eMedicine Specialties > Emergency Medicine > Psychosocial

Coping With the Death of a Child in the ED

Author: Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Contributor Information and Disclosures

Updated: Jun 3, 2008

Introduction

Health professionals often do not receive formal training in coping with pediatric deaths likely to be encountered in practice. Being unprepared for these intense experiences can negatively affect the health professional and the quality of care provided to survivors.

After a young patient is pronounced dead in the emergency department (ED), surviving family members are in crisis.¹ Survivors can benefit from the engagement of the emergency physician who treated their family member. In addition to making medical decisions during resuscitation, the role of the emergency physician is seen as one of assisting in alleviation of suffering.

A patient's death in the ED, especially the death of a child, is often unexpected. The nature of ED practice is such that the emergency physician often does not have an ongoing professional relationship with the patient's family. Indeed, a patient's death frequently finds the emergency physician and the patient's family meeting each other for the very first time. This can be a difficult and emotional situation for both the physician and the family.

In an effort to consider certain care aspects of the child who is pronounced dead in the ED, this article's suggestions are meant only as guidelines to minimize errors. Each patient death is arguably unique and a standard "cookbook" approach by the physician is arguably inappropriate.

This article is not intended to be encyclopedic. Healthcare professionals can anticipate being students of this topic for their entire professional lives. The author feels this strongly. Accordingly, readers are encouraged to share thoughts and experiences on this subject with the author via email. The opportunity for feedback from readers was a motivation for writing this article. A subject as emotional and potentially controversial as patient death in the ED has many facets. Like pieces of a jigsaw puzzle, each facet contributes to produce a complete clinical picture. Sharing thoughts and experiences is essential to the process of solving the puzzle.

Information contained in this article is intended to provide general advice on the subject. As with other aspects of clinical medicine, general advice must be modified according to the individual patient and clinical circumstances. Nothing herein should be applied uncritically to the care of any individual patient or family.

For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education article Grief and Bereavement.

A Child's Death is Arguably Different from an Adult's Death

The death of a patient is rarely seen as a positive event. Occasionally, one can feel relief when death ends the misery of patients who have endured chronic, painful, and debilitating conditions. Relief often becomes a weak counterpoint to sad feelings generated upon meeting the patient's family and experiencing their acute grief and sense of loss.

A child's death is often viewed as particularly tragic. Unlike an adult's death, a child's death is often felt to be unnatural or unfair. The following thoughts are common when dealing with the death of a child:

• Children aren't supposed to die. It's not natural.
• The child never had an opportunity to experience a full life.
• The child was innocent and didn't deserve to die.
• The child was helpless to intervene or change the outcome. This thought may be particularly strong if child abuse is suspected.

A Child's Death Can Produce Strong Emotions

Because a child's death may be viewed as especially tragic, ED personnel may have strong feelings of nonspecific sadness and loss. In the aftermath of a pediatric death, the emergency physician may have feelings that make it difficult to maintain composure. Natural psychological defenses are unconsciously summoned to assist the physician in maintaining composure. A problem may develop if the physician's defenses produce actions that are harmful to survivors of the dead child.

Survivors of a child who has recently died are likely to require emotional support. Every physician cannot be completely supportive of every family member at all times. However, it is reasonable to ask physicians to be aware of their defenses and to avoid actions that interfere with survivors' grief.

"First, do no harm" is a widely known and generally accepted clinical precept. In the care of a patient, the physician should avoid actions that cause harm or produce more harm than good.

Physicians with children may be especially vulnerable to an emotional response to a child's death. If physicians' children are nearly the same age as the deceased patient, physicians may realize suddenly, perhaps for the very first time, the possibility of losing their own children. Physicians with children may also identify with the parents' loss.

Crisis and Grief

After the death of a child, families often have strong crisis and grief reactions.

Crisis

Crisis involves powerful and often uncontrollable emotions. Individuals in crisis may need assistance in moderating their emotions. Recruiting other family members, clergy, friends, and others to support an individual in crisis is often helpful. The physician should repeatedly recommend specific actions for the safety of the person in crisis (eg, "don't drive home, call a friend or cab").

Because individuals in crisis often behave illogically or have impaired decision-making abilities, responsibilities to dependents may be forgotten. Therefore, it is wise to inquire about other children or elderly family members who may require assistance. These individuals may forget about potentially unsafe conditions at home; inquire about safety items (eg, whether electricity to a stove or water to a bath may have been left on). The physician should also ask whether the home was locked prior to coming to the hospital.

Grief

Grief is a natural reaction to the death of a child. The grief process begins with understanding that the child's death is real.

The physician should allow (not force) family members to see or hold their dead child. However, the family should be prepared for what will be seen and possibly misunderstood without prior explanation (eg, endotracheal tubes, chest tubes, other resuscitation equipment) when they enter the resuscitation area. Occasionally, offering the family the opportunity to take with them a memento (eg, a lock of hair) helps.

Suffering is a natural part of grief. The physician should accept a wide range of emotions of families suffering from the loss.

Families often feel guilty. If possible, reassure families that they did not contribute (either by acts of commission or omission) to the child's death. Reassuring families that every care procedure that could have been implemented in the ED was implemented is important.

Interacting with the Family Prior to Pronouncement of Death

If possible, begin a dialogue with the family prior to pronouncement of death. The physician managing resuscitation will not be able to leave the patient. However, a nurse or other trusted staff member may be sent to establish contact with the family, obtain a brief medical history, provide a short synopsis of the clinical situation, and escort the family to a quiet area.

Do not give false hope. Whenever possible, give bad news incrementally. Providing survivors with a narrative of deteriorating clinical condition may soften the emotional blow if the patient dies.

Interacting with the Family After Death - General Considerations

Unless ED conditions are extraordinary, the physician in charge of the patient should personally notify survivors of the patient's death.² This meeting should occur in private. Having a cleric, social worker, nurse, or other professional accompany the physician at the time of notification is helpful.

For many family members, this will be their first encounter with death. In addition to notification of death, the meeting should provide guidance to survivors concerning what policy and procedural steps will occur in the immediate future. An understanding of local medical examiner, police, funeral home, and hospital policies and procedures is necessary to provide a road map to survivors.

Whether it is proper for the health professional to display emotions, particularly tears, is a subject of ongoing controversy. If genuine, a wide range of physician behavior probably is acceptable up to the point of role reversal. Families should not be placed in the position of consoling the health professional.

Interaction With The Family After Death - Specific Considerations

Violent reactions from survivors are rare. However, be aware of this possibility and protect yourself. As with a potentially violent psychiatric patient, do not allow your access to the room exit to become blocked. If possible, arrange for another health professional to accompany you.

Often, survivors already suspect that their loved one is dead. When interacting with the family after death, consider the following suggestions:

• Use the child's name when speaking with survivors.
• Speak in short sentences. Use plain language—avoid medical jargon.
• Avoid euphemisms for death (eg, "gone to a better place"); use the word dead.
• Try to make eye contact and speak to all survivors, not just the most vocal ones.
• Look for nonverbal communication from survivors and remember to use it as a health professional. Be aware of your body language. Try to sit. Touching an arm or shoulder can be appropriate.
• If expressions of anger are directed at you or other health professionals, try to accept them without fighting back. The survivor may just be venting. If survivors have gross misconceptions, attempts at education are reasonable. If resistance is encountered, it is probably wise to return to the subject at another time and place.
• Do not "hit and run." If you say something hard, remain with survivors long enough for them to absorb it emotionally.
• Try to be comfortable with silence. Sometimes doing nothing is actually doing something. Your presence alone can help survivors.
• Accept the family's discomfort. You can support survivors in their pain, but removal of the pain is not within your abilities as a health professional.
• Do not speak philosophically or attempt to find a silver lining in discussing the death.

Self-care for Health Professionals

Physicians need not be embarrassed if a pediatric death produces strong feelings within them. What kind of person is totally dispassionate in the circumstances of a child's death? Do not hesitate to seek assistance from family, friends, clergy, and other professionals.

Emotional defenses are a natural reaction to a stressful situation. Physicians who are aware of their defenses are less likely to take actions that may be harmful to survivors (first do no harm).

If physicians feel frustrated or uptight over failure to save a patient, it may be wise to reset one's perception of success. Although the goal of resuscitation (and the physician's role as a health professional) is to give the patient the best opportunity for recovery, the outcome is beyond the physician's control.

If physicians feel angry because the death is due to abuse or neglect, it may be helpful to remember the limits of the physician's role. Health professionals have heard only one side of the history. Others (ie, police, courts, juries) have the responsibility to conduct an investigation, adjudicate, and assign guilt. Directing anger at the situation, but not at any individual, can avoid the possibility of causing great harm by placing guilt on the wrong person.

A health team debriefing after a death can have many benefits. Strengths and weaknesses of the resuscitation can be assessed with the goal of improving future patient care. Each team member can have an opportunity to ask questions or offer comments.

Keywords

pediatric death, pediatric fatalities, death in a child, child's death, child fatality, grieving parents, mourning parents, death of a child in the ED, death of a child in the emergency department, child abuse

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