May 5, 2022 | View as webpage | Too many emails? Update Subscription Preferences


In emergency services, not all outcomes are good ones. Despite the likelihood that EMS clinicians will at some point deliver a death notification on-scene – a likelihood that has grown significantly since the start of the pandemic – it's an area in which many have received little-to-no training. 

In this Paramedic Chief Leadership Briefing, Remle Crowe, PhD, shares how even a small amount of training can help EMS clinicians feel more prepared to handle a death notification.  

Linda Willing shares, “Achievement should be recognized; it’s an easy measurement of output and success. But don’t only recognize that aspect of excellence.” In a field where not everyone can be saved, Willing encourages leaders to recognize achievement in the context of teamwork, not outcomes.  

As you consider recognizing your members’ efforts and dedication, find more on how to create a culture of celebration in our EMS Week coverage. 

Stay well,   

— Kerri Hatt    
Editor-in-Chief, EMS1 


Death notification: Increased training and support needed
By Remle Crowe, PhD 

“I’m sorry, but your daughter is dead.” The thought of having to deliver this kind of news to someone even once is gut-wrenching. Now imagine having to deliver this news multiple times per day in relation to someone’s best friend, spouse, sibling, parent or child. For many EMS clinicians, this was a daily reality during the height of the COVID-19 pandemic.

In the 2022 ESO EMS Index, we evaluated the number of instances in which an EMS provider likely faced the difficult task of delivering a death notification pre-COVID vs. during COVID. We recognize there has been an increase in out-of-hospital deaths, during the COVID period, both directly due to COVID disease as well as indirectly due to other causes, including drug overdose. The measure highlights the increase in the number of patients in whom resuscitation was not attempted, or resuscitation efforts were terminated on-scene. This substantial increase in on-scene deaths during COVID means that EMS clinicians likely delivered 47% more death notifications compared to pre-COVID.

The increase is staggering, and the burden was not equally distributed, as areas hit hardest with COVID saw much greater increases in deaths.

The impact on EMS burnout

The medical community has observed a correlation between COVID rates and out of hospital cardiac arrests. In the graph, we see the difference in EMS encounters with a patient where no resuscitation was attempted, or resuscitation was attempted but the patient was pronounced dead on-scene and was not transported to a hospital in the pre-COVID time frame (June 1, 2018 – March 15, 2020) vs. during COVID (March 16, 2020 – December 31, 2021). This demonstrates a significant increase in the number of encounters where an EMS clinician would have likely had to deliver a death notification on-scene.

Notifying a family of the death of a loved one can be a challenging and stressful task for providers, especially EMS clinicians who may have to deliver a death notification on-scene for what is often a sudden and unexpected death. The provision of death notifications on-scene has been independently associated with burnout for EMS clinicians, particularly when the EMS clinician has not been equipped with formal training.

We don’t talk enough about death notification

Unfortunately, EMS clinicians typically receive little to no training on how to deliver death notifications, though they are likely to experience a situation in which a death notification will be needed. Even a small amount of training can help EMS clinicians feel more prepared to handle a death notification. One study showed that a 90-minute education session composed of a lecture, breakout sessions and role-playing helped EMS providers increase their confidence and competency in delivering death notifications. Meanwhile, avoiding this type of training can not only be harmful for EMS clinicians, but can also worsen the healing process for the survivors.

While delivering death notification is linked to EMS clinician burnout, the research also shows that death notification training, especially when integrated into ongoing EMS education, reduces the odds of EMS clinician burnout. By offering death notification training, agencies can play an integral role in helping EMS clinicians reduce burnout and have the knowledge and skills to confidently perform in their role.

Support for EMS clinicians

  • Invest in training and continuing education on delivering death notifications that is specific to EMS professionals. Delivering death notifications is linked to EMS clinician burnout, but appropriate ongoing training can help mitigate this effect.
  • Ensure all levels of EMS clinicians receive training on delivering death notifications.
  • Track the number of death notifications EMS clinicians have given. Ensure that EMS clinicians have access to resources and support to help them manage the emotional toll of delivering death notifications.
  • Foster a culture of support within your agency and actively work to remove the stigma that seeking help with mental health is a sign of weakness. Offer evidence-based counseling resources that are tailored to EMS and encourage providers to seek help when needed.

While we are possibly seeing the tail end of the COVID pandemic, the effects will linger for some time to come. First responders are still affected – especially based on the evidence above. Follow the data and provide the support needed to keep EMS clinicians healthy and safe.  

Additional resources:
Input vs. output: Why teamwork should be a measure for success
By Linda Willing 

By design, the world is conditioned to recognize achievement. You win the race. You’re first in your class. You make the most money. EMS and the fire service tend to follow this pattern of recognizing achievement and excellence.

Some people are born with natural gifts and talents – the biggest, the strongest, the smartest. Others must work hard to develop these abilities. Who among these groups does better in the long run? It depends.

Recognizing input as well as output

In any recruit class, there are those that immediately shine and those that must work hard. Some in the class may seem naturally suited to the job. Others may have to overcome obstacles to excel. Research on how these two groups perform in different circumstances provides some surprising data about how people manage challenges.

In her book “Grit: The Power of Passion and Perseverance, author Angela Duckworth talks about her research on the success rates of new candidates at West Point during an indoctrination week known as “Beast.” Those with the highest Whole Candidate score upon admission to the academy – in other words, the recruits deemed most qualified and innately talented – did not do the best during this challenging process. Instead, success was determined more by what Duckworth calls grit.

Studies done with both children and adults show that people who are praised and rewarded for innate ability tend to set performance goals for themselves. They expect to win, to get the top score, and this expectation can become part of a personal identity. In choosing performance goals, they may deliberately select problems or challenges that they know they can excel with, so they can always maintain that identity and meet expectations.

On the other hand, those who are recognized for their effort as well as results often continue to challenge themselves as they set goals that are more about learning than about specific performance.

Teamwork efforts are praise-worthy in emergency services

Achievement should be recognized; it’s an easy measurement of output and success. But don’t only recognize that aspect of excellence. Achievement in emergency services should be recognized within the context of teamwork. Assisting someone else’s success is equally important to achieving personal recognition.

So instead of saying “Good save” or “Great stop on that fire,” an officer can say, “That patient survived because you never gave up on her,” or “Great teamwork in making the stop on that fire.”

This difference may seem small and inconsequential, but it can have larger impacts. Only recognizing successful outcomes negates the nature of the emergency services and can set people up for unreasonable regrets and self-doubt. Firefighters did not cause the problem, and they can’t always fix it. It was on fire when they got there. Every medical call won’t be a save. Firefighters, EMTs and paramedics must learn to recognize that sometimes their best efforts are all they can do.

How to implement a team-oriented learning model

How can you steer people from individual recognition through performance goals to a more team-oriented learning model of success? There are three changes leaders can make that will impact members the most:

  1. Tackle a new role. Require – don’t just encourage – individuals fill diverse roles both within their own work teams and the organization. There are always going to be people who step up early, who are comfortable being more assertive and who volunteer to take a leadership role. They may be good at these roles. But they also need to understand that this is not the only way to be an important part of any team.
  2. Rotate roles. Especially when training, be sure to rotate people through different roles. Watch carefully as different people handle similar challenges. Recognize not just achievement, but also collaboration, coaching, effort and resilience. Debrief training exercises along the lines of all these factors. Mixing up roles can happen in day-to-day station life and duties as well as in training. Keep things fresh. Don’t let people get complacent.
  3. Factor effort and input into annual assessments. Personnel evaluation instruments can be modified to include factors beyond successful outcomes. Coaching that recognizes effort and improvement is likely to encourage people to keep working harder to achieve their goals.

Teaching leadership new tricks

Most leaders know that effort and perseverance are important, but they may not be actively recognizing these things. Performance goals are easy to measure. Learning goals are more subtle but are equally or more important for the success of the team.


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