Plan regular activities that help you feel good. Avoid using unhelpful coping strategies like smoking, alcohol or other drugs.
- Try to limit the time you spend watching, reading or listening to the news.
- Spend time deliberately engaging with tasks that take your mind away from the current crisis.
- If you feel overwhelmed, know that there are ways to get support. Talk to your colleagues, your manager, or someone else that you trust about how you are feeling.
- You are not alone in this situation, your colleagues are likely to be experiencing similar things to you, and you can support each other. Be compassionate to yourself and others.
- It is okay to say you are not okay.
- Focus on what is in your control. Pay attention to things that are going well when you can. Share and celebrate the successes or small wins.
- Use the same resources and advice for yourselves that you give others.
Some things to think about
Let yourself be aware of how you are feeling reading this information
- If you think about having to do this in your work, what do you think the main issues that might arise for you are? What information or resources listed here might help you with that, and, or what access to support do you have in your workplace?
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What are some of the key challenges staff might face when having to talk to others about death, dying and bereavement? How can staff manage their own distress?
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Are there any challenges to implementing the ‘things to say and do list’ in your workplace? Are there ways to overcome these?