Support and Counseling After Maternal Death
Article Outline
- Abstract
- Personal Experiences
- Preparation and Education for the Pregnant Woman
- Grief Education
- Parental Grief and the Adult Child
- Critical Incident
- Shock and Disbelief
- Documentation
- The Baby
- Designated Spokesperson
- Culture and Blame
- Social Media
- Summary
- Conclusions
- References
- Copyright
Teamwork, communication, critical incident debriefing, and grief counseling surrounding the events of an unexpected maternal death are important continuing education and practice topics for health care employees working with pregnant women. Social technologies have impacted health care institutions and systems. Ethical dilemmas have been created in hospitals as they develop policies and procedures regarding electronic communications and social networking Web sites.
Keywords: grief , critical incident stress debriefing (CISD) , grief and social media
The sudden death of a seemingly healthy young woman during labor or shortly after delivery is a tragic event that affects the lives of her immediate and extended family, friends, colleagues, the health care providers involved in her care, and her community. Maternal deaths are those reported on the death certificate to be related to or aggravated by pregnancy or pregnancy management and which occur during or within 42 days after the end of the pregnancy.1 The exact number of maternal deaths in the United States is difficult to obtain because not all 50 states report pregnancy-related complications resulting in the death of a mother the same way. Analysis by the Centers for Disease Control and Prevention shows that deaths during pregnancy and childbirth have doubled for all U.S. women in the past 20 years. In 1987, there were 6.6 deaths for every 100,000 pregnancies; in 2006, the number climbed to 13.3 deaths per 100,000 pregnancies; the last year the Centers for Disease Control and Prevention figures are available.2 In 2008, the World Health Organization reported the maternal mortality ratio for the United States to be 24 per 100,000 live births; roughly 1 death for every 2100 deliveries.3 If you are involved in the care of a mother who has died, or if you knew the mother on a personal level, this single death, her death, will change your life. The death of a young mother will change the way you think about life and change the way you practice medicine. You will not forget this tragic event.
Personal Experiences
Hospitals and offices have a unique group of employees who bring a unique set of life circumstances with them to their workplace; a predetermined set of ethical and moral principles that have helped them navigate through their personal and professional day-to-day life. Not everyone in the health care industry has experienced the death of a pet or a person, nor have they had to deal with a major loss. A hospital employee may have years of experience on the ward or unit, but may not have been involved in a resuscitation, transported a body to the hospital morgue, or seen trauma or death in the emergency room. Not all medical personnel have received education regarding death, a near miss, a sentinel event, or have had a conversation about living with grief, dealing with posttraumatic stress disorder, or helping others mourn or grieve.4
A young family who is preparing for the birth of their first child may not have experienced a significant personal loss or tragedy. Their parents and grandparents may still be living, and they may not have a family member or friend in the military. The family may not have medical knowledge or medical experience, and their extended family, friends, and colleagues could be healthy and well.
Women living in poverty and women who speak little or no English have a different perspective of life circumstances that have shaped who they are and how they are able to deal with grief and loss. Culture and customs will influence their reactions to loss or a sudden life-changing event. Everyone has a story that begins at home.
Preparation and Education for the Pregnant Woman
When is it a good time to bring up the topic of maternal death? When a woman is contemplating a pregnancy or has just realized she is pregnant, she certainly is not thinking she may die. When is it a good time to ask a seemingly healthy young woman about her advance directives, such as a living will, health care proxy, durable power of attorney, and organ donation? Has she had a previous pregnancy-related loss and did she receive posttraumatic stress disorder counseling and grief counseling?
A pre-conception counseling appointment would be an ideal time for the health care provider to discuss the future health and health decisions of the client. In reality; poor women, women who have little access to care, and women who have no prenatal care are at higher risk for maternal death. These women have less opportunity to control their fertility, make a health plan, or arrange for a pre-conception counseling appointment.5
Grief Education
Grief is an individual response to a unique set of circumstances surrounding loss. Grief is a natural, normal reaction to a serious loss of any kind—a physical, emotional, spiritual, and psychological response to a devastating event that is shaped by experience, religion, culture, physical health, along with the cause of the loss. Anticipatory grief is the normal mourning that occurs when a patient or family is expecting a death. Grief that follows an unplanned death is different from anticipatory grief. Unplanned grief may overwhelm the coping abilities of a person, making normal functioning impossible.5, 6
Nursing programs provide education regarding culture, ethnicity, spirituality, loss, grief, and death. Nurses are taught that throughout their nursing career they will be taking care of people who will experience loss in health and change in quality of life. Stages or steps are identified in the grief process; however, it is important to remember there is no single correct way to grieve, and people do not go neatly from one stage or step to another. Grieving is an ongoing process with movement back and forth between the stages and phases of grief.4, 5, 6
For the most part, discussions about death and dying may be difficult for some; people generally avoid thinking or talking about death with friends and family. Our attitudes and beliefs about loss, grief, and death change during our lifetime, regardless of profession. By thoughtful reflection and recognition of our feelings, along with continuing education about grief, loss, coping, and stress, we can be sensitive and provide support to the family grieving a maternal loss and a colleague who may be grieving.6
Parental Grief and the Adult Child
Parents and grandparents of the deceased mother may be forgotten. Attention may be focused initially on the surviving husband or partner and the children. The older bereaved parent can be in an extremely vulnerable position and may suffer from the absence of a support system.7 Grief education for health care providers should include how a maternal death will impact the entire family; every family member needs to grieve the loss, no matter the age.
Critical Incident
Labor and delivery and postpartum are typically places in a hospital where new life is celebrated and family phone calls share happy news. A critical incident is an event or a situation that causes intense stress, and this distress has a negative impact on the person's ability to cope and adjust after the traumatic event. A critical incident can involve any situation that causes a distressing, dramatic, or profound change or disruption in the individual's physical and psychological functioning.4, 8 Support from nursing management, physicians, hospital clergy, social work, bereavement counselors, employee assistance counselors, and hospital administration should include critical incident stress debriefing (CISD) to help the staff involved process the event. Research on the effectiveness of applied critical incident debriefing techniques has demonstrated that individuals who are provided CISD within 24-72 hours after the initial critical incident experience less short-term and long-term crisis reactions or psychological trauma.8, 9
Nurses working in labor and delivery or on the postpartum unit are familiar with obstetrical emergencies and conditions affecting the mother during or after delivery. These units typically are not familiar with a full code involving a resuscitation team, hospitalist, anesthesiologist, pharmacist, respiratory therapist, just to name a few.
A maternal death may also occur in the emergency room, leaving the emergency room personnel devastated. The emergency room may not have obstetrical experts immediately available; the emergency department should be included in all obstetrical emergency education and preparations.
After a maternal death, debriefing with the resuscitation team will give nursing staff opportunities to make changes and arrange for future simulation learning.8, 9 The hospital and risk management team will do their own internal debriefing with all the medical departments involved with the maternal death.
Shock and Disbelief
Whether the death of a mother is a witnessed event, with many team members involved in resuscitation, or whether a health care colleague finds the mother lifeless in bed, the immediate reaction is one of shock and disbelief. At the time of the event, hospital personnel will be caught off guard and their thought process and ability to function may appear to be fragmented and nonsensical.
Adequate staffing must be available to continue to provide safe care for the other women on the unit. If a checklist of who to notify is available on the unit, delegate the responsibility to someone who will be at the phone. Notify the nurse manager, nurse supervisor, nurse educator, and any available nursing personnel to help make calls to mobilize staff in anticipation of replacing staff involved in the incident. If not already done, notify the medical director of labor and delivery and postpartum. The medical director will notify the hospital administration team, including risk management and the human resources team to have employee assistance personnel immediately support staff. The secretary or unit clerk must be informed to help coordinate services.
If the mother does not have family with her, the hospital chaplain and social worker will help the family when they arrive. If the family has been at the bedside, the chaplain and social worker can help them to a private room and offer immediate comfort and initiate steps in grief support. The medical staff involved with the event must first collect their thoughts to be able to speak collectively with the family later. The first meeting with the family may be a conversation of few words; the purpose is to show empathy and compassion to the family and to share what information is available, answer their questions as best as possible with the information available, and tell them you will be updating them as information becomes available.
Documentation
As soon as reasonably possible, assemble the staff involved to complete the required charting and documentation. It is important that documentation of the facts be done before casual conversation. Conversation may be distracting to some, and the conversation and comments by seemingly supportive staff may interfere with the recall of facts and timeline of events. It is important for staff at this time to refrain from discussion of the events with personnel who were not providing care to the mother. News of a tragic event can take on a life of its own, and speculation will only add inaccurate information that will be distressful for everyone involved.
Electronic medical records are identified by the time of each entry, and accuracy is critical. Documentation should be honest and done independently without collaboration. Speculations about the event are completely inappropriate and should not be charted, and only facts should be reported. The nurses may find it helpful to use the vital signs automatically documented to recall how they responded to the events preceding the mother's death.
This is where previously developed algorithms and protocols practiced in the simulation laboratory can benefit the nurse: when these vital signs are observed, we do this. The nurse may also find it beneficial to write out a timeline for her recall; when she makes an entry to the electronic medical record, it is done with minimal correction.
Each person involved in the resuscitation is responsible for his or her professional performance, and not the performance of the team. During the debriefing, the entire event will be outlined and the individual actions will be made more specific. Quality and risk teams will also outline the details in thorough reports after the documentation and interviews are completed.
Not every maternal death is the result of a medical error, and not every maternal death will result in a wrongful death lawsuit along with allegations of malpractice or negligence. The family wants to know what is going on, what happened, and without delay. We would expect the same courtesy if we were in their situation. The initial conversation with the family is very important.
The Baby
The family has just been told that a seemingly healthy woman who came to give birth has now died. The family may be focused on the surviving newborn and will need assurance that the baby is doing well. If the infant is a preterm baby, the family may need to see the infant before they can process any information regarding the mother. Most Neonatal Intensive Care Units (NICUs) have a strictly enforced visitation policy; however, this is not the time to enforce the policy. Allowing the entire family to see the infant will enable the family members to receive the same information, minimizing the chance for misinterpretation of medical information. They are already in shock; they need compassion and kindness during their first NICU visit, as well as the support of their extended family.
The family may ask to hold their healthy term newborn when they talk with the doctor. This may not be part of the newborn nursery policy, but recognizing the family may want to keep the baby close is understandable and important to them at this time. Coordination between the maternal, newborn, and neonatal services departments will allow the family to visit a secured area without drawing attention to themselves as the family that is in shock regarding a maternal death.
Designated Spokesperson
The family deserves one story, the right story, the first time with no omissions or revisions of information. Information that the family receives must be accurate and must reflect the care their family member received.
Does your institution have a protocol directing which member of the health care team to communicate medical information to the family? The chaplain and social worker may be the initial contact with the family, and as soon as possible, the obstetrician, perinatologist, and nurse should join the chaplain and social worker to talk with the family, even if the opportunity is brief. The family needs to have some initial information so that they can start to process their loss.
Listen to what is being said as well as nonverbal expressions. Hospital staff should refrain from discussing their own personal experiences and should not offer personal advice at this time. Bereavement and Advance Care Planning Services is a department at Gundersen Lutheran Medical Foundation, Inc., a not-for-profit 501(c)(3) corporation located in La Crosse, WI. This is one facility that offers several options for staff education, which are available online or through brochures and Webinars.10
Culture and Blame
At no time should the family get the impression that blame has been put on a single person or the performance of one individual while their loved one is in the hospital. The family does not need this distraction and should not focus on the staff or the staffs' reaction to this maternal death.
Clinicians working in a culture of blame and punishment do not report all errors, primarily because they fear punishment. Fears of reprisal and punishment have led to a norm of silence; however, silence kills, and health care professionals need to have conversations about their concerns at work, including errors and dangerous behavior of coworkers. The goal is for individuals and organizations to be able to move from individual blame toward a culture of safety, where the blame and shame of errors is eliminated and reporting is rewarded.11 We should not play the name/blame/shame game.
Social Media
If the mother has been in the hospital for any length of time, the family may have started a social media family support page, such as a CaringBridge Web page. CaringBridge provides free Web sites that connect people experiencing a significant health challenge to family and friends, making each health journey easier.12 The family may also have posted on other social media sites such as YouTube, Flickr, Facebook, MySpace, Friendster, LinkedIn, and Twitter.13, 14 Some hospitals have a family support page on the organization's Web site that allows the family to communicate with their friends. Hospital Web sites also have strict policies with regard to their own Web sites.
It is never appropriate for any hospital personnel in any department to comment on a patient's status using any form of social media, including text message, instant message, and Twitter. It may be tempting to add condolences on a social media obituary or post on a Facebook wall of remembrance; however, hospital personnel are licensed and employed to take care of those in need when they enter the institution for health care, they are not friends. A clearly stated and enforced policy about social media should be given to all health care personnel. Continuing education about technology, including the personal restraint required to read a post and not respond to a post, should be included.
The Pew Research Center notes that tools such as e-mail and social networking sites can and are being used in harmful ways. One such way is the Internet, which can engage many people into a social connection where they expose private information.15 When information about a maternal death is posted on the Internet, the assumption is that there was negligence in care or a medical error. Many individual opinions can cause great distress to the family and hospital personnel who may read (but not respond to) the posts on the Internet that contain speculation and assumptions, and may contain few, if any, facts.
Summary
An unexpected maternal death in labor and delivery, postpartum, or the emergency room is a tragic and devastating event for the family, hospital, and community. Everyone directly involved in care leading up to this death should receive supportive grief counseling; at least, an interview with a grief counselor to understand that stress and grief may affect their work performance and interactions with family and friends at home should be conducted. Grief counselors will be able to assure everyone that their grief is valid, that the way they process grief and move forward will be unique to them, and that the effects of a tragic event may last for a long period.
Employee education regarding the process of debriefing and CISD after a critical incident and a near miss should be offered to all staff as educational opportunities. Employee education programs about grief and loss should be included in annual education opportunities, as many hospital employees may have had limited continuing education on grief and loss. Include departments such as nutrition services, housekeeping, laboratory, and pharmacy if they request grief counseling after a maternal death.
Create checklists for staff to use in the event of a maternal death. Consider making the checklists available on computer software that can be accessed by all staff; checklists have been shown to be helpful to staff in emergency situations.
For accuracy, verify the patient's emergency information and advance directive information, including organ donation, and confirm that all information is accurate and available on the electronic medical record. Time is critical if a family wishes to donate organs; organs such as heart and lungs must be received by the recipient within a 4-hour window.16 The family may experience an added sense of loss if they have missed their opportunity to donate their loved ones' organs because of medical technicalities beyond their control.
The future of electronic social communication and evolving hospital policies may be of concern, as mostly everyone stays connected to friends, family, school, work, or a news source, with some sort of electronic device through an electronic network. Etiquette and legal concerns of social media must be communicated with staff to ensure electronic communications are appropriate and meet the expectations of the organization at all times. Electronic social media should never add distress to those hospitalized or bereaved.
Conclusions
Support and counseling after a maternal death requires debriefing and education from multiple disciplines to assist those involved in this tragic event. Professionals in grief counseling, employee assistance programs, social workers, and the hospital chaplain can assist staff to identify coping strategies to help them with their journey through grief. As hospital personnel initially coordinate the departments that will assist the family with their loss and grief, hospital staff will also need support to process their personal loss and grief.
References
- . Women's Health USA . In: Rockville, MD: U.S. Department of Health and Human Services; 2010; http://Mchb.hrsa.gov
- . Doubling of Maternal Deaths in U.S. “Scandalous,” Rights Group Says . CNN Health . March 12, 2010;
- . Trends in Maternal Mortality: 1999 to 2008 (Estimates Developed by WHO, UNICEF, UNFPA and the World Bank) . Geneva, Switzerland: World Health Organization; 2010; http://www.who.int/gho/mdg/maternal_health/situation_trends_maternal_mortality
- Mental Health America: Coping with Bereavement . http://www.nmha.org/go/information/get-info/grief-and-bereavement/coping-with-loss
- . Bereavement, Loss, Grief . http://www.webmd.com
- When an Employee Is Grieving . www.compassionatefriends.org/brochure/when_an_employee_is_grieving.aspx http://www.compassionatefriends.org/brochure/when_an_employee_is_grieving.aspx
- . How To Go On Living When Someone You Love Dies . New York, NY: Bantam; 1991;
- . http://www.icisf.org
- . Providing Critical Incident Stress Debriefing (CISD) to Individuals and Communities in Situational Crisis, 1998 . http://www.aaets.org
- . http://bereavementservices.org/research_resources/a_mothers_memory http://bereavementservices.org/index.asp
- . Chap 5: Patient Safety and Quality: An Evidenced-Based Handbook for Nurses . Rockville, MD: Agency for Healthcare Research and Quality (US); 2008;
- CareingBridge.org http://www.caringbridge.org
- . Death and Social Media: What Happens to Your Life Online? . http://arstechnia.com/tech-policy/news/2010/03/death-and-social-media-what-happens-to-your-life-online 2010;
- . Social Media Obituaries . http://socialmediamore.com/social-media-obituaries 2011;
- . The Future of Social Relations . http://www.pewInternet.org/topics/Future-of-the-Internet.aspx 2010;
- . Core Curriculum for Transplant Nurses . St. Louis, MO: Mosby; 2008;
PII: S0146-0005(11)00162-5
doi:10.1053/j.semperi.2011.09.016
© 2012 Elsevier Inc. All rights reserved.
