Breaking bad (news) death-telling in the emergency department

Many physicians struggle with death-telling in sudden death. Families can be negatively impacted by suboptimal death-telling. Appropriate preparation and education can make death notification less stressful for the physician and may help decrease the development of pathologic grief in the surviving family members that can occur when death is unexpected. Although still controversial, there is a growing body of evidence that family witnessed resuscitation may be beneficial to the grieving process and desired by the public. A previously healthy 21-year-old male comes toyour community emergency department (ED) for a cough that started 4 days ago. He denies fever, shortness of breath, and chest pain. He does admit to a remote history of drug abuse. He states he is feeling "OK" and is only here because his family insisted he come because they were worried he might have pneumonia. His vital signs are normal and he appears well; therefore, he is triaged to the waiting room. About 30 minutes lates the patient complains of shortness of breath and he is brought back to an exam room. The patient is now hypotensive, tachycardic, and pulse oximetry is noted to be 87% on room air. A chest x-ray reveals severe pulmonary edema and an EKG shows ST segment elevation in multiple leads. The patient is taken to the cardiac catheterization lab by the interventional cardiologist, who makes the diagnosis of a ruptured aortic valve due to damage from endocarditis. The patient is returned to the ED to await emergent transfer to a tertiary facility; however, the patient rapidly decompensates and a Code Blue is called. Despite the absence of return of spontaneous circulation, resuscitation efforts are prolonged while the ED social worker attempts to contact the patient's family to come to the ED. Finally, the resuscitation is terminated and the patient is pronounced dead. Several hours later the patient's elderly mother arrives and asks you: "What's going on with Mikey?"