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Accident and Emergency Nursing (2003) 11, 153–157 doi:10.1016/S0965-2302(02)00221-7
Personal View
A nurse’s reflection on paediatric trauma Keywords: Sudden death; Paediatric trauma; Bereavement; Crisis intervention
This reflection focuses on an event that took place in the accident and emergency (A&E) setting and relates to the victims of a trauma. It will begin by out-lining the event that took place and go on to examine the incident, highlighting both the positive and negative actions of the multidisciplinary team. The trauma involves the death of a child and therefore relates predominantly to the reactions and treatment of the child’s family with an emphasis on the child’s mother. Medical management, mechanism of injury, ethical and legal issues as well as the psychosocial effects on all involved will be discussed and conclusions will be drawn. The casualty, a two year old child, had fallen behind the wheels of a reversing vehicle and sustained head injuries incompatible with life. The child was brought into A&E following a standby call by two paramedics who were attempting resuscitation. The team standing by consisted of three experienced nurses, a junior doctor and a locum registrar who had a little experience in paediatric care. The A&E consultant had been contacted and was on his way. The child’s mother who had witnessed the accident had been restrained at the scene and prevented from seeing her child. She was now unable to face being with the child during the resuscitation attempt and had attended the hospital alone. The resuscitation attempt lasted for approximately 10 minutes before the consultant arrived, at which point it was stopped immediately and the mother was informed of her child’s death. Other family members had by this time been contacted and were on their way to the hospital. The mother now wanted to see her child and was advised by the A&E consultant that she could spend as
long as she wanted with the child. After 2 hours holding her child the mother was persuaded to allow nurses to take the child from her and allow the child to be cleaned. A relatives’ room away from the resuscitation area was provided and the child was brought back to the mother. The Roman Catholic priest was contacted and came to pray with family members, comfort was gained from the thought that the child was being christened. The mother spent most of that night with her child, only leaving the hospital when she was assured by nursing staff that her child would spend the rest of the night in a nursery and that she could return the next day to see the child and dress it in favourite clothes. The mother returned early the next morning (a bank holiday) and the child was dressed by nursing staff in favourite clothes; photographs, foot prints and a lock of hair were taken from the child and were given to the maternal grandmother. The police family liaison officer was in attendance and the mother was interviewed by social workers. Again the mother would not leave her child and by late afternoon staff who were concerned for her state of mind sought a psychiatric evaluation. Knowing that there would be a post-mortem the next day the mother spent the entire night in the hospital, parting with the child for only a few hours in which it was returned to the mortuary and again was changed into pyjamas at the mother’s request. At seven the next morning the child, who was by now showing signs of decomposition, was taken from the mortuary so that the mother could spend some time with the child before
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the post-mortem at nine. A nurse, with whom the mother had formed a close bond, had come to work on her day off so as to be the one to take the child. This again was what the mother wanted. At nine thirty the mother was finally persuaded to leave her child, the post-mortem was performed and the child was taken by the undertakers later that day.
The care given in the pre hospital setting It can be argued that the mother should not have been prevented from being with her child immediately after the time of trauma (Bluebond-Langer 1978). Whilst the intention may have been good, i.e., protection from the awful sight of traumatic injuries, Wilkinson (1991) highlights that parents have a right to be with their child however inconvenient or distressing it may be. This is supported by While (1989) who recognises that parents have their role to play, however passive. They may need the reassurance of seeing that everything possible is being done for the child (Murren 1995) or when looking back it can be crucially important for grieving parents to know that they did the last thing they could possibly do for their child, just be there (Hindmarch 1994). When considering the mechanism of injury the question may also be asked: should an attempt at resuscitation have been started? The child had suffered overwhelming damage to the head at the time of trauma, injuries that would be described by Mackway-Jones et al. (1998) as incompatible with life and resulting in death within minutes whatever was done. The decision taken to attempt resuscitation could be interpreted in a number of ways. After the inevitable death it may be of some comfort to family members to know that an attempt to save their child was made or this action may have been seen as a cruel deception giving a false hope in a desperate situation (Buckingham 1990). Considering the actions of paramedics: in accordance with the European Resuscitation Council Guidelines (Bossaert 1998) in the case of a child under sixteen, apart from major un-survivable disruption of the body’s integrity or decomposition, resuscitation should always be attempted.
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The management of the trauma in hospital A standby call given by ambulance control allowed necessary personnel to be informed and essential advanced planning to take place before the arrival of the patient (Ali et al. 1999). It can again be argued that resuscitation should have been stopped on arrival as the child had no signs of cardiac output or cerebral activity despite attempts at cardiopulmonary resuscitation (Mackway-Jones et al. 1998). A&E personnel should know that ‘It is important to commence resuscitation promptly and effectively, but also to know when such measures are contraindicated and when they should cease’ (UK Resuscitation Council 1998, p. 91). However, consideration must be given to the relatively inexperienced doctors who were dealing with the trauma and the anxiety they must have felt resulting from their responsibility for the child (Stewart 1997). Even with the support of experienced nurses this anxiety, in conjunction with the fear of making a wrong decision, may have led to the need to wait for confirmation by a more experienced doctor that they were doing the right thing (Cook 1999). The UK Resuscitation Council (1998, p. 90) states that ‘An inexperienced doctor would be wise to heed the advice of trained and experienced health care professionals but legal obligation rests with the most senior medically qualified practitioner present’, in this case a locum registrar. Points that should also be made are that no harm can be done to somebody who is already dead by attempting to resuscitate (Hinchliff & Montague 1992) and that the Advanced Life Support Group recommend that in the case of a child the decision to stop resuscitation should ideally be made by a consultant (MackwayJones et al. 1998). Now considering the mother during the inhospital resuscitation attempt. On arrival in the A&E department a nurse had been allocated to look after the child’s mother so as to keep her informed and explain her options in an attempt to prevent any further unnecessary anxieties (Riches & Dawson 2000). It is essential in situations where death occurs, particularly in the sudden and unexpected death of a child, to keep parents informed of what is happening, to
A nurse’s reflection on paediatric trauma
give them the opportunity to be with their child during resuscitation attempts, to contact other family members and most importantly just to be there for support and the security of knowing there is somebody to turn to for whatever reason (Hindmarch 1994). These needs were being met. Proceeding to look at the care given in the first hours after the decision to stop resuscitation had been made and death was pronounced. The most experienced member of the team, the consultant, gave the news to the mother that her child was dead so promoting a situation in which any questions she asked could be answered by the most knowledgeable person (Corr & Corr 1996). Doka (1989) suggests that any apprehension that may be displayed by a junior doctor could be picked up by a parent and lead to later feelings that more could have been done to save their child. The child’s mother, now in the state of disbelief that goes hand in hand with any sudden death (Gunzburg 1993), was encouraged to see her child. ‘Facing reality requires unambiguous explanation and evidence, and ultimately seeing is believing’ (Hindmarch 1994, p. 223). The consultant advised the mother that she could spend as much time as she wanted with her dead child, as recommended by Wilkinson (1991), Stedeford (1994) and Penson (1990). There was no time limit on how long the grieving family should spend with their dead child. The child was cleaned in an attempt to make the experience less traumatic for the family (Mead & Sibert 1991) and a relatives’ room away from the resuscitation area was arranged so as to provide a place of privacy in which the family could see and hold the child (Judd 1989). It may be suggested that the family should have been moved to a relatives’ room earlier as their presence in the resuscitation area could have compromised the team’s readiness to deal with the next crisis (Hindmarch 1994). Consideration was given to religious needs and the Roman Catholic priest was contacted to attend A&E to say some prayers with the family. It is a fact that people often find comfort in religion (Lifton 1997), however this action presented as something of an ethical dilemma. The mother, who had not yet had her
child christened, took great comfort in the prayers and believed a christening was taking place at this time. Staff looking after the family were aware that, according to the catholic religion, once dead a person cannot be christened (Jackson 1966) and a conscious decision was made not to tell her. It could be argued that this was not ethical as staff were not being honest with the family (Brykczynska 1992). As identified by Pennington et al. (1999) keepsakes can play an important part in the grieving process and after the death of a child the parents may want to keep clothes, a lock of hair, foot/hand prints or take photographs. The need for these items to be kept was identified by nursing staff and appropriate arrangements were made. However, the taking of photographs can also be criticised when a child has disfiguring injuries; it could be argued that they would serve as a reminder of how the child was damaged when family members may wish to remember the child as they were (Riches & Dawson 1998). Criticism can also be made of the nursing staff who told the child’s mother, on the day of the death, that the child would spend the night in the nursery. This act that was intended to comfort the mother may easily have resulted in a lack of trust in the nursing team had she realised the dishonesty (Winnicott 1986). Now reviewing the care given the day after the child’s death when the family returned to the A&E department. A nurse who had spent time with the family the day before was again allocated to look after them, providing continuity of care and the reassurance of knowing it was not a stranger looking after their dead child (Buckingham 1990). The child was again brought to a relatives’ room in the A&E department to provide familiarity of surroundings and prevent problems that may have arisen from seeing the child in the mortuary (Cleary 1992). The mother’s options were again explained to her and she was given the choice of dressing the child herself; when unable to do this necessary support was given and a nurse carried out the request of the mother (Wilkinson 1991). It is important at this time for parents to be encouraged to do whatever they feel is right and ‘The role of health professionals must be to support the family with whatever help is needed and to
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strengthen the family’s own way of coping with the situation’ (Pennington et al. 1999, p. 25). Attention was also given to social problems that may occur due to the loss of a child and the family was referred to outside agencies such as social services, health visitor and the police family liaison team, such agencies being in a position to provide essential after care (Penson 1990). Parkes and Parkes (1984) indicate that support to families after the death of a loved one is likely to have a beneficial effect on adjustment in the long term. Whilst outside professional agencies were contacted Schwab (1997) would argue that although professional intervention may be helpful, the bereaved gain best comfort, understanding and hope from others who have been through despair and the recovery that follows; it may have been beneficial to contact a family support group. Given that the mother would not leave her child and appeared not to comprehend the situation, a psychiatric evaluation was sort by staff who believed her to be showing signs of complicated grieving as described by Penson (1990). This action would be criticised by Pincus (1976) who suggests that the mother, so early into the bereavement process, was showing a normal reaction by wanting to cling to her child and McMahon (1993) who identifies denial as a normal grief reaction. From the coroner’s point of view it could be argued that over handling of the child could have led to a loss of important forensic evidence (Green & Green 1992). It can also be said that whilst the mother was supported in the decisions she made, vitally important at this time (Riches & Dawson 2000), other family members may have been given less consideration. Jennings (1992) concludes that all family members, not just mothers, need help to cope with many varied difficulties. More attention could have been paid to the needs of the grandparents who were not only grieving for their dead grandchild but had to witness their own child suffering (Stedeford 1994). Again little attention was given to the needs of the father who was seen more as a crutch for the mother than a grieving parent, a problem identified by Muller et al. (1986). Some may also make the point that keeping the child out of the mortuary to the point where decomposition was starting to become evident
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deprived the child of rights to dignity (Green & Green 1992). Finally considering the multidisciplinary team, criticism can be made that no debriefing of the team involved in the trauma took place and it can be argued that without an opportunity to reflect, as a team, professionals could suffer preventable feelings of guilt or failure (Doka & Morgan 1993). Debriefing allows for the expression and identification of problems that may be improved, for example with education or further training, i.e., Advanced Paediatric Life Support (1998). It also gives an opportunity to highlight things that went well (Butterworth & Faugier 1992). As identified by Lewis (1998), as individuals and professionals, it is important to recognise that in any situation personal feelings will be present. Staff in the A&E department are the families’ vital first contact and as identified by Wright (1996), although staff themselves may be horrified at the sight of a badly injured child they will feel the need to remain composed for the sake of the family. This can add to stress on staff and gives weight to the need for the organised debriefing sessions identified by Anderson (1985). Attention should also be drawn to staff not directly involved in the trauma who, with reduced manpower, had to deal with the normal workload of a busy A&E department and coped well without complaint, indirectly giving support to their colleagues (Kaplan 1995). Staff coming into work on their day off could be suggestive of over involvement (Gunzburg 1993), or as Wilkinson (1994) describes, the important process of returning to say goodbye to both the dead child and the family after a relationship has been formed can be beneficial to both nursing staff and families. In conclusion a number of issues have been discussed during the course of this reflection and both positive and negative actions of the multidisciplinary team have been highlighted. Arguments have been put forward both to defend and criticise the initial decision to attempt resuscitation and the apparent uncertainty of some medical staff. The mother’s care was found to be holistic but more consideration might have been shown to other family members and the dignity of the child. Care for all staff involved needs to be
A nurse’s reflection on paediatric trauma
addressed and improved, as debriefing was omitted apart from debriefing of a small number of staff involved which took place some weeks after the incident and, in the authors opinion, too late. However there is no doubt in the author’s mind that all concerned acted in the best interests of both the family and the child, and suggests that however good the outcome there is always room for constructive criticism and improvement.
References Advanced Life Support Course Sub-Committee of the Resuscitation Council (UK) (eds) 1998 Advanced Life Support Course Provider Manual, 3rd edn. United Kingdom, Resuscitation Council, UK. Ali J, The American College of Surgeons Committee on Trauma 1999 Advanced Trauma Life Support for Doctors: Student Manual, 6th edn. American College of Surgeons, USA. Anderson P 1985 Children’s Hospital. Bantam Press, New York Bluebond-Langer M 1978 The Private Worlds of Dying Children. Princeton University Press, Princeton. Bossaert L (ed) 1998 European Resuscitation Council Guidelines for Resuscitation.Elsevier, Amsterdam. Brykczynska GM (ed) 1992 Ethics in Paediatric Nursing. Chapman & Hall, London. Buckingham RW 1990 Care of the Dying Child: A Practical Guide for those who Help Others. Continuum, New York. Butterworth C, Faugier J 1992 Clinical Supervision and Mentorship in Nursing. Chapman & Hall, London. Cleary J 1992 Caring for Children in Hospital: Parents and Nurses in Partnership. Scutari Press, London. Cook P 1999 Supporting Sick Children and their Families. Bailliere Tindall, London. Corr C, Corr D 1996 Handbook of Childhood Death and Bereavement. Springer, New York. Doka KJ 1989 Disenfranchised Grief: Recognising Hidden Sorrow. Lexington Books, Lexington. Doka KJ, Morgan JD (eds) 1993 Death and Spirituality. Baywood Publishing Company, New York. Green J, Green M 1992 Dealing with Death: Practice and Procedures. Chapman & Hall, London. Gunzburg JC 1993 Unresolved Grief: A Practical, Multicultural Approach for Health Professionals. Chapman & Hall, London Hinchliff S, Montague S (eds) 1992 Physiology for Nursing Practice. Bailliere Tindall, London. Hindmarch C 1994 Caring for Dying Children and their Families: Sudden Death. Chapman & Hall, London. Jackson EN 1966 The Christian Funeral: Its Meaning, its Purpose and its Practice. Channel Press, New York. Jennings P 1992 Coping mechanisms. Paediatric Nursing 4(8): 13–15
Judd D 1989 Give Sorrow Words: Working with a Dying Child. Association Books, London. Kaplan LJ 1995 No Voice is Ever Wholly Lost. Simon & Shuster, New York. Lewis C 1998 Loss and change on the neonatal intensive care unit. Paediatric Nursing 10(3): 21–23. Lifton RJ 1997 The Broken Connection. Simon & Schuster, New York. Mackway-Jones K, Molyneux E, Phillips B, Wieteska S 1998 Advanced Paediatric Life Support: The Practical Approach, 2nd edn. BMJ Publishing Group, London. McMahon B 1993 Mental Health Nursing from First Principles to Professional Practice: Psychodynamic Approaches. Chapman & Hall, London. Mead D, Sibert J (eds) 1991 The Injured Child: An Action Plan for Nurses. Scutari Press, Middlesex. Muller DJ, Harris PJ, Wattley L 1986 Nursing Children: Psychology, Research and Practice. Harper & Row, London. Murren E (ed) 1995 Our Children: Coming to Terms with the Loss of a Child. Hodder & Stoughton, London. Parkes CM, Parkes J 1984 Hospital versus hospice: care re-evaluation after 10 years as seen by spouses. Postgraduate Medical Journal 60: 120–124 Pennington D, Gillen K, Hill P 1999 Social Psychology. Arnold, London. Penson J.1990. Bereavement: A Guide for Nurses. Harper & Row, London. Pincus L 1976 Death in the Family: The Importance of Mourning. Faber & Faber, London. Riches G, Dawson P 1998. Lost Children, Living Memories: The Role of Photographs in Processes of Grief and Adjustment among Bereaved Parents. Death Studies 22(2): 121–140. Riches G, Dawson P 2000 An Intimate Loneliness: Supporting Bereaved Parents and Siblings. Open University Press, Buckingham. Schwab R 1997 Parental mourning and children’s behaviour. Journal of Counselling and Development 75(4): 258–265 Stedeford A 1994 Facing Death: Patients, Families and Professionals, 2nd edn. Sobell Publications, Oxford. Stewart W 1997 An A–Z of Counselling Theory and Practice, 2nd edn. Stanley Thrones, Cheltenham. UK Resuscitation Council 1998 Advanced Life Support Course Provider Manual, 3rd edn. TT, London. While AE 1989 The needs of dying children and their families. Health Visitor 62: 176–178 Wilkinson T 1991 The Death of a Child: A Book for Families. Julia MacRae Books, London. Wilkinson T. 1994 Caring for Dying Children and their Families: The Extended Family and Other Carers. Chapman Hall, London. Winnicott DW 1986 Home is Where We Start From. Penguin, London Wright B 1996 Sudden Death: A Research Base for Practice. Churchill Livingstone, Edinburgh.
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Personal View
A nurse’s reflection on paediatric trauma Keywords: Sudden death; Paediatric trauma; Bereavement; Crisis intervention
This reflection focuses on an event that took place in the accident and emergency (A&E) setting and relates to the victims of a trauma. It will begin by out-lining the event that took place and go on to examine the incident, highlighting both the positive and negative actions of the multidisciplinary team. The trauma involves the death of a child and therefore relates predominantly to the reactions and treatment of the child’s family with an emphasis on the child’s mother. Medical management, mechanism of injury, ethical and legal issues as well as the psychosocial effects on all involved will be discussed and conclusions will be drawn. The casualty, a two year old child, had fallen behind the wheels of a reversing vehicle and sustained head injuries incompatible with life. The child was brought into A&E following a standby call by two paramedics who were attempting resuscitation. The team standing by consisted of three experienced nurses, a junior doctor and a locum registrar who had a little experience in paediatric care. The A&E consultant had been contacted and was on his way. The child’s mother who had witnessed the accident had been restrained at the scene and prevented from seeing her child. She was now unable to face being with the child during the resuscitation attempt and had attended the hospital alone. The resuscitation attempt lasted for approximately 10 minutes before the consultant arrived, at which point it was stopped immediately and the mother was informed of her child’s death. Other family members had by this time been contacted and were on their way to the hospital. The mother now wanted to see her child and was advised by the A&E consultant that she could spend as
long as she wanted with the child. After 2 hours holding her child the mother was persuaded to allow nurses to take the child from her and allow the child to be cleaned. A relatives’ room away from the resuscitation area was provided and the child was brought back to the mother. The Roman Catholic priest was contacted and came to pray with family members, comfort was gained from the thought that the child was being christened. The mother spent most of that night with her child, only leaving the hospital when she was assured by nursing staff that her child would spend the rest of the night in a nursery and that she could return the next day to see the child and dress it in favourite clothes. The mother returned early the next morning (a bank holiday) and the child was dressed by nursing staff in favourite clothes; photographs, foot prints and a lock of hair were taken from the child and were given to the maternal grandmother. The police family liaison officer was in attendance and the mother was interviewed by social workers. Again the mother would not leave her child and by late afternoon staff who were concerned for her state of mind sought a psychiatric evaluation. Knowing that there would be a post-mortem the next day the mother spent the entire night in the hospital, parting with the child for only a few hours in which it was returned to the mortuary and again was changed into pyjamas at the mother’s request. At seven the next morning the child, who was by now showing signs of decomposition, was taken from the mortuary so that the mother could spend some time with the child before
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the post-mortem at nine. A nurse, with whom the mother had formed a close bond, had come to work on her day off so as to be the one to take the child. This again was what the mother wanted. At nine thirty the mother was finally persuaded to leave her child, the post-mortem was performed and the child was taken by the undertakers later that day.
The care given in the pre hospital setting It can be argued that the mother should not have been prevented from being with her child immediately after the time of trauma (Bluebond-Langer 1978). Whilst the intention may have been good, i.e., protection from the awful sight of traumatic injuries, Wilkinson (1991) highlights that parents have a right to be with their child however inconvenient or distressing it may be. This is supported by While (1989) who recognises that parents have their role to play, however passive. They may need the reassurance of seeing that everything possible is being done for the child (Murren 1995) or when looking back it can be crucially important for grieving parents to know that they did the last thing they could possibly do for their child, just be there (Hindmarch 1994). When considering the mechanism of injury the question may also be asked: should an attempt at resuscitation have been started? The child had suffered overwhelming damage to the head at the time of trauma, injuries that would be described by Mackway-Jones et al. (1998) as incompatible with life and resulting in death within minutes whatever was done. The decision taken to attempt resuscitation could be interpreted in a number of ways. After the inevitable death it may be of some comfort to family members to know that an attempt to save their child was made or this action may have been seen as a cruel deception giving a false hope in a desperate situation (Buckingham 1990). Considering the actions of paramedics: in accordance with the European Resuscitation Council Guidelines (Bossaert 1998) in the case of a child under sixteen, apart from major un-survivable disruption of the body’s integrity or decomposition, resuscitation should always be attempted.
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The management of the trauma in hospital A standby call given by ambulance control allowed necessary personnel to be informed and essential advanced planning to take place before the arrival of the patient (Ali et al. 1999). It can again be argued that resuscitation should have been stopped on arrival as the child had no signs of cardiac output or cerebral activity despite attempts at cardiopulmonary resuscitation (Mackway-Jones et al. 1998). A&E personnel should know that ‘It is important to commence resuscitation promptly and effectively, but also to know when such measures are contraindicated and when they should cease’ (UK Resuscitation Council 1998, p. 91). However, consideration must be given to the relatively inexperienced doctors who were dealing with the trauma and the anxiety they must have felt resulting from their responsibility for the child (Stewart 1997). Even with the support of experienced nurses this anxiety, in conjunction with the fear of making a wrong decision, may have led to the need to wait for confirmation by a more experienced doctor that they were doing the right thing (Cook 1999). The UK Resuscitation Council (1998, p. 90) states that ‘An inexperienced doctor would be wise to heed the advice of trained and experienced health care professionals but legal obligation rests with the most senior medically qualified practitioner present’, in this case a locum registrar. Points that should also be made are that no harm can be done to somebody who is already dead by attempting to resuscitate (Hinchliff & Montague 1992) and that the Advanced Life Support Group recommend that in the case of a child the decision to stop resuscitation should ideally be made by a consultant (MackwayJones et al. 1998). Now considering the mother during the inhospital resuscitation attempt. On arrival in the A&E department a nurse had been allocated to look after the child’s mother so as to keep her informed and explain her options in an attempt to prevent any further unnecessary anxieties (Riches & Dawson 2000). It is essential in situations where death occurs, particularly in the sudden and unexpected death of a child, to keep parents informed of what is happening, to
A nurse’s reflection on paediatric trauma
give them the opportunity to be with their child during resuscitation attempts, to contact other family members and most importantly just to be there for support and the security of knowing there is somebody to turn to for whatever reason (Hindmarch 1994). These needs were being met. Proceeding to look at the care given in the first hours after the decision to stop resuscitation had been made and death was pronounced. The most experienced member of the team, the consultant, gave the news to the mother that her child was dead so promoting a situation in which any questions she asked could be answered by the most knowledgeable person (Corr & Corr 1996). Doka (1989) suggests that any apprehension that may be displayed by a junior doctor could be picked up by a parent and lead to later feelings that more could have been done to save their child. The child’s mother, now in the state of disbelief that goes hand in hand with any sudden death (Gunzburg 1993), was encouraged to see her child. ‘Facing reality requires unambiguous explanation and evidence, and ultimately seeing is believing’ (Hindmarch 1994, p. 223). The consultant advised the mother that she could spend as much time as she wanted with her dead child, as recommended by Wilkinson (1991), Stedeford (1994) and Penson (1990). There was no time limit on how long the grieving family should spend with their dead child. The child was cleaned in an attempt to make the experience less traumatic for the family (Mead & Sibert 1991) and a relatives’ room away from the resuscitation area was arranged so as to provide a place of privacy in which the family could see and hold the child (Judd 1989). It may be suggested that the family should have been moved to a relatives’ room earlier as their presence in the resuscitation area could have compromised the team’s readiness to deal with the next crisis (Hindmarch 1994). Consideration was given to religious needs and the Roman Catholic priest was contacted to attend A&E to say some prayers with the family. It is a fact that people often find comfort in religion (Lifton 1997), however this action presented as something of an ethical dilemma. The mother, who had not yet had her
child christened, took great comfort in the prayers and believed a christening was taking place at this time. Staff looking after the family were aware that, according to the catholic religion, once dead a person cannot be christened (Jackson 1966) and a conscious decision was made not to tell her. It could be argued that this was not ethical as staff were not being honest with the family (Brykczynska 1992). As identified by Pennington et al. (1999) keepsakes can play an important part in the grieving process and after the death of a child the parents may want to keep clothes, a lock of hair, foot/hand prints or take photographs. The need for these items to be kept was identified by nursing staff and appropriate arrangements were made. However, the taking of photographs can also be criticised when a child has disfiguring injuries; it could be argued that they would serve as a reminder of how the child was damaged when family members may wish to remember the child as they were (Riches & Dawson 1998). Criticism can also be made of the nursing staff who told the child’s mother, on the day of the death, that the child would spend the night in the nursery. This act that was intended to comfort the mother may easily have resulted in a lack of trust in the nursing team had she realised the dishonesty (Winnicott 1986). Now reviewing the care given the day after the child’s death when the family returned to the A&E department. A nurse who had spent time with the family the day before was again allocated to look after them, providing continuity of care and the reassurance of knowing it was not a stranger looking after their dead child (Buckingham 1990). The child was again brought to a relatives’ room in the A&E department to provide familiarity of surroundings and prevent problems that may have arisen from seeing the child in the mortuary (Cleary 1992). The mother’s options were again explained to her and she was given the choice of dressing the child herself; when unable to do this necessary support was given and a nurse carried out the request of the mother (Wilkinson 1991). It is important at this time for parents to be encouraged to do whatever they feel is right and ‘The role of health professionals must be to support the family with whatever help is needed and to
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strengthen the family’s own way of coping with the situation’ (Pennington et al. 1999, p. 25). Attention was also given to social problems that may occur due to the loss of a child and the family was referred to outside agencies such as social services, health visitor and the police family liaison team, such agencies being in a position to provide essential after care (Penson 1990). Parkes and Parkes (1984) indicate that support to families after the death of a loved one is likely to have a beneficial effect on adjustment in the long term. Whilst outside professional agencies were contacted Schwab (1997) would argue that although professional intervention may be helpful, the bereaved gain best comfort, understanding and hope from others who have been through despair and the recovery that follows; it may have been beneficial to contact a family support group. Given that the mother would not leave her child and appeared not to comprehend the situation, a psychiatric evaluation was sort by staff who believed her to be showing signs of complicated grieving as described by Penson (1990). This action would be criticised by Pincus (1976) who suggests that the mother, so early into the bereavement process, was showing a normal reaction by wanting to cling to her child and McMahon (1993) who identifies denial as a normal grief reaction. From the coroner’s point of view it could be argued that over handling of the child could have led to a loss of important forensic evidence (Green & Green 1992). It can also be said that whilst the mother was supported in the decisions she made, vitally important at this time (Riches & Dawson 2000), other family members may have been given less consideration. Jennings (1992) concludes that all family members, not just mothers, need help to cope with many varied difficulties. More attention could have been paid to the needs of the grandparents who were not only grieving for their dead grandchild but had to witness their own child suffering (Stedeford 1994). Again little attention was given to the needs of the father who was seen more as a crutch for the mother than a grieving parent, a problem identified by Muller et al. (1986). Some may also make the point that keeping the child out of the mortuary to the point where decomposition was starting to become evident
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deprived the child of rights to dignity (Green & Green 1992). Finally considering the multidisciplinary team, criticism can be made that no debriefing of the team involved in the trauma took place and it can be argued that without an opportunity to reflect, as a team, professionals could suffer preventable feelings of guilt or failure (Doka & Morgan 1993). Debriefing allows for the expression and identification of problems that may be improved, for example with education or further training, i.e., Advanced Paediatric Life Support (1998). It also gives an opportunity to highlight things that went well (Butterworth & Faugier 1992). As identified by Lewis (1998), as individuals and professionals, it is important to recognise that in any situation personal feelings will be present. Staff in the A&E department are the families’ vital first contact and as identified by Wright (1996), although staff themselves may be horrified at the sight of a badly injured child they will feel the need to remain composed for the sake of the family. This can add to stress on staff and gives weight to the need for the organised debriefing sessions identified by Anderson (1985). Attention should also be drawn to staff not directly involved in the trauma who, with reduced manpower, had to deal with the normal workload of a busy A&E department and coped well without complaint, indirectly giving support to their colleagues (Kaplan 1995). Staff coming into work on their day off could be suggestive of over involvement (Gunzburg 1993), or as Wilkinson (1994) describes, the important process of returning to say goodbye to both the dead child and the family after a relationship has been formed can be beneficial to both nursing staff and families. In conclusion a number of issues have been discussed during the course of this reflection and both positive and negative actions of the multidisciplinary team have been highlighted. Arguments have been put forward both to defend and criticise the initial decision to attempt resuscitation and the apparent uncertainty of some medical staff. The mother’s care was found to be holistic but more consideration might have been shown to other family members and the dignity of the child. Care for all staff involved needs to be
A nurse’s reflection on paediatric trauma
addressed and improved, as debriefing was omitted apart from debriefing of a small number of staff involved which took place some weeks after the incident and, in the authors opinion, too late. However there is no doubt in the author’s mind that all concerned acted in the best interests of both the family and the child, and suggests that however good the outcome there is always room for constructive criticism and improvement.
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