Sudden deathwork

Sudden deathwork Dr Tricia Scott Senior Lecturer, Centre for Research in Primary and Community Care, University of Hertfordshire p.scott3@herts.ac.uk

“We imagine ourselves surrounded by loving friends, the room filled with serene quietude that comes from nothing more to say, all business finished; our eyes shining with love and with a whisper of profound wisdom as to the transiency of life, we settle back into the pillow, the last breath escaping like a vast ‘Ahh!’ as we depart gently into the light.” (Levine, 1988 p8)

The A&E sudden death scenario is stripped of ‘good death’ characteristics. Reduced to a socially rationed attempt to resuscitate, in the absence of loving friends involving a barrage of invasive procedures and measurements conducted within a resuscitation specific frame. (Timmermans, 1999)

Rationale • Provide a substantive theory of sudden deathwork • Illuminate problems of dealing with sudden death • Enhance interprofessional working relationships • Provide a catalyst to inform change in service provision

Literature review • Death trajectories (Timmermans 1999) • Status passage (Glaser and Strauss 1971) • Deathwork (Goffman 1959; Prior 1987) • Embodiment (Scott and Morgan 1993) • The body ‘polluting’ (Grosz 1994; Shilling 1997) • Dramaturgy (Simmel 1950; Bradbury 1990) • Dirty work (Hughes 1981) • Emotional labour (Hochschild 1983)

Method • Chicago tradition • Grounded theory • Constant comparative method • Theoretical saturation • Triangulation

Location and sites • 3 A&E departments in the North of England • Department 1 – major trauma centre treating 75,000 patients annually • Departments 2 and 3 – acute general hospitals collectively treating 80,000 patients annually

Accessing the field • A&E Staff Nurse in Department 1 • A&E Sister in Department 2 • A&E Senior Lecturer covering all 3 departments • Reputation as the ‘sudden death expert’ • Solidified relationships enabling comparison of sudden deathwork

Ethics Approval • Ethics Committee approval was obtained from 3 Acute NHS Hospital Trusts • Chief Superintendent of the Traffic Division • Ambulance Service Head of Operations

Data collection • Ethnography • 9 focus groups 45-90 minutes duration • 3 groups of paramedics • 3 groups of A&E nurses • 3 groups traffic officers • Informant narratives

Data analysis • Researcher transcription of 225 A4 pages containing 108,000 words • Coded within a non-numerical unstructured data indexing, searching and theorising package (NUDIST NVivo)

Results Three trajectories concern the collapse to death career of the patient en route to a mortuary • Direct • One-stop • Elaborate

Direct trajectory Main features concern collapse followed by failed resuscitation, death declaration and early paramedic disengagement from the scene

One-stop trajectory Focuses on a ‘dead on arrival’ scenario in the ambulance outside the A&E department. Minimal interaction is followed by early disengagement of emergency personnel and transportation of the body to the mortuary

Elaborate trajectory Involves an extensive range of activity and interaction between emergency personnel and others. An intricate procedural base exists that centres on pastoral support and, the representation of the body to relatives

Schutzian relevances • Role • Legitimation rhetoric • Emotionality • Dehumanisation • Spiritual relevances

Role resignation “I suppose its afterwards when you think (shrugs) “Yeah”, that’s when it hits you. But I think, at the time, you don’t think, “I don’t like doing this, I don’t want to do it”. You just know what you’ve got to do and you just do it” (NA paragraph 235)

Role resignation “I personally don’t find it difficult to deal with the body, more so the pressure of knowing that very shortly relatives are going to be arriving” (TPB paragraph 445)

Role resignation “Its the longest walk you’ll ever do I think, I know! You’re just trying to scurry on and its even worse when its silent and nobody says anything… I try to walk faster to get them to the room quicker” (NC paragraph 264)

Role uncertainty “I was on my own down there (mortuary) attempting to clean a body and it wasn’t until I realised that I was making a right hash of it that er, I got in touch with (name) and he said there was a technician that you can call out. You know, you’re not expected to, nobody had told me.” (TPA paragraph 48)

Role obstruction “You ask them to turn back and you explain, and you know, they are still wanting to come through, “Well I have to drive ‘cos I have to get to my mates up there!” And you’d like to tell them to F. Off!” (TPC paragraph 836)

Role obstruction “Sometimes I don’t give a toss about the guy in the bed ‘cos I’ve seen what he’s done to somebody else. I just want to see him blow in that bag and I can go, he can die for all I care. I just want to make sure that I can secure the best evidence to support the other party” (TPC paragraph 2012)

Role routinisation “We have to move them out quickly for the next person so the way that we deal with it might not be ideal” (NB paragraph 83)

Role routinisation “It just seems to me that, I mean, they’ve lost their kiddie and the kiddie has been dealt with and sorted out and everything. And those heartless bastards of policemen want to come along and take the kiddie’s bed furniture and stuff like that” (TPC paragraph 953)

Good innings “It’s a waste of life whereas the older ones are better that they’ve done it (lived a full life) but the younger ones aren’t even going to get a chance” (PC paragraph 163)

Mode of death “…you see like, the elderly that have been hit by a car and you think, “God that’s so tragic to get through live and survive this long” (NC paragraph 130)

Personal analogy “Accidents involving kids are always the worst because with me having a young family myself you know, I always thought in the back of my mind, “Well, bloody hell it could be my two” (TPA paragraph 316)

Coping “There was something like three (deaths) in a row and it was always me that was going in with the relatives. There should be a different person if you’ve recently dealt with one” (NC paragraph 964)

Emotional exhaustion “You feel awful saying it, but it’s definitely horrible going down there (mortuary)…” (TPA paragraph 293) “Nobody else wanted to, and I went down, and it was awful. It was upsetting, it was awful, and I didn’t want to do it again” (NB paragraph 1138)

Emotional exhaustion “…the daughter, she was so grief stricken it was hard. I had to go out ‘cos the tears were just streaming down and she was literally begging us to do something. She had hold of us and she was saying “Please, Please, save her, she’s my mam she’s my life, I just don’t know what I…” And I looked at her and I just felt I’d failed her in a way ‘cos I just couldn’t stay and I said to (name) “I’ve got to go” (NC paragraph 461)

Annoyance “…and people ‘tutting’ in the waiting room after you’ve just dealt with something and you feel like saying to them, “Get down there and just…”, but you can’t, and that pulls your stress levels up” (NC paragraph 1075)

Annoyance “I was personally annoyed that that lady was injured. I was annoyed at the way the accident happened. I was annoyed at the standard of the other guy’s driving… consequently, I bent over backwards to a) get herself sorted out with the car etc. and the family and b) put the best file I possibly could together to secure the conviction of the driver” (TPB paragraph 1517)

Humour “I used to think, when I was a student, that the staff were really sick because they would laugh after like, something bad that’s gone on and yeah, now I do it myself. Its just like human, I mean if you don’t laugh you’ll cry” (NC paragraph 1200)

Humour “There’s another one woke up dead!” (PC paragraph 394) “Hoo hoo!” (PC paragraph 627) “Was his jacket damaged?” (PAparagraph389) “TFM’s my favourite station!” (NC paragraph 374)

Liminality “Well they used to say open the windows to let the soul depart…Some people believe it and some don’t… its just when I started my training that was what everybody did and I just continued. If the soul is going to go then its going to it’s fair enough” (NB paragraph 447)

Liminality “I must admit I still talk to the person. I can’t do it silently, I’ve still got to tell them what I’m doing. It sounds really silly but I’ve got to, I mean they haven’t been dead for hours, they’ve just gone that minute…I’ve still got to talk to that patient and treat him like he’s still alive” (NB paragraph 436)

Liminality “And you’re not just wrapping them up like a piece of meat, ‘cos that’s what it sometimes seems like. It’s a person who maybe not more than two hours ago was actually walking around” (NC paragraph 323)

Dehumanisation “Sometimes at the point of contact with it (body) you don’t look at it as a person, you know, you don’t think of the person who’s standing or running about and talking, its just like something that isn’t a person at all” (TPC paragraph 243)

Dehumanisation “I find that horrible, wrapping them up, I think its awful. I’m all right till I put the cover over the head, they’re like a Christmas parcel, its just horrible that bit, I don’t like that. It would be all right if you left the head exposed, but as soon as you put the cover over its just like a figure isn’t it?” (NB paragraph 412)

Humanisation “But the man who collapsed had all these packages of money identified for his grandchildren for Christmas, it was Christmas week, and he’s gone out and he’s got his pension…” (NA paragraph 281)

Embodiment “I wouldn’t want to let go of my baby with having a nursing background and the knowledge of them going in the fridge, it would just tear me in two…I think myself grateful because I don’t think I could sleep knowing where my child was” (NA paragraph 428)

Conclusion • Provides a substantive theory of sudden deathwork in A&E • Much sudden death work sits in the non-accountable range of activity • Internal consistency provided a relatively accurate rendition of events and discussions • Useful to position myself at the edge of my society operating within and without

Conclusion • Rich detail of ‘happenings’ were revealed enabling procedural comparison • Ethnography produced a ‘warts and all’ account • Triangulation reduced personal bias from a single researcher, single method, single theory study • Suggestions for procedural change related to e.g. baby clothes and, the mortuary sheet

Thank you

References • Scott, T. 2010 ‘Religion in trauma care: grand narratives and sacred rituals’ Trauma 12(3):183-192. • Van loo, M. Rabbetts, C. Scott, T. 2008 ‘Emergency nurse initiation of discussion about tissue donation with suddenly bereaved relatives’. International Emergency Nursing, 16(4):257-265. • Scott, T. 2007 ‘Sudden traumatic death: caring for the bereaved’, Trauma. November 9(2):103-109. • Scott, T. 2007 ‘Expression of humour by emergency personnel involved in sudden deathwork’, InternationalJournalofMortality. November 12(4):350-364.

Sudden deathwork