Death is a major stressor. Some deaths are expected, others unexpected or preventable. We recently wrote a paper titled “The after-death telephone call to family members: a clinical perspective” (1). We refer to the literature review of this article in our effort to formulate guidelines for teaching and supervising the after-death call, which we define as “The call made by the health care provider to the family member(s) after the provider first becomes aware of the death of a patient.”
There are four main principles gleaned from the literature review. The first is the need for the call. A telephone call by the clinician is expected and appreciated by the family after a patient dies (2). The second principle is the optimal time to call. Schreiner et al. (3) suggested that 5 to 8 days after death was the best time to call. The third is the optimal manner. The best approach is for the clinician to listen rather than talk. During the telephone call, what may have been discussed at the time of death is reiterated. To personalize the interaction, the deceased patient’s first name is always used (4). Finally, the fourth principle is the optimal end of the call. The call is ended by leaving contact information and inviting the family to call with questions.
McClement and Degner (5) discuss “no regrets” as the core basis of family satisfaction surrounding a death. Families who felt most comfortable described “no regrets” about decision-making regarding the course of treatment and decisions to withhold or withdraw treatment. Such families felt assured that everything possible was done, had a chance to say good-bye, and felt that the patient heard a final message of love. Unfortunately, families often have a feeling of uncertainty or dilemma. Families of the dying have constant anxiety and feel helpless and ill-equipped to make complex clinical decisions. Slomka (6) and Kirchoff et al. (7), refer to a “cascade” or “vortex” of uncertainty as a surge of unexpected events unfolds (decompensation, ICU admission, and finally death).
Practice implications for the mental health professional can be derived. Clinicians must process anxiety and grief, listen, and comfort the family. We should help the family move from uncertainty to a final goal of “no regrets.” An after-death telephone call can serve as a finishing analysis of the patient’s care (4), while addressing grief and obtaining closure.
After-Death Call: Teaching Principles
For residents and medical students treating the dying, the after-death call is a learning opportunity, particularly since death and dying are less frequently taught in psychiatry. The Accreditation Council for Graduate Medical Education (8) outlined core competencies for residency training. The after-death call offers an opportunity to teach residents interpersonal and communication skills, professionalism, systems-based practice, and advocacy for quality patient care. It is an opportunity for supervisors to help trainees to understand their role in providing quality care and to alleviate suffering. The rich diversity of teaching moments along with a humane, compassionate approach makes it, in our opinion, an example of “best practices” and an integral part of patient care and teaching.
We outline the issues involved in supervising trainees making the call:
1. Supervisors should highlight the duties of mental health providers, which include patient confidentiality even after death, enhancing family well-being, learning from mistakes to promote organizational change, and alerting authorities if abuse or neglect is suspected in causing death.
2. Processing of feelings by both the supervisor and supervisee is essential to plan and conduct an effective after-death call.
3. Supervisors should explore the following feelings: guilt surrounding the death, results of the psychological autopsy, ambivalent feelings toward the patient, discomfort with emotions of family members, grief or attributions of blame, and lingering doubts concerning medical care.
4. Teaching empathic listening is a vital part of psychiatric training. The after-death call provides an exceptional opportunity to teach the role of listening in healing.
5. Validation of the care provided by family members may allow the student facilitator to build rapport with the family, underlining to the trainee that even discussions involving death may be framed in positive, health-inducing ways.
6. Addressing family concerns is essential to optimal care throughout treatment, and after a patient’s death. Care of the caregiver continues even after the patient dies and this call is a way to deliver such care.
7. The role of hospice is often discussed in an after-death call. It provides an opportunity for a resident and supervisor to discuss end-of-life issues.
8. Discussion of ethical concepts such as treatment refusal or withdrawal. Their effects on the family’s adjustment to the patient’s death are interesting topics to address in supervision and to explore in the after-death call.
9. A good supervisor-trainee relationship may be reflected in how comfortable students feel in discussing difficult emotional material in supervision. A supervisor should be attentive to emotions that trainees and families may experience during an after-death call. He may then guide the trainee in making the call supportive for the family, while also negotiating difficult emotions and pitfalls of such a call. Knowing the trainee’s personal background may help a supervisor guide a trainee in a situation-specific and individual-specific manner.
10. Discussion of legal risks and obligations is essential in supervision. Boundaries should be maintained in after-death discussions with the family. The deceased was the original patient, but any telephone or face-to-face contacts with the bereaved family may involve considering the family as the new client(s). Careful consideration must be given to what is discussed in such clinical contacts. Supervisors may help trainees identify at what point a bereaved family should be referred to another clinician for any further care.
This discussion centers around the supervisor-supervisee interaction to teach residents and students how to properly conduct an after-death call. Curriculum provides a framework that students can later use as a foundation to develop clinical skills needed for such a call. Teaching subjects such as death and dying, end-of-life issues, hospice care, empathic listening, and ethics will all prepare a clinician for the moment when he or she must comfort a grieving family. Such offerings enhance the understanding of trainees as they prepare themselves for the vast variety of clinical challenges encompassed in the scope of the after-death call. A limitation of the after-death call as a teaching tool is that it may not be generalizable to all trainees. This is a highly specific and personal interaction between clinician and family which is best taught in one-on-one supervision, and not as well in a classroom format. However, some students may be reluctant to discuss highly charged personal material even when encouraged by a supervisor. Also, an after-death call is only one type of tool to reach out to a bereaved family. Other tools are cards or letters of condolence. These may have their own implications and meanings for family, clinician, and the supervisory relationship.
Mr. A was a 90-year-old legally blind African American male followed in the geropsychiatry clinic for many years. He had severe Alzheimer’s disease. In the last year of his life he started to show signs of failure to thrive and decubitus ulcers. The visiting nurse conferred with the psychiatrist and noted that he might be nearing the end of life. She discussed this with the patient’s wife. She thought that death was imminent and asked the distant family to come visit him. They all arrived within the next 2 weeks. This was fortunate, as Mr. A suddenly became short of breath and was referred to hospice. Coincidentally, the psychiatrist called the wife right at this time, and spoke with her and briefly with the patient (who could hear but could not answer). The wife asked that the primary care physician be notified. He called her and addressed all her concerns. The patient died shortly after.
The psychiatrist called the wife after Mr. A’s death. She thanked the team for their support at the time of death. She thanked hospice for the hands-on care, and the psychiatrist and the primary care physician for their availability by telephone. She especially appreciated the visiting nurse who accurately predicted the end of life, thereby enabling the family to say goodbye. The issues were:
1. this was a predicted death
3. the whole family was able to say goodbye
4. hospice was available and supportive
5. the primary care physician and psychiatrist were accessible throughout care and especially at the end
6. the wife felt in control, and family and friends could offer comfort
The after death-call must be modified for different clinical situations, which include:
1. Unexpected death: A sense of unfairness about loss of an unfulfilled life may elicit angry feelings of being cheated.
2. Traumatic death: Family members may be in shock, with numbness, anger, or guilt. They may be accusatory or even blame themselves.
3. Death of a child: usually more emotionally charged and the greatest stressor that parents may ever face.
4. Death associated with substance abuse: often linked with blaming self or others for failing to stop the substance abuse or lacking self-control. Such feelings may impede the processing of grief.
5. Iatrogenic death: Consultation with supervisors and with quality management services may help a clinician plan how to manage the after-death call. The family may be angry and may need to discuss their anger. If a mistake was made, the literature supports acknowledging and apologizing for the error (9). Clinicians should not blame each other, as this is distressing and unhelpful for families and clinicians alike. The after-death call may have limited use, and face-to-face contact may be better after an iatrogenic death.
6. Suicide: The after-death call may play a different role as the first clinician contact to the patient’s family after hearing about the suicide. The initial expression of sympathy during the after-death call may be viewed as the first step of the active postvention phase of crisis intervention (10), to be followed by one or more family meetings to further process the trauma. The clinician’s delicate role is that of comforting the family, while also coping with his or her own grief and worry that the family may blame the clinician.
7. Homicide: Here too the after-death call may serve as the initial contact of the postvention phase (10). The clinician should consult quality management services or the hospital attorney to help in planning the after-death call in a way that is helpful to the family, while representing the institution appropriately.
For these at-risk situations, listening empathically at the start of the call may give the clinician a sense of where the family member is in his or her stage of the grief process. The clinician may then, with a few well-placed questions, elicit the family member’s feelings which are close to the surface, and make supportive comments. It may be better not to explore deeply buried feelings in a brief telephone call; eliciting powerful emotions without the facility to fully process them may not be helpful. In this case, it is preferable to offer additional face-to-face sessions to help process the death. In case of death of a child or death from substance abuse, bereaved families describe pervasive guilt and loneliness which may be the thematic focus of the call. A preventable death may cause the family to feel angry or cheated. These families are at high-risk for complicated grief, so it may be better to offer to see the family for a few visits, and then refer to a colleague for longer term treatment.
In this article, we note the psychotherapeutic value of the after-death call in addressing complex emotions and its impact on coping with bereavement. We propose that the after-death call has sufficient value for clinicians to consider making it part of routine practice. It provides an opportunity for closure and healing by reframing past hurts in an empathic light; validation and praise of the care by the family member(s) over a lifetime; integration of grief, traumatic memory, and loss for family members and for health professionals; and offering support and help to the family, and emphasizing the availability of the health care team during and after the death of the patient (1).
Supervisors may use these situations as special “teaching” moments, emphasizing that the therapeutic relationship does not end abruptly with the death of a patient. Therapeutic response to such a traumatic event may trigger a healing process for surviving families and clinicians.