The Doctor is in—

Questions and answers about behavioral and
emotional problems in children

DR. RICHARD MARTINI, MD

aFall 2000

What to do if a child dies suddenly?

I recently experienced the sudden death of a nine-year-old patient. She was playing with friends in front of her house when she ran into the street and was struck by a car. She and her family were transported to our local hospital for care. I arrived after being paged by the emergency room physician. Although the ER staff was heroic in its attempts to save the child’s life, she succumbed to her injuries. The experience was traumatic for everyone involved. The family was terrified and later overwhelmed with grief. Nurses and physicians were heartbroken that their best efforts could not save this child’s life. In the days that followed, I thought about the tragedy and wondered whether there are recommendations for the care and support to families of dying children in the emergency room. I also wondered whether health care professionals can anticipate these events and be prepared practically and emotionally.

Dr. D. Richard Martini responds:

Unfortunately, thousands of children die suddenly in emergency rooms each year. The problem of how to deal effectively with families and hospital staff in these situations recently led to a multidisciplinary conference sponsored by the National Association of Social Workers and the Health Resources and Services Administration. The resulting manuscript was published in the International Journal of Emergency Health. Recommendations for emergency room personnel are as follows:

Prepare the emergency room staff for the care of a critically ill child

A statement is written by the hospital outlining the family-centered priorities of the emergency room when faced with a dying child. Timely communication and collaboration with family including consideration of cultural, religious, and practical needs are emphasized. Emergency room personnel follow protocols when contacting private physicians, medical examiners, child protection authorities, organ and tissue teams, media, outside consultants, and police.

Emergency room personnel, including nurses, physicians, students, security, social workers, and clerical staff, are trained on the needs of family members during a life-threatening crisis. This includes information on typical emotional responses of parents, cultural factors that affect family functioning, and reactions of siblings at various stages of emotional development. Staff members are also given practical recommendations on providing information on the child’s medical condition, answering questions from loved ones, responding to emotional outbursts, and telling the family about the death of a child. The nature and extent of the training depends upon the needs and resources of the hospital.

Family members are escorted to a room designated for this purpose. The room should be close to the resuscitation rooms and easily accessible for ER staff members. The environment is not only comfortable but practical with available local and long distance phone lines. A single family care provider is designated to guide the family through the entire process and serve as a liaison to the medical team. This individual is typically trained in crisis and grief counseling.

The presence of family members in the trauma room during the resuscitation is controversial and not universally supported by caregivers. Some argue that the parents feel more involved in the care of the child by their presence and better appreciate the efforts made to save their child’s life. Opponents are concerned that family members may witness interventions that are painfully dramatic and leave them with intrusive thoughts and memories. Loved ones may also be overcome by the circumstances and take staff time and effort away from the child’s care.

Family interventions begin as soon as the patient arrives in the ER

Staff response should be immediate but organized, giving the family a sense of security and trust. The family care provider learns the principal concerns of the family and notes any recurrent themes in their questions and conversation. It is important to be sensitive to these issues throughout their stay in the ER. The family care provider also serves as a resource for the treatment team. She provides important medical and psychosocial information about the patient and family.

When the child dies

The emergency room physician informs the family of the child’s death as quickly and compassionately as possible, with guidance from the family care provider. The meeting is never rushed, giving the family enough time with the physician to ask questions, review the medical interventions performed on their child, and seek emotional support. Staff members expect a variety of grief reactions including anger, sadness, extreme agitation, and loss of consciousness. This is also an opportunity for staff members to reinforce the family’s efforts to save the child. They emphasize their prompt response to the crisis, sensitivity to the child’s symptoms, and obvious strong emotional bond. Family members may ask for privacy to sort out their reactions and ask questions among themselves about the death and the steps that should follow. Some, but not all, may ask for a religious or spiritual leader to be present, including the hospital chaplain. The family care specialist makes herself available to the family after the hospital stay and provides information on follow-up services when necessary.

Autopsies are required in certain situations. Families are informed about the process and simple explanations are provided to dispel any misconceptions about the procedure. Organ and tissue donation is discussed when appropriate and in accordance with state law. Funeral arrangements may be a source of anxiety, not only in the choice of practitioner but also in the anticipated cost. Staff members can provide information about private and public resources available in the community.

Families occasionally wish to spend time with the deceased child before leaving the hospital. In such cases, medical staff clean and prepare the resuscitation room, removing medical equipment and materials used to treat the child. Signs of medical intervention are also removed from the patient.

Follow-up after the child’s death

A staff member, preferably the family care specialist, contacts the family and offers assistance in the areas of funeral planning, approach to sibling reactions, need for mental health services, autopsy decisions, and the availability of support groups such as “Compassionate Friends,” which offer group meetings. Support is offered to the family for one year, along with regular contact from the family care specialist and at least one contact from the emergency room physician. The results of the autopsy are discussed with the family at a scheduled meeting. The primary care physician assists with this meeting and becomes an available source of information for the family. Hospitals routinely schedule memorial services for children who die. These are frequently held on the anniversary of the death and are arranged by the chaplain.

Helping the staff cope with childhood death

Emergency room staff members are easily worn down when regularly facing the sudden death of children. Turnover is high, and personnel experience emotional responses typical of post-traumatic stress disorder. Preparation, education, and proper supervision are available so that staff may anticipate the needs of the patient and family and create a sense of confidence and purpose in the treatment team. Despite the best efforts of hospital administration, ER staff members may be traumatized by the crises surrounding a child’s death. In such cases, debriefing sessions by a crisis intervention specialist not affiliated with the hospital are recommended. Every child cannot be saved and medical professionals, particularly those in the intensive care services, must not associate their sense of accomplishment and self-worth simply with the results of treatment. It is important for ER staff members to be rewarded for their outstanding work and dedication regardless of the outcome.

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