The Journal of Emergency Medicine, Vol. 58, No. 1, pp.

141–147, 2020
Ó 2019 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

https://doi.org/10.1016/j.jemermed.2019.09.034

Administration of
Emergency Medicine

EMERGENCY DEPARTMENT GRIEF SUPPORT: A MULTIDISCIPLINARY

INTERVENTION TO PROVIDE BEREAVEMENT SUPPORT AFTER DEATH IN THE
EMERGENCY DEPARTMENT

Julie J. Cooper, MD,* Rachel C. Stock, RN, BSN, CEN,* and Sister Julian Wilson, ACC, MA†
*Department of Emergency Medicine, Christiana Care Health System, Newark, Delaware and †Department of Pastoral Services, Christiana
Care Health System, Newark, Delaware
Corresponding Address: Julie J. Cooper, MD, Department of Emergency Medicine, Christiana Care Health System, 4755 Ogletown Stanton
Rd, Newark, DE 19718

, Abstract—Background: The nature of death in the
emergency department (ED) may put survivors at higher
risk for complicated bereavement. Access to bereavement
care could mitigate this, but many EDs do not include
bereavement follow-up as part of their routine practice.
Objective: We describe the implementation at our institu-
tion of ED Grief Support, a program developed to extend
care to the bereaved through in-person, telephone, and e-
mail follow-up for 1 year after the death of a loved one.
Methods: Bereavement follow-up was preferentially
extended to survivors of patients <45 years of age who
were chosen because of the higher likelihood of unexpected
death in this age group. Detailed records of each case were
collected prospectively using online data management soft-
ware and outcomes were recorded. Successful strategies to
navigate communication and resource referrals are dis-
cussed. Results: We enrolled 192 patients during our 2-
year period of observation. The majority died from trauma
and parents were the most common next-of-kin to be con-
tacted. Commonly requested services included: clarification
of the circumstances of death, the interpretation of autopsy
reports, referral to community bereavement resources, and
family meetings. Challenges included supporting the
emotional well-being of staff and the resource-intensive na-
ture of the follow-up. Staff members who worked with ED
Grief Support find it meaningful and note a positive
influence on their well-being as providers. Conclusions:
Reprints are not available from the authors.
Longitudinal bereavement follow-up from the ED is feasible
and had a perceived positive impact on the bereaved as well
as ED staff. Ó 2019 Elsevier Inc. All rights reserved.
, Keywords—bereavement care; ED administration;
follow-up care; grief support; palliative care
Thank you for showing me that you value the life of my
son.
–A bereaved family member contacted by ED Grief
Support
INTRODUCTION
Death, both expected from chronic illness and unex-
pected from sudden illness or injury, is a common occur-
rence in the emergency department (ED) (1,2). The death
of a patient may occupy just a few minutes of an emer-
gency medicine provider’s shift. For survivors, however,
the death notification marks the beginning of a period of
bereavement that can continue for months or years.
Grief is a normal response to loss and is defined as the
psychological, behavioral, social, and physical reactions
to loss of someone closely tied to a person’s identity.
Bereavement describes the time period during which

RECEIVED: 24 July 2019;

ACCEPTED: 20 September 2019

141
142
grief is experienced (3). The bereaved are more likely to
have an abnormal or prolonged grief reaction (compli-
cated grief) in the setting of sudden or violent death, death
of a spouse or child, perception of the loved one suffering,
feelings of guilt that they may have contributed to the
death, lack of social support, history of psychiatric
illness, or lack of understanding of what happened
(4,5). Complicated grief can manifest as a ‘‘frozen or
chronic state of mourning’’ associated with anger or
bitterness, nonacceptance of the loss, avoidance, seclu-
sion, and regret, and can be associated with poorer health
outcomes for the bereaved persons themselves (6–8).
There is a relative paucity of literature on bereavement
services in acute care settings, and much of that literature
focuses on pediatric death (9–11). Support of the
bereaved can include any number of interventions or
services. Acute care interventions frequently include in-
person or telephone outreach, further information when
needed about the circumstances of the death, or referral
to individual or group counseling or mental health ser-
vices. While not every bereaved person will need or
want specialized bereavement care, it is reasonable to as-
sume that providing the access to such services and main-
taining an open line of communication could benefit
those who need support. Challenges to bereavement
follow-up in the ED are numerous and are summarized
in Box 1 (2,13).
A few principles of bereavement care have been
described that are pertinent to the emergency setting
(5). One principle is delaying meetings to weeks or
months after the death when more data are available
Box 1. Challenges to Emergency Department
Bereavement Care
 Families may not be present at the time of unexpected
death and there may be delays in notification. Death
notifications may come from other sources, such as
police
 Shift work means that the team caring for a patient may
no longer be available to answer questions
 Information available to families or the ability to view a
loved one’s body may be delayed in the setting of a
suspected crime
 Due to the nature of prehospital care patients are
frequently brought or transferred to hospitals far from
home
 Practical questions for family members often linger after
a sudden death, such as the need for survivors to be
screened for genetic disease
 The trajectory of recovery might be longer for those who
experience sudden or violent loss (12)
J. J. Cooper et al.
and to allow time for the family to formulate questions.
Another principle is that new information (e.g., autopsy
results or cause of death) should be discussed with the op-
portunity to answer questions, and visiting the location of
death can be helpful for closure if family was unable to be
present (11).
The ED Grief Support team was formed at Christi-
ana Care Health System in response to a perceived gap
in access to bereavement services after death in the
ED, despite the circumstances putting the bereaved at
higher risk for complicated grief. In our health system,
patients who die at home or in the field may receive
bereavement care resources from the medical examiner,
funeral home or hospice provider (if enrolled). From
the inpatient setting, bereavement care can be accessed
through pastoral services. Before our program, patients
who died in the ED were not captured by these mech-
anisms. ED staff members also expressed moral
distress dealing with the recently bereaved on shift
and concern about what would happen to them moving
forward. This prompted efforts to improve access to
follow-up care. Because circumstances of ED deaths
and individual needs are variable, we created ED Grief
Support to maintain an open line of communication
with bereaved families. The program is accessed at
the time of need and provides the resources families
identify as most helpful.
To honor those concerns and begin to close the gap in
access to resources, the ED Grief Support program was
created to support best practices in bereavement care.
We created a multidisciplinary team to provide ongoing
bereavement follow-up to families who were thought to
be most at risk for complicated grief. Our goal was to
extend bereavement support and open an ongoing conver-
sation with these survivors to assist them in moving for-
ward after their loss.
MATERIALS AND METHODS
An informal pilot of our program was started in 2011 and
included efforts to follow up with a bereavement card, let-
ters, and phone calls. In 2016, the program was expanded
to its current form with institutional review board
approval and we began the routine collection of detailed
information surrounding follow-up calls.
Location
The project was implemented at an independent aca-
demic medical center with 1227 beds across 2 hospitals.
There are 3 EDs (2 hospital-based and 1 freestanding)
including level I and level III trauma centers. In 2018
there were 195,000 ED visits across the 3 sites.
ED Grief Support
Participants
The ED Grief Support team is multidisciplinary and in-
cludes members from ED nursing, pastoral services, a
behavioral health specialist, a patient relations represen-
tative, and an emergency physician champion.
Procedure
ED Grief Support procedures are shown in Figure 1. At
the time of any death in the ED, staff are encouraged to
sign a bereavement card that is mailed by clerical staff
to the next of kin in approximately 48 h. These cards
are part of the standard death packet. A chaplain from
pastoral services identifies deceased ED patients
<45 years of age from a database search every month.
The age cutoff was set to identify deaths that were likely
to have been unexpected given our limited resources to
contact every family. Patients of any age can be referred
by ED staff members through a dedicated email account
or in person to ED Grief Support staff.
Identified cases are collected and managed in Redcap,
electronic data capture tools hosted by Christiana Care
Health System (14). Demographic information, circum-
stances of the death, care team members, next of kin pre-
sent, and contact information are abstracted. Additional
information is sometimes sought in emergency medical
services records, police reports, or online obituaries.
Approximately 2 weeks after the index visit, a letter is
mailed to next of kin introducing ED Grief Support and
offering phone and email contacts for families to reach
out for follow up. Lines of communication available
include a dedicated email address maintained by pastoral
services and a voicemail and phone line that off-hours
goes to a continually staffed family support phone (held
Figure 1. Overview of the recommended timeline for emergency department (ED) Grief Support follow-up.
143
Box 2. Sample Scripting of Follow-Up Calls
‘‘Hi, this is [Name]. I’m calling from [Christiana Care Health
System hospital] and wanted to see how you are doing
since [patient’s name] died.’’
 ‘‘I’m so sorry it has been such a difficult time. Tell me
more about how things have been lately.’’
 ‘‘I’m glad to hear that you are coping well, finding
strength in a difficult time is important.’’
 ‘‘Some families find they need information or have
concerns they weren’t ready to discuss with the doctors
when they were in the emergency department. Did you
have any of those concerns?’’
 ‘‘Some people find it’s helpful to talk about their
experience with others who have also experienced the
loss of a loved one. We can help you with resources for
support groups, bereavement counsellors..’’
by a chaplain or behavioral health specialist with family
support training).
A staff of 2–4 senior ED nurses and 1 behavioral
health specialist use their paid nonclinical/administrative
time to make phone calls to next of kin at approximately
6 weeks, 6 months, and 1 year after the index visit. Script-
ing for the call openings (Box 2) is provided and occa-
sionally also used as language for emails if that is the
preferred communication. Family meetings are offered
to families that request them to include the emergency
physician champion and a representative from patient re-
lations and any other ED Grief Support staff available.
Cases can be ‘‘closed’’ at the discretion of the callers
with a default of continuing to reach out for a full year un-
less the family requests no further contact.
144
RESULTS
Between January 1, 2016 and December 31, 2018, 933
patients died in our 3 EDs. That does not include
patients pronounced dead in the field, except a few in-
stances where a patient was pronounced dead prehospi-
tal and then transported to the ED for a variety of
extenuating circumstances, such as paramedic safety.
Those patients were not generally included in our pro-
gram because they did not receive care from ED pro-
viders. If a family did reach out, they were enrolled.
Table 1 summarizes the characteristics of the 192 pa-
tients enrolled in ED Grief Support during the study
period.
Starting with the phone call at 6 weeks, Box 3 summa-
rizes common resources requested or offered to survivors
based on their conversation with the team. Common is-
sues included identifying other survivors or relatives
who may need assistance (i.e., a surviving parent refer-
ring another child to our services). Many families ex-
pressed lingering concerns or questions about the
patient’s last moments if they were not present, and
some wanted to see the place where their loved one
died if they came in for a meeting. There was significant
involvement of the criminal justice system in many of our
cases, including victims of abuse or intimate partner
violence, gang violence, or cases involving illicit sub-
stance use. We were able to maintain relationships with
law enforcement to aid with victim services and help fam-
ilies navigate bureaucracy.
There were also some unanticipated requests: 1 parent
wanted to become a hospital volunteer, 1 requested to be
matched with an anti–gun violence group to volunteer in
honor of a lost child, and another sought addiction re-
Table 1. Characteristics of ED Grief Support Population
(January 1, 2016 to December 31, 2018)
Total No. of Patients Enrolled with ED
Grief Support
Average age, y*
<18 y, n
Type of visit, n
Trauma
Out of hospital arrest (medical)
Other death in the ED
Unknown
Primary contact person relationship, n
Parent
Spouse/partner
Grandparent
Sibling
Child
Other/unknown
ED = emergency department.
* Patients selected for inclusion were by definition <45 years of
age, but some staff referrals included older patients. The ages
ranged from 11 days to 85 years.
J. J. Cooper et al.
sources for a surviving daughter whose sibling had died
of overdose.
Notably, we encountered only a handful of families
who expressed hostility or mistrust toward the program
or hospital. If a family expressed hostility during phone
contact, they could be immediately placed on the ‘‘case
closed’’ list if requested. Some families were angry dur-
ing the initial contact; however, the act of reaching out
sufficiently diffused the situation to allow us to move for-
ward and even build a successful future relationship. Risk
management was contacted for 1 case where a survivor
said they were pursuing legal action, and we made sure
to avoid redundancy if a case was also being followed
by another hospital group.
We found it important to continue to attempt contact
over the full year when we were able to leave messages
as in some cases family did not respond for the first
time until the 6-month or 1-year mark. Their needs
evolved over time and the reminders may have caused
them to reflect on that at intervals.
DISCUSSION
The ED cares for a heterogeneous and complex patient
population where one size certainly does not fit all
when it comes to bereavement care in the hospital or in
the community. We believe that proactively reaching
out surrounding grief and loss normalizes the bereave-
ment process. It lets survivors know that what they are
experiencing is not unexpected or abnormal, especially
when the circumstances surrounding a death are chal-
lenging. While there are many barriers to consistently
reaching next of kin, most families we interacted with ex-
pressed gratitude for the follow-up and were accepting of
resources when needed.
Implementing and maintaining ED Grief Support has
had some notable challenges. Abstracting the charts,
searching for family contact information, attempting
192 phone calls, and leaving messages is time consuming.
Team members do find the process of reading the medical
29
26
records, news reports, and obituaries to be emotionally
distressing. Importantly, they also found that the process
103 of following up and beginning to see survivors move for-
74
12
ward and progress through their grief is highly rewarding,
3 especially with families that are followed over time. ED
nurses on the team appreciate spending a meaningful
105
38
amount of time communicating with just 1 person or fam-
5 ily in contrast to their work in the department which is
7 hectic and often does not offer time for deeper connec-
2
35
tion.
We found several strategies that were successful in
designing the ED Grief support program. First, we
created a workflow that allows for flexibility both on
the part of our team and the families we are trying to
ED Grief Support 145

Box 3. Commonly Requested or Offered Resources During Phone Follow-Up

Type of Resource Offered Description

Clarification regarding care of the patient Many families had difficulties obtaining or interpreting the autopsy report from
or circumstances of the death the medical examiner or had questions about the circumstances of the death
because they were not in the hospital when it occurred
Crisis hotlines Various crisis phone and text lines available for survivors, including specialty
hotlines for survivors of accidents and murder
Local online website/clearinghouse Online clearinghouse for survivors with crisis and mental health services, police
and victim services, grief support groups and services, and listing of online
and print resources
State-run human services referrals Free online and phone-based human services referrals and community
resources for issues such as housing and social work
Parent-specific support groups For perinatal and pediatric losses
Victim services Offered by victim advocates at local and state police departments
Gift of life Provide support to donor families
Medical examiner Access to autopsy reports frequently requested to provide closure as to the
cause of death. The physician champion from Emergency Department Grief
Support provides interpretation of these reports if requested.
Pastoral services Hospital-based chaplains can provide spiritual and emotional support by
phone or in person

reach. This allowed for a ‘‘push and pull’’ of opening CONCLUSIONS

space for families to contact us when ready and actively
contacting them at regular intervals. We made more
than expected use of email, with many families preferring
email follow-up to phone calls. Using a multidisciplinary,
team-based approach to calls (>1 nurse in an office or
conference room calling, documenting and pulling re-
sources together) helped reduce some of the emotional
burden on staff members and made it a collaborative
and more enjoyable activity.
While we have not looked specifically at medicolegal
outcomes in relation to ED Grief Support, to our knowl-
edge none of the families we have spoken to went on to
pursue legal action involving the ED. Anecdotally, we
have noted that being able to proactively answer medical
and procedural questions surrounding the care of a loved
one has diffused tension and made the care more trans-
parent. Our ED Grief Support staff has felt an increase
in well-being from their participation, and we hope to
begin including the original care team in follow-up to
help them see that survivors are cared for after their visit.
Limitations
ED Grief Support is a resource-intensive program and we
were unable to follow-up every death that occurred in the
ED. Because of the sensitive nature of our communica-
tion with the bereaved we did not obtain formal survey
or satisfaction data from them. We did summarize their
concerns and comments with each interaction and used
that information to identify themes.
Anyone who experiences a loss in the ED should know
that their care is an extension of their loved one’s care.
As ED providers we hope to cultivate meaning in our
work by caring for the bereaved as valued members of
the community and filling the gaps in access to bereave-
ment care. Longitudinal bereavement follow-up from the
ED is feasible and had a perceived positive impact on the
bereaved as well as ED staff.
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ED Grief Support 147

ARTICLE SUMMARY
1. Why is this topic important?
While death in the emergency department (ED) is a
common occurrence, little has been reported regarding
best practices in support of the bereaved. Circumstances
surrounding death in the ED may put survivors at higher
risk of complicated grief.
2. What does this study attempt to show?
We review our ED Grief Support program that provides
longitudinal bereavement follow-up after death in the ED
as well as best practices and challenges faced in the devel-
opment of the program.
3. What are the key findings?
While the process of follow-up is resource-intensive,
we had success using a multidisciplinary team working
together sending letters and making phone calls. Mainte-
nance of a 2-way, open line of communication with the
bereaved allowed for questions to be answered and re-
sources to be shared as they were needed. Staff found
the process of longitudinal follow-up beneficial to their
well-being as clinicians.
4. How is patient care impacted?
Considering care of the bereaved as an extension of the
care of the patient is supported by best practices in palli-
ative medicine, normalizes the experience of grief, and
may help the bereaved identify resources to provide an
additional layer of support when needed.