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Care of the child with a fatal illness
814
May, 1970 The Journal of P E D I A T R I C S
Care of the clAM with a fatal illness C A R ~ OF T H E patient with a fatal illness is a difficuit task for every physician; for the pediatrician it can be an overwhelming one because in the specialty of pediatrics the greatest empathy is often found between physician and patient. Whereas death is accepted as inevitable for the adult, children are meant to live, not die. In addition, the pediatrician must be concerned, not only with the child, but with his parents. To these factors, peculiar to pediatrics, are added the many considerations common to all physicians regarding death and the pat i e n t - t h e senses of guilt, anger, frustration, and denial. One wonders if the problems relative to the dying child are the same for the pediatrician of today as for his predecessor of yesteryear. Both undoubtedly shared the same deep-seated emotional reactions to the dying child; they were probably very x~mch the same type of human being. Yet there were real differences in their circumstances. Lacking the therapeutic armamentarium capable of prolonging life, the pediatrician of yesterday had little to offer but comfort and support. To the parents of that day, death was probably more readily accepted as inevitable, even in childhood, and there would have been less questioning of the physician's inability to prevent it. Parents were appreciative of his efforts and their distress was assuaged by his presence. Furthermore, death came quickly, sparing the child, his parents, and the physician the weeks and months of agonized waiting. The pediatrician of today faces a set of circumstances unknown to his predecessor. Death for childre~ no longer comes quickly and mercifully. The pediatrician has in his Vol. 76, No. 5, p. 814
power the means to prolong life, even the potential for averting death. No longer does he lay on hands only. He has been schooled to employ all the means of modern medicine to extend life; to avoid using them creates dilemmas as serious as does their use. Having made the decision to prolong life, he must be prepared to share with the parents and child the agonizing time ahead, often the living death. Here another problem confronts the peJiatrician: While giving support to the parents, he, in turn, needs their trust in him. Modern parents are obviously better informed of medical affairs than those of earlier generations, and still while the elements of faith and confidence in the physician remain, there is an increasing tendency to question, to request consultation, or even referral to others. Even while admitting the justification of these requests, the pediatrician may sense the implication of a lack of confidence which the parents may have in him. Thus, we find the pediatrician today faced with an agonizing and difficult problem which is taking on new shades of complexity. The papers in this issue by Showalter and by Weiner document the gravity of the problem. Furthermore, they indicate potential approaches to it through the development of a better understanding of physicians' reactions and also through training in the ways of approaching the child with a fatal illness and his bereaved parents. Richard W. Olmsted, M.D. Department o[ Pediatrics University o[ Oregon Medical School Portland, Ore.
May, 1970 The Journal of P E D I A T R I C S
Care of the clAM with a fatal illness C A R ~ OF T H E patient with a fatal illness is a difficuit task for every physician; for the pediatrician it can be an overwhelming one because in the specialty of pediatrics the greatest empathy is often found between physician and patient. Whereas death is accepted as inevitable for the adult, children are meant to live, not die. In addition, the pediatrician must be concerned, not only with the child, but with his parents. To these factors, peculiar to pediatrics, are added the many considerations common to all physicians regarding death and the pat i e n t - t h e senses of guilt, anger, frustration, and denial. One wonders if the problems relative to the dying child are the same for the pediatrician of today as for his predecessor of yesteryear. Both undoubtedly shared the same deep-seated emotional reactions to the dying child; they were probably very x~mch the same type of human being. Yet there were real differences in their circumstances. Lacking the therapeutic armamentarium capable of prolonging life, the pediatrician of yesterday had little to offer but comfort and support. To the parents of that day, death was probably more readily accepted as inevitable, even in childhood, and there would have been less questioning of the physician's inability to prevent it. Parents were appreciative of his efforts and their distress was assuaged by his presence. Furthermore, death came quickly, sparing the child, his parents, and the physician the weeks and months of agonized waiting. The pediatrician of today faces a set of circumstances unknown to his predecessor. Death for childre~ no longer comes quickly and mercifully. The pediatrician has in his Vol. 76, No. 5, p. 814
power the means to prolong life, even the potential for averting death. No longer does he lay on hands only. He has been schooled to employ all the means of modern medicine to extend life; to avoid using them creates dilemmas as serious as does their use. Having made the decision to prolong life, he must be prepared to share with the parents and child the agonizing time ahead, often the living death. Here another problem confronts the peJiatrician: While giving support to the parents, he, in turn, needs their trust in him. Modern parents are obviously better informed of medical affairs than those of earlier generations, and still while the elements of faith and confidence in the physician remain, there is an increasing tendency to question, to request consultation, or even referral to others. Even while admitting the justification of these requests, the pediatrician may sense the implication of a lack of confidence which the parents may have in him. Thus, we find the pediatrician today faced with an agonizing and difficult problem which is taking on new shades of complexity. The papers in this issue by Showalter and by Weiner document the gravity of the problem. Furthermore, they indicate potential approaches to it through the development of a better understanding of physicians' reactions and also through training in the ways of approaching the child with a fatal illness and his bereaved parents. Richard W. Olmsted, M.D. Department o[ Pediatrics University o[ Oregon Medical School Portland, Ore.