Death Among Family Members

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.

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.

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.

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

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.

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