Loss, grief and bereavement is something we all come across within our lifetimes, whether it is in a professional or personal capacity. This discussion will focus on sudden death and the devastating effects it can have on the significant others of the deceased. Theoretical concepts about loss, grief and bereavement will be explored, and the impact that paramedics can have using evidenced based holistic care.

“Loss, grief and bereavement are about more than just death and dying” (Nicol, 2017, p.44). All three processes are interlinked together, potentially evoking a highly emotive response whether the death was expected or sudden (Alexander and Klein, 2012). Grief can manifest itself in a number of different ways including physical, psychological and emotional responses to name a few. Costello (2012) and supported by Malkinson (1996) suggests that there is an expectation that there will be various stages of grief such as the five stages of grief model (Kübler-Ross and Kessler, 2005), but the extent to which an individual experiences grief can also affect the individuals’ experience of being bereaved. Costello (2012) discusses ‘complicated grief’; an umbrella term used to group together a number of various forms of grief such as pathological, abnormal and absent grief. Costello (2012, p.93) also asserts that there is no distinction between what would be classed as ‘normal’ and ‘abnormal’. The experience of grief to each person can very individual, but there is no right or wrong way to grieve. Parkes (2008) argues that a dependent relationship can result in chronic grief, which can be extreme and intense from the start and potentially last for an unknown period of time.

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The unexpected death of a loved one can be extremely distressing to all involved. “Where the event is a traumatic bereavement then the assumptive world may be utterly shattered” (Trickey, 2005, quoted in Mallon, 2008, p.6). The loss of a significant other is seen as a negative event, follow by intense reactions (Malkinson, 1996). In the case of an unexpected death, the way in which the person reacts can be very different and, in some cases, extreme. The intense shock of a sudden death could be incredibly painful for some, but also highly emotional for others (Littlewood, 2014). Alexander and Klein (2012) concluded that a traumatic event can cause the affected individual to become overwhelmed. The nature of the death can affect how the person grieves for their loved one, and can potentially cause psychological issues and affect the way the person can function on a daily basis. Malkinson (1996, p.155) states that “grieving is crucial, necessary and unavoidable for successful adaptation”. How the affected person begins to function is their way of adapting their normal activities of daily living in order to cope with the loss.

Strobe and Schut (1999) developed the dual process model of coping with bereavement, which was designed to describe coping and to better predict how a person would react whether it would be well or poorly. If the coping mechanism is adequate, the mental and physical health issues that can be associated with a bereavement may begin to subside, but this may take some time as it can be a very difficult and distressing period. According to Strobe and Schut (2010), coping must be seen in a different context too, as bereavement is a process and coping is seen as mechanism. 

Colin (1996) implied the level of the person’s attachment to the deceased person would also affect how the individual would react to the loss. John Bowlbys’ work into attachment theory looked into how the disruption of the maternal-child relationship could affect the mental health of the affected child in later life (Fonagy, 2001). “The theory of attachment is an attempt to explain both attachment behaviour, with its episodic appearance and disappearance, and also the enduring attachments that children and other individuals make to particular others” (Bowlby, 2012, p.32). Bowlby first published his research into attachment in 1958, and described how a child would form an attachment with a maternal figure which would last into later life. This attachment was seen as an affectionate bond which would only exist with a limited number of people (Bowlby, 2005). Bowlby later joined forces with Colin Murray Parkes (1970) where they devised that some adults would ‘yearn and search’ for a lost loved one during periods of grief. Parkes (2010) refers to Bowlby as being the ‘god father’ of attachment theory, but also looked into his own perspectives of grief. 

Parkes (2008) developed his own version of phases of grief comprising of four stages, which is based on the work of Bowlby and attachment theory. The theory takes into account the history, experiences to date and in particular the relationship with the deceased, and therefore addresses the need to adjust these accordingly. This theory has been compared and contrasted with Kübler-Ross over the years, even by Parkes himself. The theory put forward by Kübler-Ross consist of five stages, but has been heavily criticised, as the origins of her theory were founded by Robertson and Bowlby (1952), but then further applied by Bowlby and Parkes (1970). The theory is based around denial, anger, bargaining, depression and acceptance (Kübler-Ross, 2014). From observing and interacting with the terminally ill, she concluded that denial resolves into partial acceptance and always leads to a form of anger (Kübler-Ross, 2014). The theory appears to focus more on the mental and physical aspect of grief where as the approach from Parkes takes a more holistic approach.

Parkes and Prigerson concluded that a “bereavement by death is an important and obvious happening which is unlikely to be overlooked” (2010, p.3). Parkes also studied how the effect of a traumatic bereavement can influence the persons overall response. An unexpected loss can exhibit a problematic bereavement in some due to the unpreparedness a sudden death can bring. Parkes (2008) found that there were higher levels of distress when a traumatic bereavement had occurred, and were more likely to obtain psychiatric help. Davies (2010) comments on his own experience of bereavement stating it is personal knowledge, compassion, and own experience that creates our judgement that directs end of life care, whether it be for a sudden or expected death. Davies further states that “we have a professional obligation to extend a thoughtful condolence to surviving family members (2010, p.570).

Holistic care is patient centred, and concerns the whole person and the whole situation (Ahmed et al., 2014). Edwards and Purves (2005) acknowledge that caring for the relatives of the deceased can be one of the most challenging cases that paramedics as health care professionals must respond to. The relatives have to be considered and their needs looked after as well as the deceased patient. When a patient dies, the health care practitioner has a duty of care to the next of kin and any other relatives (Buckman, 1992).
As previously mentioned, it can be extremely traumatic for the relatives when the death in unexpected, so good communication skills are needed to accommodate the emotional and mental needs of others. 

The Care Quality Commission (CQC, 2014) regulate all health and social care providers including ambulance services across England, with a purpose to ensure health care services provide safe, effective and compassionate care at a high standard. Part of the West Midlands Ambulance Service trust vision asserts delivering the right patient care, in the right place, at the right time (WMAS, 2018) and encourages effective communication amongst all of their staff. The Health Care Professionals Council (HCPC) also implores good communication amongst all registrants.  The Paramedic standards state that professionals should communicate appropriately and effectively, and they must listen to service users and carers, and take account of their needs and wishes (HCPC, 2016). The HCPC standards of proficiency (2014) state that registrants need to be able to identify anxiety and stress in patients, carers and others and recognise the potential impact upon communication. It is evidently clear that communication is a big part in providing effective holistic care. Stone et al. (2009) identified the need for further training for how to discuss death with the persons’ family and friends, but also acknowledged that paramedics must communicate effectively and understand their legal obligations.

Edwards and Purves (2005) asserts that is is important that pre-hospital practitioners need training to understand grieving to better equip themselves with the skills to adequately support bereaved relatives. Douglas at al. (2013) further acknowledges the lack of education surrounding death for paramedics. National Health Service England formulated a document title ‘National guidance on learning from deaths’ as they recognised that deaths were not being given enough priority or consideration. Dealing respectfully, sensitively and compassionately with families and carers of dying or deceased patients within the NHS is crucially important (NHS England, 2017, p.15).

Breaking bad news is a process, and not a single one off event (Warren, 2015). It is something health care professionals have to face on a regular basis, and can be distressing for the practitioner as-well as the bereaved party. The communication of bad news to a relative is the first step in the bereavement process, and can help to facilitate a normal grieving process if they receive good support from health care professionals (Reid, 2011).

According to the National institute for health and care excellence (NICE, 2017) family members should have bereavement support access applicable to their circumstances incorporating cultural and spiritual aspects.