Violent Deaths and Traumatic Bereavement: the Importance of Appropriate Death Notification

The communication of a death due to unexpected and traumatic causes is considered a very sensitive issue that can deeply affect both operators responsible for reporting the incident and the mourning process of family members, relatives, and other survivors. By focusing particularly on cases of traumatic death, this article tries to explain how inadequate communication of death may adversely affect the course of mourning. The article also illustrates the basic principles of correct notification of death. In this way, we hope to contribute to the ongoing dialogue on this topic and the promotion of new studies aimed at setting best practices for those professionally involved in the challenging task of communicating that a life has ended. This would be important in order to safeguard the emotional integrity of notifiers whilst effectively helping the survivors to cope with the early stages of their difficult mourning process.


Introduction
Whatever the cause, the loss of a loved one is always a source of suffering, pain, and loneliness not only for survivors (family members and friends) who are to fill the void of a bond torn, but also for all those people who, for various reasons, have the task of communicating that death has occurred.These individuals, too, are subject to intense emotions.This is particularly true in the case of a sudden, unexpected, and violent death (caused by external causes such as suicide, murder, road accident, work-related accident, natural disaster, etc.), which throws the survivors into a state of shock and anguish, with their emotional reactions significantly influenced by the manner in which the event is communicated.In fact, attitude and words used by the death notifier(s) not only impact survivors' bereavement, but also may turn into memories capable of accompanying them forever [1][2][3][4].The way death is communicated should empathetically acknowledge survivors' perceptions, and involve clear language and information [4].
By considering two separate perspectives, one for notifiers (health care professionals, police officers, priests, etc.) and one for survivors, and focusing on when and where death notification occurs (or should occur) and, above all, on behavior and type of communication involved, this article intends to contribute to the debate around protocols of best practices for such a critical moment.In fact, operators tasked with giving the tragic news to family members, in addition to their personal discomfort, need to learn how to manage the emotional turmoil displayed by survivors.Thus, they have to become fully aware of how their attitude and language can affect the reactions of survivors [5][6][7].It is clear that giving the news of a sudden death is, anyway, a difficult task, which could be complicated by a lack of or incomplete training about it [8][9][10][11].
Addressing, in particular, issues such as death communication in a hospital setting-where health care teams are crucially important in supporting survivors [9]-and in the case of accidents and murders [3,[12][13][14][15], this article examines the most important phases of the first stage of the journey of mourning, with attention also to the delicate moment of the identification of the body [16][17][18][19][20].

Communication of Death
Notification of death is usually defined as the moment when "notifiers" (health professionals, police officers, clergy, etc.) officially communicate the death of a person to family and friends (the "survivors").It is a form of communication that should be planned, in order to make operators sufficiently resilient and confident and survivors fully aware of the fatal circumstances.In particular, in cases of sudden, unexpected, and violent death (e.g., a car crash), survivors may be exposed to a process of prolonged grief, compounded by the inability to greet their loved one [21,22].This can cause a "double pain", as defined by Kendrick [23], being the by-product of what has been lost and what cannot be called back anymore.
To make the moment of death notification emotionally bearable, there are "best practice" protocols intended to help notifiers in becoming aware of the important role they play [13,24,25].These protocols provide guidance to notifiers on how to behave in order to support those persons whose lives will be marked forever by the news they are going to receive [19].Although no protocol can prevent unforeseen circumstances or completely diminish the sensitivities of persons involved, their use can significantly impact the way survivors accept and process the sudden loss of their loved one [26,27].There is general consensus that notifiers should undergo personal training to learn how to act in an adequate, effective, and less traumatic way as possible [10,11].
Information related to a death should never be given in a superficial manner or in an inadequate setting, simply because this would cause additional stress and anguish to survivors [3].That is why it is so important that the communication of death is given, first of all, in ways and places that are most appropriate [25].

Death Communication in Hospital Settings
Although health professionals might deal daily with death, when they have to interact with family members and survivors of a victim of a violent death inevitably they are also called to experience a situation of intense discomfort and personal anguish [23,28].If not properly managed, these emotions may interfere with health professionals' ability to respond in a clear and comprehensive way to survivors' questions, possibly creating confusion and bewilderment.
In hospitals, the death of a patient is usually due to two main reasons: it can be the result of an illness of some duration or, instead, the tragic outcome of a road accident, suicide, etc. [29].In both cases, the task of notifying death often represents a severe source of distress for even experienced physicians [24,25,30].While one might think that the enduring presence of a disease could make it easier to communicate its fatal evolution to the family (and the family to accept it) [26], the approach should be different when the death of a person has taken place in sudden and traumatic circumstances.In these cases the doctor, or the staff member, may face a series of intense emotional reactions that can become bigger when he/she is not able to give the sad news accurately and empathetically [26,31].In situations where the health care team may not have had any previous relationship with the family of the deceased, in notifying death health operators should show communication skills that enable survivors to gradually understand what happened.Interpersonal sensitivity and training on death notification would be very desirable assets of notifiers [27,32].
If the dying individual is admitted to the intensive care unit, it is important that health professionals provide family members with an up-to-date status on a patient's condition and gradually prepare them for the inevitable.Sharing information with family members about the health status of the patient will facilitate acceptance and understanding of what is about to happen.Iserson [26] defines the stage that the health care team is approaching as "presaging" or "anticipatory grief": members of the team have initially informed the family and/or close relatives of the severity of the case, emphasizing the actual situation with simple and clear words; in subsequent meetings, they have informed family members that although health workers are doing their best, the situation does not seem to improve, and there is no certainty that the life of the patient can be saved.Finally, the time comes when the death has to be communicated [7,26].
Sometimes caregivers can appear as cold or detached, especially when they experience feelings of inadequacy, discomfort or even excessive involvement.This may be reflected in a defensive, hurried and dry type of communication, characterized by the use of conventional words, along with an aseptic and emotionless attitude [19,27,[33][34][35].This can turn into a situation experienced negatively not only by survivors (who would never forget it), but also by the professional themselves, who may experience uneasiness and anxiety caused by the perception of personal inadequacy [5,26].
To limit the occurrence of these negative emotions, Naik [7] and Roe [36] have provided a few practical suggestions.For example, they think that it should be the most experienced doctor to make the communication to one, or a maximum of two family members, possibly in a private room (not the hospital corridor or the emergency waiting room).The use of plain, linear language is recommended, accompanied by a calm and empathetic voice, without any reference to technical or unsympathetic terms.In order to avoid any kind of misunderstanding in a climate of strong emotional tension, notifiers should not use circumlocutions such as he/she has "gone" or "left us"; on the contrary, the phrase "I'm sorry, but your loved one is dead", said at the appropriate time, allows survivors to immediately know what has happened.It is possible that the news should be repeated several times due to the shock to which family members and relatives are exposed.In this case, the notifier has to speak with a lot of patience, kindness, and respect, trying to understand the extreme delicacy of the moment.After the notification, the doctor (or other medical staff) should be able to spend a bit of time with the family of the deceased, showing willingness to answer any questions or concerns that may arise from survivors.Emotional closeness and participation can also be demonstrated with small gestures of physical contact, such as a hand on the shoulder as a sign of vicinity [19,27,33].
Especially in cases of sudden and traumatic death it is possible that reactions of family members are so strong to be hardly controllable.In light of this, it would be appropriate to have availability of a separate room where family members and relatives can start to process the sad news, being free to express their own emotions and support each other.In some cases it may happen that the medical staff is the target of insults and expressions of anger.It is important that the staff does not react negatively but show understanding for the exceptionality of the situation [33][34][35].
From this brief description it is possible to imagine the level of stress that the health care team may undergo in notifying death.In addition, if the event occurred in the context of an emergency ward, it should be kept in mind that health professionals cannot stop the care of the other patients, to whom they must rapidly return often without having had the time to adequately process the death they have just communicated [37].

Communicating Violent Death in Non-Hospital Settings
When death does not occur in a hospital but in other contexts, such as in case of traffic accidents, homicide, or suicide, usually it is the duty of police officers, forensic authorities or religious officers to communicate the sad news [12].It is of paramount importance that death notification is provided in a timely manner: it would be unacceptable for survivors to apprehend the news from the media [38].
Stewart, Lord, and Mercer [39] deal in detail with the notification of death due to road accident suggesting a few basic guidelines for proper communication of it.First of all, they consider the correct identification of the deceased to be of fundamental importance: as many details as possible have to be collected about the identity of the deceased, in order to be well informed when communicating the news.Then, it is important that notifiers try to acquire information also on survivors, particularly on whom is going to be the main recipient of the communication [39].In the event that the recipient is an elderly person, or someone with psychological problems or other disabilities, notification of death, if not supplied appropriately, could further aggravate these conditions [39].It is also important to collect as much information about the accident as possible, documenting the injuries and the emergency interventions that were carried out, in order to be ready to respond in detail to the questions eventually asked by the family [15,39].In case communication of death is carried out at the home of survivors (as often occurs in case of unexpected deaths), it is recommended that the notifier be accompanied by a colleague or other professional, in order to better contain emotional reactions of family members and to lessen the feelings of isolation and vulnerability during those dramatic moments [15,39].It is important that the notifier refers to the deceased by using his/her name: the defunct is still a person, alive and real, for family members [39].
After announcement of the death, survivors may experience a wide range of different reactions: for example, dissociative episodes with disconnected words and inappropriate behavior; lack of facial expression and emotions; feelings of being detached from own body (depersonalization); or feelings of living in a dream or an unreal world (derealization) [40,41].These emotional reactions are often generated for defensive purposes in relation to a situation that is perceived as unacceptable and intolerable [41].When faced with such delicate moments, for notifiers it could be useful to accompany survivors to a quieter room, trying to bring them back into the "here and now" [39].Only once the survivors have regained contact with reality, they can be provided with more detailed information concerning the death of the loved one [39].
Outside of hospital settings, police officers are those most often involved in the difficult task of notifying death.Motor vehicle accidents, suicide, and homicide cases are frequent circumstances in which police officers are requested to manage sentiments and reactions manifested by survivors.Sometimes, these reactions can be physically violent and include aggression or self-harm and suicide attempt episodes [5,42,43].In these situations, it is important for police officers to be well aware of the type of information that may or may not be reported to survivors.Particulars related to agonizing bodies or descriptions of disfigurement should be spared to family members, as well as premature attributions of responsibilities in accident dynamics [15].
Family members should never be informed of the death by telephone.If this were the only possible way (although the least desirable), the notifier-before communicating the death-should ensure that the recipient is not alone.If this is not the case, Stewart, Lord, and Mercer [39] provide a set of recommendations that could prove useful in the event that the person contacted by telephone were alone at the time of notification.Although initially written in relation to cases of death due to road accidents, these recommendations can be considered appropriate also in cases of murder [15].The notifier should make at least two telephone calls: the first to inform the family that their loved one has been the victim of a crime and that it would be important if the person were able to contact another family member willing to be around and close in such a difficult time.Usually the family member receiving the phone call would pressure for more details, but the notifier-trying as much as possible to maintain a calm communication-would need to answer all questions with great discretion, merely reporting the basic information.After confirmation of the presence of another family member, a second call would serve to communicate the death [15].
When the communication is given in person, it is preferable that the notifiers not only decide in advance what can be reported to family members and what is better to avoid but also who will be the spokesperson of the news.Again, it is recommended that communication be participated by two or maximum three police officers [3].This would permit a better management of emotional reactions, and the provision of practical help to survivors if necessary [5,15].If minors were present, it would be advisable that they do not listen to the news, which should instead be reported later, in a more appropriate manner, by a family member [15,43].
Once the death notification has been provided, police officers should be available to respond to questions from the family, without adding any superfluous information.It is important that family members be given explanations in a comprehensive way as to what happened, because the persistence of unclear information or questions that are not followed by exhaustive answers over time could hinder proper development of the grieving process [38,39].
After the encounter with survivors, police officers that were members of the notification team should meet (as soon as possible) to debrief the situation.This should include assigning responsibility for any follow-up tasks concerning survivors and a review of the death notification process that just occurred.Emphasis should be put on various aspects of the communication: positive and negative factors; problems potentially arising in survivors; what could have been done to make the news more bearable for the survivors and what could be learned for future cases.Death notifications can be very distressing and sometimes also very depressing.Concerns and emotional reactions should be shared in a candid and honest way.Possible affinity with the notified (e.g., in relation to one's own loss of a loved one) can add to the stress of the notification experience.Team members should be able to effectively support each other [38].

Identification of the Body
As stated before, the loss of a loved one is often followed by emotional turmoil, especially when death was sudden and violent [40].Feelings can be so powerful as to ward off survivors from reality and make them incapable, in most critical situations, to even perform basic activities [41,44].First, they live in disbelief of the loss of the loved one.The thought of not having the deceased physically close anymore becomes increasingly harrowing; the idea that life is now not worth living may be recurring, if not constant.For survivors it may now appear senseless to plan for the future, as well as to think that something beautiful can still happen in their life [26,41].
The proxies of the victim, in fact, feel the news as inexplicable and unjust, experiencing reactions-both physical and psychological-in tune with the cultural context in which they are immersed [7].Feelings also depend on gender (males and females react differently), age, and social class [41].Reactions may occur in a silent manner (no visible pain, no tears).In other cases, strong emotional outbursts, accompanied by shouts and anger manifestations, may be the prominent features [11].Additionally, for these reasons, the way death is communicated assumes a great importance for survivors: the memory of that moment remains for a long time [1][2][3]45].Some studies claim that the "need to know", often present in parents who have lost a child in a sudden manner, is a normal part of the grieving process [41].On the other hand, children may want to know the amount of pain or injury suffered by their parent [46].Indeed, the ability to obtain adequate information about the accident is associated with a better return to everyday life, as this would give survivors a chance to gradually begin to realize what happened, and slowly rebuild their life after the loss [47][48][49].
An especially difficult death notification can be represented by a case of murder.In fact, although all sudden deaths are a source of enormous pain, murder is seen as the most extreme violation that an individual can inflict on another [15].The greater the perception of survivors of the cruelty of the murder, the greater the sense of discomfort they experience [50,51].Murphy, Johnson, and Lohan [52], in a study conducted in 2002, claimed that most parents who survived the assassination of a child had, in the five years following the event, a persistent level of psychological distress, often identifiable with the diagnosis of post-traumatic stress disorder [15].
Survivors describe their pain as excruciating and unremitting; the cruel nature of the deliberate act amplifies their feelings of anger and despair [13].In tune with this, police officers consider the moment of notification not only as the most difficult part of their job, but also the situation for which they feel less prepared [38].This inadequacy is indirectly confirmed by the families who receive the news, and who often describe police officers as insensitive and detached [13].
In many cases, the step that follows notification of death is the identification of the body of the victim [16][17][18][19].This is also very difficult and delicate, for both notifiers and survivors.The identification of the body can have a double meaning, because on the one hand it definitely ends the hopes of re-embracing the loved one-plunging survivors into a deep sense of despair-while on the other hand, it indicates the end of physical suffering: the victim is now free from the pain he/she was inflicted [15].
In any case, it is important that the decision to see the body is taken autonomously.Notifiers should inform survivors about what they are going to see and also illustrate alternative options to reach conclusive identification, such as DNA, fingerprints, etc. [20].
Regarding the mourning process in connection to body recognition, literature provides limited and somewhat conflicting data.Some scholars [53], for example, consider it inappropriate that survivors view the body, fearing that this type of memory-too strong-can accompany them for long time, negatively influencing their adaptation process.Conversely, Worden [54] argues that, especially in the case of a violent death, the vision of the body could be useful, as the impromptu event would put the survivors into such a sense of unreality that only the sight of their loved one could convince them that what happened is tragically real.Worden also argues that the "letting go" (i.e., to acknowledge the departure of their loved one) is an essential step in the grieving process that can be facilitated by the vision of the body [54].
Chapple and Ziebland [20] have examined factors that can motivate survivors to view the body of the deceased, investigating what feelings and emotions this operation may trigger.Most survivors stated that their decision to see the body proved useful, both because they actually ascertained the identity of their loved one, and also because this gave them the opportunity to care for him/her for the last time.In addition, many survivors consider the vision of the body as less painful than not having this possibility [55].At the emotional level, Chapple and Ziebland have described a set of reactions ranging from deep regret to the sense of relief at having found that their loved one has stopped suffering [20].
In cases of violent death in which recovery and vision of the body are not possible (such as, for example, in case of an airplane crash or terrorist attack), the process of mourning may present particular difficulties because the absence of the body keeps alive the hope that the loved person is not among the deceased ones [56].The "unverified" death, i.e., the one that cannot be directly ascertained but which is referred to as undeniable, can lead survivors to continue hoping, while not accepting the accident and not "working through" the pain.
With regards to the importance that the identification of the body plays in the whole process of mourning, some scholars [3,19,28,55,[57][58][59] concur in proposing the following best practices.If it is not necessary to view the body for legal reasons, it is important that survivors may choose whether they wish to or not.However, if this were a required step, it would be of importance to make sure that survivors are supported in every single moment of this difficult process.Often, family members want to touch their loved one for the last time: if this were possible, it is recommended to grant the right time for this contact.In cases where police investigations are still ongoing, it is likely that this option is not available, at least in the short timeframe.Therefore, advance warning should be provided to the family about this probable event, clearly explaining needs and obligations of the investigative process.In the meantime it would be useful to reassure family members that, after completion of the investigations, they will be allowed to see the body.It is important that the phase of the identity recognition is made the least dramatic as possible, and that the body is presented cleaned, with more obvious wounds adequately covered [39,55].
Although there seems to be a generalized attitude to allow survivors to recognize the body, it would be useful to promote more in-depth studies on this particular topic.The existing literature on the impact of body recognition in the bereavement process is rather limited and further research would certainly be welcome.Furthermore, although there is increasing attention to best practices and guidelines aimed at "correct" communication of death, a lot has still to be done in order to deepen the knowledge specific to the notification of a sudden and violent death and its impact on the course of the bereavement process.

Conclusions
The traumatic deaths that have been considered in this article have in common at least two characteristics: the violence with which they occurred and their unpredictability.By definition, these are two aspects that are beyond the control of both the professionals involved in death notification procedures and the survivors, suddenly forced to manage the emotional void of the physical absence of the loved one.Although protagonists of these situations experience their pain in intimate and personal ways, they are all linked by a particular circumstance that binds them together: the communication of death.Despite huge variability in degree of involvement and personal sensitivities, both notifiers and survivors would find it useful to be able to share the following certainties: for notifiers the reference to a code of conduct or protocol they could rely on in order to cope better with the challenging task of notifying that a tragedy occurred; for the proxies of the deceased to be told the untellable in a way that does not create extra-suffering and allow them to mourn through a path appropriate to their personal situation.In all cases, notifiers and survivors share together a moment that would never be forgotten.