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Coping with pediatric death in the ED by learning from parental experience
Clinical Notes
Coping With Pediatric Death in the ED by Learning From Parental Experience RAYMOND G. HART, MD, MPH, WILLIAM R. AHRENS, MD The death of a pediatric patient in the emergency department generates an intense emotional response in the physician and staff. A majority of emergency physicians describe this as the most stressful event in emergency medicine, Few emergency physicians are instructed in the complexities of dealing with the death of a child. The authors have developed a teaching module that introduces aspects of pediatric deathtelling through the eyes of parents who have personally experienced the death of a child, (Am J Emerg Med 1998;16:67-68, Copyright © 1998 by W.B. Saunders Company} The death of a pediatric patient in the emergency department (ED) is an intensely emotional experience for the physician and staff. When done poorly, pediatric deathtelling can have profoundly negative consequences for the dead child's family} In a recent survey, a majority of emergency physicians reported feelings of guilt and inadequacy after a failed pediatric resuscitation, and described informing parents that their child died as the most stressful experience they confront in emergency medicine. The vast majority of physicians surveyed had no training in informing parents of their child's death, and thought that such a course would be useful} The Emergency Medicine Residency Program at the University of Illinois, Chicago, devised an interactive teaching module for instructing emergency residents in how to better manage a pediatric death. The panel focuses on practical aspects of managing pediatric deaths. The discussion includes the need for communication with the parents during the resuscitation, the need for a quiet environment during the death-telling interview, the importance of allowing the parents to hold the dead child, and, perhaps most importantly, the language the physician should use during the interview. The panel stresses that the physician should be direct and nonjudgmental, and should emphasize and re-emphasize that the parents are not at fault. They relate to physicians that it is important to parents that the child be referred to by name, rather than as "the baby." They stress that it is appropriate and desirable From the Departments of Emergency Medicine and Pediatrics, University of Illinois at Chicago, Chicago, IL. Received October 25, 1996, returned November 11,1996; revision received December 2, 1996, accepted December 2, 1996. Address reprint requests to Dr Hart, Department of Emergency Medicine, University of Illinois Hospital, 1740 West Taylor St, Suite 1600 (m/c 722), Chicago, IL 60612-7354. Key Words:Teachingmodule, pediatric, deaths, emergency department. Copyright © 1998 by W.B. Saunders Company 0735-6757/98/1601-001558.00/0
for the physician to express sympathy and sorrow for the parents, but should avoid statements such as "I know how you feel." The panel then describes details of management that are extremely important to parents in the days after their child's death. These include making sure that any clothes or personal belongings are returned, the importance of explaining the process of the autopsy, if one is being performed, and potentially asking parents about organ donation. Physicians are also encouraged to offer the parents a physical memento of the child, such as a lock of hair, or a hand or foot print.
METHODS The module is taught by a senior emergency medicine attending physician and a pediatrician. Four case studies of simulated pediatric emergency department deaths are presented and discussed, with resident participation. Particular focus is placed on the emotional response of the physician toward the parents and dealing with the patient's family in the context of a busy ED. Issues discussed include determination of when to terminate the resuscitation, the presence of parents in the resuscitation room, and dealing with the emotional reaction of the ED staff. The discussion is allotted 1 hour. The following hour consists of a panel discussion with senior members of the Illinois chapter of the Sudden Infant Death Alliance. The members of the panel have extensive experience in counseling parents whose children have died in EDs. Allowing emergency medicine residents to interact with parents who have lost children will give them an objective framework that will allow them to better cope with the emotions they will encounter when they must tell parents that their child is dead. The panel participants describe their own ED experiences, emphasizing both what was done well and what was done poorly. They focus on the typical emotions parents feel during the time of the resuscitation, during the death-telling interview, and the immediate period after their child's death. The panel further describes their experience with the effect the child's death has on the family. This includes a discussion of the reaction of surviving siblings. A question-and-answer session follows, during which audience participants are encouraged to interact with the panel. The session is concluded with a brief lecture by the senior attending physician. This includes a summary of the major issues and audience comments or questions.
DISCUSSION The death of a child in the ED is an extremely difficult experience for physicians and staff that, when poorly managed, can have profoundly negative consequences for 67
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 1 • January 1998
the patient's family. 3,4 However, education in pediatric death-telling is not part of the recommended emergency medicine residency curriculum. It is difficult to imagine that such a stressful situation can be well handled without prior training. 5 Simply lecturing residents on the literature on death management or describing anecdotal experience in managing pediatric deaths may not allow participants to confront the true emotional intensity of the experience. Even role-playing with professional actors potentially has this limitation. The inclusion of a panel of parents who have lost children in an ED is a means of introducing an emotional component to the discussion that can never be conveyed in a lecture format. The Sudden Infant Death Alliance is a well-organized institution that has an in-depth understanding of the grieving process and extensive experience in counseling both bereaved parents and health care professionals. There may be other support groups in other states that could conceivably fulfill the same role. This course has been accepted and effective in our residency setting. Participant evaluations have noted that they are better prepared to deal with a pediatric patient's
death both in terms of practical management and in confronting their own emotions and those of the patient's families. A prospective study comparing this format with other teaching methods would be useful to determine the optimal way to increase physician comfort with pediatric death-telling and to ascertain the best way to ensure that the El) becomes a place where the process of bereavement can begin in the best manner.
REFERENCES 1. Davis WK: A program to teach residents humanistic skills for notifying survivors of a patient's death. Acad Meal 1989;4:505-506 2. Ahrens WR, Hart RG: Emergency physicians' experience with pediatric death. Am J Emerg Med 1997; 15:642-643 3. Edlich FR, Kubler-Ross E: On death and dying in the emergency department. J Emerg Meal 192;10:225-229 4. Swisher LA, Nieman LZ_,Nilsen GJ, et al: Death notification in the emergency department: A survey of residents and attending physicians. Ann Emerg Med 1993;22:1319-1323 5. Dubin WR, Sarnoff JR: Sudden unexpected death: Intervention with survivors. Ann Emerg Med 1986;15:54-57
Coping With Pediatric Death in the ED by Learning From Parental Experience RAYMOND G. HART, MD, MPH, WILLIAM R. AHRENS, MD The death of a pediatric patient in the emergency department generates an intense emotional response in the physician and staff. A majority of emergency physicians describe this as the most stressful event in emergency medicine, Few emergency physicians are instructed in the complexities of dealing with the death of a child. The authors have developed a teaching module that introduces aspects of pediatric deathtelling through the eyes of parents who have personally experienced the death of a child, (Am J Emerg Med 1998;16:67-68, Copyright © 1998 by W.B. Saunders Company} The death of a pediatric patient in the emergency department (ED) is an intensely emotional experience for the physician and staff. When done poorly, pediatric deathtelling can have profoundly negative consequences for the dead child's family} In a recent survey, a majority of emergency physicians reported feelings of guilt and inadequacy after a failed pediatric resuscitation, and described informing parents that their child died as the most stressful experience they confront in emergency medicine. The vast majority of physicians surveyed had no training in informing parents of their child's death, and thought that such a course would be useful} The Emergency Medicine Residency Program at the University of Illinois, Chicago, devised an interactive teaching module for instructing emergency residents in how to better manage a pediatric death. The panel focuses on practical aspects of managing pediatric deaths. The discussion includes the need for communication with the parents during the resuscitation, the need for a quiet environment during the death-telling interview, the importance of allowing the parents to hold the dead child, and, perhaps most importantly, the language the physician should use during the interview. The panel stresses that the physician should be direct and nonjudgmental, and should emphasize and re-emphasize that the parents are not at fault. They relate to physicians that it is important to parents that the child be referred to by name, rather than as "the baby." They stress that it is appropriate and desirable From the Departments of Emergency Medicine and Pediatrics, University of Illinois at Chicago, Chicago, IL. Received October 25, 1996, returned November 11,1996; revision received December 2, 1996, accepted December 2, 1996. Address reprint requests to Dr Hart, Department of Emergency Medicine, University of Illinois Hospital, 1740 West Taylor St, Suite 1600 (m/c 722), Chicago, IL 60612-7354. Key Words:Teachingmodule, pediatric, deaths, emergency department. Copyright © 1998 by W.B. Saunders Company 0735-6757/98/1601-001558.00/0
for the physician to express sympathy and sorrow for the parents, but should avoid statements such as "I know how you feel." The panel then describes details of management that are extremely important to parents in the days after their child's death. These include making sure that any clothes or personal belongings are returned, the importance of explaining the process of the autopsy, if one is being performed, and potentially asking parents about organ donation. Physicians are also encouraged to offer the parents a physical memento of the child, such as a lock of hair, or a hand or foot print.
METHODS The module is taught by a senior emergency medicine attending physician and a pediatrician. Four case studies of simulated pediatric emergency department deaths are presented and discussed, with resident participation. Particular focus is placed on the emotional response of the physician toward the parents and dealing with the patient's family in the context of a busy ED. Issues discussed include determination of when to terminate the resuscitation, the presence of parents in the resuscitation room, and dealing with the emotional reaction of the ED staff. The discussion is allotted 1 hour. The following hour consists of a panel discussion with senior members of the Illinois chapter of the Sudden Infant Death Alliance. The members of the panel have extensive experience in counseling parents whose children have died in EDs. Allowing emergency medicine residents to interact with parents who have lost children will give them an objective framework that will allow them to better cope with the emotions they will encounter when they must tell parents that their child is dead. The panel participants describe their own ED experiences, emphasizing both what was done well and what was done poorly. They focus on the typical emotions parents feel during the time of the resuscitation, during the death-telling interview, and the immediate period after their child's death. The panel further describes their experience with the effect the child's death has on the family. This includes a discussion of the reaction of surviving siblings. A question-and-answer session follows, during which audience participants are encouraged to interact with the panel. The session is concluded with a brief lecture by the senior attending physician. This includes a summary of the major issues and audience comments or questions.
DISCUSSION The death of a child in the ED is an extremely difficult experience for physicians and staff that, when poorly managed, can have profoundly negative consequences for 67
68
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 1 • January 1998
the patient's family. 3,4 However, education in pediatric death-telling is not part of the recommended emergency medicine residency curriculum. It is difficult to imagine that such a stressful situation can be well handled without prior training. 5 Simply lecturing residents on the literature on death management or describing anecdotal experience in managing pediatric deaths may not allow participants to confront the true emotional intensity of the experience. Even role-playing with professional actors potentially has this limitation. The inclusion of a panel of parents who have lost children in an ED is a means of introducing an emotional component to the discussion that can never be conveyed in a lecture format. The Sudden Infant Death Alliance is a well-organized institution that has an in-depth understanding of the grieving process and extensive experience in counseling both bereaved parents and health care professionals. There may be other support groups in other states that could conceivably fulfill the same role. This course has been accepted and effective in our residency setting. Participant evaluations have noted that they are better prepared to deal with a pediatric patient's
death both in terms of practical management and in confronting their own emotions and those of the patient's families. A prospective study comparing this format with other teaching methods would be useful to determine the optimal way to increase physician comfort with pediatric death-telling and to ascertain the best way to ensure that the El) becomes a place where the process of bereavement can begin in the best manner.
REFERENCES 1. Davis WK: A program to teach residents humanistic skills for notifying survivors of a patient's death. Acad Meal 1989;4:505-506 2. Ahrens WR, Hart RG: Emergency physicians' experience with pediatric death. Am J Emerg Med 1997; 15:642-643 3. Edlich FR, Kubler-Ross E: On death and dying in the emergency department. J Emerg Meal 192;10:225-229 4. Swisher LA, Nieman LZ_,Nilsen GJ, et al: Death notification in the emergency department: A survey of residents and attending physicians. Ann Emerg Med 1993;22:1319-1323 5. Dubin WR, Sarnoff JR: Sudden unexpected death: Intervention with survivors. Ann Emerg Med 1986;15:54-57