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. [1, 2, 3, 4]
After a young patient is pronounced dead in the emergency department (ED), surviving family members are in crisis.  Survivors can benefit from the engagement of the emergency physician who treated the 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 often 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 physician and family.
In an effort to assist 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. A standard "cookbook" approach by the physician is arguably inappropriate.
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.
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.
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 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 was been left on). The physician should also ask whether the home was locked prior to coming to the hospital.
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 also 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 can 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.
Parents' memories of the events surrounding their child's death tend to focus on perceptions of health care staffs' efforts. It is paramount to display kindness, genuineness, and empathy toward the family, as well as maintain clear and continual communication as much as possible. 
It is important to give parents a realistic prognosis of their child. Do not give false hope. Overly hopeful or overly pessimistic outcomes communicated to families can disrupt the trust in caregivers. Whenever possible, give bad news incrementally. Providing survivors with a narrative of deteriorating clinical condition may soften the emotional blow if the patient dies.
It can also be valuable to allow parents to be with the child during the dying process. Parents may feel as they have helped the child, assisted in alleviating some of the child's suffering, and fulfilled their parental responsibility by being present during the death. 
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.  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"). To avoid ambiguity, use the word "dead", "died", or "death".
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.
Remember that suffering in survivers is natural. 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
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 [1, 2] (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. The goal of resuscitation (and the physician's role as a health professional) is to apply professional knowledge and skill to allow the patient the best opportunity for recovery. However, the stochastic nature of clinical medicine means that the outcome is beyond physicians' 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 care team debriefing after a death can have many benefits.  Both formal and informal debriefings have been shown to promote increased self-efficacy and overall functioning in health care workers. Strengths and weaknesses of the resuscitation can be assessed with the goal of improving future patient care. Each team member can take this time to ask questions or offer comments. The death of a child can create intense feelings of uncertainty, insecurity, despair, and even hopelessness in the health professional. This can be an opportunity to share any personal emotional feelings about the situation.
Debriefings give an important opportunity to counter these thoughts of powerlessness and encourage positive efforts as well as areas for improvement. Debriefings also allow an opportunity for strengthening the health care team by providing a space to recognize and accept the emotional effects that work has on individuals and the group. Validating worthwhile and positive actions that contributed to the overall well-being of the patient, family, and health care team can reinstate a sense of meaning and purpose in clinicians and their work. 
Occasionally, a child's death may evoke an intense reaction in the health professional. Signs or symptoms of such a reaction may include hypervigilance (ie, anxiety, sleep disturbance) or depression (ie, feelings of detachment or emotional numbness). The health professional may benefit from applying a validated screening examination, such as the 4-question Primary Care PTSD Screen,  to assist in bringing matters into focus. Do not hesitate to seek assistance from family, friends, clergy, and other health professionals.
It is important for the ED staff to contact their local Organ Procurement Organization (OPO) when impending brain or cardiac death is suspected. Separating the death declaration from the donation request, a method called "decoupling" is standard practice as developed by the organ donation breakthrough collaborative. It is mandated that only a requestor trained by the OPO approach families about organ donation.
If a child satisfies the national criteria for brain death (GCS < 5 or presence of only 2 brainstem reflexes, on a ventilator with a heartbeat) a referral to the hospital's local OPO must be made within one hour of pronouncement of brain death. If the family brings up organ donation prior to pronouncement of brain death, the OPO representative must wait to discuss further details until the ED physician can declare death. If the child suffers a cardiac death, the patient can still be a tissue donor with parental consent. A tissue donor must be older than 2 years of age. At the authors' institution, tissues may be recovered up to 24 hours with refrigeration of the body and up to 18 hours at room temperature.
Because the death of a child in the ED is often unforeseen, families are unlikely to have contemplated the possibility of organ donation. This can make it difficult for families to reach a stage of acceptance of their child's death that is necessary for families to address the donation request. When contemplating the donation decision, donor families should feel that the health care team is supportive of them regardless of whichever choice they make. They also should feel that the health care team has empathy for what they are experiencing. Families must have sufficient privacy to discuss donation. Studies have shown that positive interactions between families and the health care team during clinical care of patients influenced favorable donation decisions. [11, 12]
What would you like to print?
- A Child's Death is Arguably Different from an Adult's Death
- A Child's Death Can Produce Strong Emotions
- Crisis and Grief
- Interacting With the Family Prior to Pronouncement of Death
- Interacting with the Family After Death - General Considerations
- Interaction With The Family After Death - Specific Considerations
- Self-care for Health Professionals
- Organ Donation
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