(English) Death Among Family Members

Organisation that collected the incident: UNIVIE

Date of recording the critical incident: 29.11.2015

Keywords for cataloguing the incident:

  • Paramedic; emergency vehicle / emergency medicine
  • Death & dying
  • Family members mourning
  • Medical procedure , communication style

Professional domain (professional domain of the narrator):

Paramedic

The incident

Please give a short account (10-15 sentences) of a critical incident you experienced. Write from your own point of view. Include where and when the incident took place, how you felt, what you did. (Do not analyse the incident, that will be a next step.)

As a paramedic, I was often confronted with rather ambiguous information when sitting in the emergency vehicle driving to a potential emergency case, such as: “Patient unconscious. Maybe. We don’t know. Just give it a look.” Receiving this type of information made me feel a certain kind of alertness, not necessarily nervous but focused on the situation that was to come, thinking about which measures to be taken, which instruments to be brought along. One time I arrived at a site with the team – two full-time paramedics, one emergency physician and me – having only some vague information about a woman being unconscious.

As we entered the woman’s apartment, we were greeted by five to ten people of different ages and genders who were family members of the patient. They were screaming and crying desperately while loudly and incessantly talking at us. Because of all the commotion and the fact, that only one of the people present spoke German, it took a rather long time to figure out what had happened. The only German-speaking person, the granddaughter, finally explained to us that her grandmother had simply fallen over and lost consciousness. It took ages before we were led into the room of the patient. From one look at her I confirmed that she was not unconscious but dead. Her gaze was fixed and empty and she was lying completely still in a very unnatural pose. Clearly dead. While we had to perform the standard measures (taking her pulse, preparing the defibrillator etc.) the entire family was continuously screaming at us and looking at us imploringly. Due to the language barrier, I can only assume that they were begging us for help. We asked them to leave the room and let us do our job many times, with increasing determination, before they responded to our request. Again, this “discussion” took quite a while due to the language barrier and because the granddaughter had to translate. Finally, after the family had left the room with one of my colleagues, we started resuscitation. I could hear loud voices from the other room while performing the resuscitation measures – which were destined to fail since the patient had already been dead for over half an hour.

I was left with a very confused feeling.  I was also baffled by the fact that the family had wasted so much time screaming and crying, instead of trying to help the grandmother by trying to resuscitate her. They didn’t even try to make her comfortable since they thought she was unconscious. They let her just lie there. All the family members had been waiting at the door when we arrived. No one stayed with the grandmother. Instead of helping they even made our work somewhat impossible. What was even more confusing to me, was that while they were not doing anything to help the grandmother, the family members seemed in grave emotional distress.

Identities of the actors in the situation

Who are the actors involved in this cross-cultural situation, what are the elements of their social identities (age, sex, origin, profession, etc.), what kind of connections are there between them and with their social groups?

Narrator

The narrator of the incident is an Austrian-born, German-speaking male, who has been living in Vienna for his entire life. He describes himself as agnostic, having been raised in a traditionally Catholic country by Catholic parents who were not actively practising, yet having attended a Catholic primary school. At the time of the incident he was twenty years old, a high-school graduate and working full-time as paramedic. Thus, he was professionally trained within the Austrian health care system (adherence to a Western system of medicine and treating patients according to medical indication, diagnosis and professional procedure). His social background can be described as middle-class.

Para-medic team members

The narrator was working with a team of two other trained paramedics and one emergency physician, all male, in their 30s, Austrian nationals and German speaking. The team was working together on a regular basis except for the narrator who had only known the others by sight. The paramedics working on emergency vehicles are specifically trained and choose to do emergency cases. In this sense the narrator describes paramedics working on emergency vehicles as “a specific type of people”.

Family members

The other protagonists were family members of an elderly woman (80+) who died, having had a long history of health issues. The family members were the woman’s children and their spouses, males and females of varied ages, between 30 and 40 years old, one granddaughter around 18 years and the only German-speaking relative present. All the others spoke a Slavic language, their national background being a former Yugoslavian country. Aside from the woman’s children and granddaughter there were also members from the extended family present, such as nephews and nieces. From the living conditions (district, type of housing, interior) it can be deducted that the elderly woman came from a working-class background.

The narrator of the story has no recollection of the specific country or region the family members came from or of any signs in the apartment of the religion practiced by the dying woman. 

Aside from all the protagonists living in the same city, there are not many connections between the professionals and the family members. They do not share a common language (except from one family member). While the professional identities of the emergency team are core in the situation at hand, the relatives are mainly defined by their familial connection to the dying woman. We have no knowledge about their professional identities or other relevant personal characteristics aside from being related to the dying woman. 

Context of the situation

What is the concrete situation/context in which this scene takes place (physical context, social, psychological, etc.)?

Physical context

The incident happened in an apartment in Vienna, situated in a block of council flats in a district that is still within central Vienna but not located especially close to the city centre. The district can be described as traditional working-class living area which has been widely populated in the last 30 years by migrant families mainly from Turkey and the Ex-Yugoslavian countries.

The apartment belonged to an elderly woman and was made up of two rooms of a considerable size that felt narrow and cramped to the narrator with all the people present. The dying woman was lying on the floor in her bedroom while the paramedics were greeted at the door by all the other people present and then moved to the living room, subsequently being led to the bedroom, again with all people present accompanying them.

Psychological context

The narrator describes the atmosphere as being very loud and agitated. People were talking at once in a Slavic language. The narrator himself was in an alert stage, working an emergency case but not knowing beforehand what type of situation he would be confronted with and what type of medical measures he would have to perform.

The family members present were in a shocked, distraught and very emotional state.

Social context

In Austria and especially in its capital there is a long tradition of people from Yugoslavia and later former Yugoslavian countries settling. From the 1960s onwards mostly male workers from Yugoslavia were recruited to work in Austria, with a view to returning to their countries of origin after a period of work. Following the war and dissolution of the Yugoslavian state and subsequently war in Kosovo a great number of people sought refuge in Austria. Currently about 8% of the Viennese population are of migrant background from countries in former Yugoslavia. Taken together, migrants from Bosnia and Herzegovina, Croatia and Serbia including Montenegro comprise of the biggest migrant group in Vienna, followed by migrants from Turkey and Germany.

When groups of “foreigners” or “migrants” are being invoked in stereotypical representations or political debates, people with origins in Ex-Yugoslavian countries are constituted as one main group as well as people from Turkish origins.

3. EMOTIONAL REACTION

The shock reaction: feelings of the narrator, and if the shock raised any particular reaction (feelings, behaviour etc).

The narrator was put off by the family members’ inactivity concerning the dying woman. He couldn’t understand why none of the family members stayed with the dying patient while the paramedics arrived, and that she was simply lying on the floor in an awkward pose, having fallen down, without being tended to. He felt stunned that the family members did not support the patient with a cushion or a glass of water.

Moreover, he was irritated by the very emotional state of the family members present seemed to be in, their loud and very uninhibited demeanour and their lack of consideration for the medical professionals who were there to treat the patient. He felt disturbed in his work mode – his normal way of assisting people in need of paramedic support. In a typical situation, the paramedic would have gone to the patient immediately without distraction from relatives or circumstances. He felt anxious since everything was taking so long and was also getting impatient.

Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock.

Paramedics are trained how to act in emergency situations. They have to follow certain procedures in order to give quality care and in a basic sense to keep the patient from dying. They follow a procedural understanding of how to handle life and death situations. This professional procedure was threatened by the family members’ actions.

Preference for a direct communication style

Communication pathways were disturbed – typically paramedics expect short and clear information about the patient (medication, medical history, food and drinks, what happened) which could not be given. Not having this type of information impedes paramedics’ work and can also decrease the quality of care. Language barriers played a part in the disturbance of communication pathways.

The narrator exhibits a disdain for the uncertainty of the situation. He is oriented towards clear verbal information which indicates to him how to react.

Professional procedure handling life and death / style of medical treatment

By not complying with the paramedics’ expectations (quick communication of relevant information and leaving the room for resuscitation etc.) the family was perceived as disturbing the professionals’ work. The narrator’s sense of professional conduct was threatened.

On the other hand, some of these procedures serve to protect relatives: they should not watch the patient die, being injured, being treated (or see mistakes the paramedics make). This illuminates the narrator’s adherence to a Western style of medical treatment. It is customary that patients visit the doctor on their own and are treated on their own. Medical information is considered highly confidential.

Death is a matter commonly handled by medical experts and institutions; their established procedures are considered most promising to keep death from happening. At the same time death is seen as something inevitable and logical at a certain point in life, when a patient is old and has had prior health issues.

The family members did not follow the narrator’s rationale of how to handle critical situations. His value of being able to prioritise what is important and what not was questioned. Confronted with the breakdown of a patient, the narrator values staying rational, acting thoughtfully and goal-oriented. He has a clear vision of the things that shall be done in order to improve the health of a patient. While he recognizes, that he might be less incapacitated confronted with an emergency situation due to his training, he questions why the family members did not even do simple things to help the patient. Being emotionally distraught while not taking action to aid the patient is irrational to him.

Professional experience of time for paramedics is different than for other professionals because every minute counts. Therefore, every minute that passes not leading to the aid of the patient (in the expected way) is experienced as extremely long period.

Conception of family and role of family members

The narrator’s expectation of the role of relatives was not met because the family members should have helped or pathed the way for the paramedics to work. On the other hand, he was bewildered by the state of agitation of the people present were in, since it conflicted with his notion of family. This shows that he has a clear view of who (which family members) is entitled to mourn. Mourning excessively for a distant relative (aunt, cousin etc.) does not fit his picture.

The narrator’s vision of empathy means being emotional about someone while staying with the person or assisting the person in need. The way in which the family members expressed their emotions collides with the narrator’s view of empathy and caring for a loved one. Caring means helping the person physically, not collectively expressing one’s emotions in a dramatic fashion.

Approaching life and death / practices of mourning

Mourning seems to be something that is more authentic when done individually.

On the other hand, the expression of devastation conflicted with how the narrator has learned to interpret cases of dying patients. There is an implicit rule for paramedics not to mourn, if a patient is old and dies, because that happens routinely. It would not be bearable to be distraught by every patient that dies. Paramedics are only “allowed” to be emotional, when a younger person dies. While this can be attributed to professional practice of handling the type of work emergency paramedics do, it also sheds light on ideas about life and death. Death is considered something that will happen eventually in the process of aging. When death is rationally within the scope of imagination for a certain person, loss should not be considered as dramatic as when people die unexpectedly.

5. What image emerges from the analysis of point 4 for the other group (neutral slightly negative, very negative, “stigmatized”, positive, very positive, real, unreal) etc?

e.g. positive, negative, neutral, bizarre etc.

Negative image: irrational; loud; emotional; in the way; chaotic; not understandable

6. Representations, values, norms, prejudice: The frame of references of the person or group that is causing the shock / that caused the shock in the narrator.

Expression of emotions

Sadness is expressed collectively (maybe even in the sense of a collective act) instead of individually.

A loud, ongoing expression of agony and agitation is an acknowledgement of the patient and a sign of respect, love or care.

Furthermore, by loudly expressing agony and agitation the family members signal to the paramedics that the situation is critical and needs their attention. They turn to indirect communication; this may be exacerbated by the language barrier.

Family solidarity

Orientation towards collectivism: Families do everything together, answer the door together etc. Family represents the basic unit of social organisation.

Importance of family members is not defined by degree of relation, i.e. the relationship between niece and aunt is not per se less meaningful than the relationship between mother and daughter. Rather familial solidarity and cohesion encompasses all family members in a strong way and the notion of family includes extended family.

The collective demonstration of sorrow can also be understood as pointing to the central position the grandmother fulfilled in this family. If the grandmother was a primary person holding the collective together, her demise can be perceived as threat to the collective order. Death is most upsetting for a social group, if it concerns a member primal for social organisation. This order or sense of community then needs to be re-enacted or reproduced by a collective demonstration of loss or pain.

Representation of death

A concept of death as threatening to the community could be linked to the family members’ collective display of agitation. Their actions then serve to re-establish community in the face of death. Moreover, the incident may be understood as starting point for a ceremonial process; collective agitation as necessary precursor for mourning and mortuary procedures.

The family members’ restraint in tending to the grandmother physically might point to taboos concerning the touching of a dying body. On the one hand, physically being in contact with illness and death by touching the grandmother could be a taboo. On the other hand, the family maybe did not dare to touch the body so as not to hurt her / do harm. This could point to a fear of being accused for not doing the right thing or being responsible for the grandmother’s death. Such a fear can be tied to their migrant status – insecurities of how to behave in novel contexts but also experiences of being blamed and stigmatised.

The soul is more important than the body. There is not so much need to deal with the dead body as such, but rather to mourn emotionally. Caring for the broken down patient is not manifested in getting a cushion or a glass of water, but in reaching an alarmed mental state that is expressed collectively in a vehement manner.

Difference between biological death and social death: While the narrator holds on to the idea of death as an event which happens at an identifiable moment in time, the family members might approach the sickening and dying of the grandmother as a process that is extending well over the described timeframe of the incident.

Acculturation

The family members, who for the most part are not able to communicate with the paramedics via spoken language, try to enact the proper way of handling an emergency case as they imagine it to be. Thus, they might not be following exactly their own cultural procedures of dealing with sickness and death by fear of going against local expectations. On the other hand, it could be that the family members, like the paramedics, feel disturbed at their way of dealing with the situation and dare not follow their rules with the medical experts present. This attempt of bridging learned cultural procedures with assumed ways in Austria (in a context with medical experts) might contribute to a conflict of practices for the family members.

It might also be possible that the situation is so exceptional for the family members, that there are no clear rules and ideas what to do and how to act.

Professional procedure handling life and death / medical expertise

The family members consider the arrival of paramedics as experts in this situation. The paramedics are waited for in order for the patient to receive help. In this sense the relatives trust in the trained professionals and the emergency care system and do not try to take over themselves.

Experience of time

Time is experienced differently by the family members than by the paramedics. The duration of certain acts is not experienced as crucial or detrimental to the health of the patient. There might be a difference between the professional experience of time (“every second counts”) and the layperson’s experience. The family members might be experiencing time in a polychromic way differing from the linear sense of the paramedics by which time is experienced as one action following another.

7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?

1) Dealing with patients’ relatives

In critical medical situations, the professional attitude towards communication and time may clash with the attitudes of the general public (patients, relatives), who find themselves in exceptional situations in which they are over-emotional. Emergency situations are somewhat routine for paramedics as they have specific procedures of conduct. Laypersons, who are present, might not know about these procedures or not find themselves in a state in which they can comply with them. This incongruence does not mean that the relatives will not try to aid the professionals in a different way. At the same time resuscitating a patient is never routine, not even for long-term emergency paramedics. So, these situations are always characterised by a sense of tension for all people involved.

The typical way to deal with relatives is to send them away while the paramedic team works, so that they don’t watch critical situations or listen to discussions. The focus is on the patient and not the relatives or bystanders present. When death occurs (is confirmed), the medical staff’s job is thought to be over. Dealing with relatives, who are mourning and in pain, is usually considered as a nuisance rather than professional task.

Paramedics rely on verbal (quite specific) information. Their work is altered when certain types of information is lacking. Language barriers between paramedics and patients can be detrimental to the care they are able to give to patients. Yet they have to perform lifesaving measures quickly even when relevant information is missing.

Paramedics regularly have to work in dire circumstances (loud sounds, cramped or inaccessible places, agitated bystanders).

Professional training could increasingly focus on how to deal with relatives in critical situations and how to better understand their needs. Aside from improving the relatives’ experience, this could strengthen the staff’s capacity to follow professional procedures while at the same time attending to relatives.

2) Different cultural attitudes towards death / Coping strategies in emergency situations

Dying is managed professionally yet it happens at the private home of a patient with her relatives present (bridging the public and the private). The professional equation of old age with death (that is also common in Western approaches to dying) and its implication for authentic mourning, collide with the family’s experience and demonstration of loss and sorrow.

Relatives’ taboos concerning the touching of a dying body as well as their insecurities on how to handle unconscious or dying bodies might clash with a professional paramedic approach towards these bodies.

Different experiences of time: professional time vs. layperson time, linear time vs. polychronic time

Difference between biological death and social death as well as between death as event and death as process.

3) Orientation towards professional conduct vs. orientation towards familial solidarity

Discrepancy between the professionals’ definition of a situation (unconscious woman / dead woman) and the family members’ experience. While the paramedics aim to professionally deal with the emergency at hand, the family members might need additional information, clear instructions on what to do or an acknowledgement that the grandmother really has died.

Conflicts between the orientation of paramedics and the orientation of family members

Conflicts arising from the family members’ efforts to comply with local expectations, or, respectively, their insecurity on how to act.

3) Orientation towards professional conduct vs. orientation towards familial solidarity

Discrepancy between the professionals’ definition of a situation (unconscious woman / dead woman) and the family members’ experience. While the paramedics aim to professionally deal with the emergency at hand, the family members might need additional information, clear instructions on what to do or an acknowledgement that the grandmother really has died.

Conflicts between the orientation of paramedics and the orientation of family members

Conflicts arising from the family members’ efforts to comply with local expectations, or, respectively, their insecurity how to act