Emergency physicians' experience with pediatric death

doi:10.1016/S0735-6757(97)90177-7

The American Journal of Emergency Medicine

Volume 15, Issue 7, November 1997, Pages 642-643

https://doi.org/10.1016/S0735-6757(97)90177-7 Get rights and content

Abstract

Based on the hypothesis that managing pediatric death—particularly, communicating with survivors—is extremely difficult for most emergency physicians, 122 general emergency physicians at a written board review course were surveyed to assess their attitudes toward pediatric death. Sixty-six percent reported that communicating with the family of a child who had died was the most difficult experience in emergency medicine. Sixty-six percent considered communication with the family of a child who had died to be much more difficult than communication with the family of an adult who had died. Sixty-four percent reported feelings of guilt or inadequacy after unsuccessful pediatric resuscitation, and 47% reported feeling impaired for the remainder of their shift. Only 8% of physicians were aware of published guidelines regarding managing pediatric emergency department (ED) deaths, and only 14% of physicians had ever had any training in death notification. Ninety-two percent of physicians responded that a course directed toward managing the family of a child who had died in the ED would be helpful in dealing with this difficult situation.

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Inter-specialty differences were common across several survey items, which highlights the diversity of experiences and perspectives across specialties with respect to caring for patients with BD/DNC. Pediatric residents were significantly less likely to feel that it has become emotionally easier to deal with the death of patients, which is not surprising as pediatric deaths are often viewed as out of the ordinary or avoidable;19 studies have reported that physicians generally find it more difficult to cope with the death of pediatric vs. adult patients, and more difficult to communicate with families of children who have died than with families of adults who have died.20 Comfort in having discussions with family members of dying pediatric patients may not as readily improve with training and experience.21
Residents often are involved in discussions with families regarding brain death/death by neurologic criteria (BD/DNC); however, they receive no standardized training on this topic. We hypothesized that residents are uncomfortable with explaining BD/DNC and that formal didactic and simulated training will improve residents’ comfort and skill in discussions surrounding BD/DNC.
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Prior to the training, only 56% of residents correctly identified BD/DNC as synonymous with death. Additionally, 40% of residents had explained BD/DNC to families at least once, but 41% of residents reported never having been taught how to do so. The biggest fear reported in discussing BD/DNC with families was being uncomfortable in explaining BD/DNC (48%). After participating in the training, 99% of residents understood the definition of BD/DNC and 92% of residents felt comfortable discussing BD/DNC with families.
Participation in a standardized curriculum improves residents’ understanding of BD/DNC and their comfort in discussing BD/DNC with families.
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In 2013, 55,000 infants and children, aged 0 to 14, died in the United States. Nearly 7,000 of those deaths were attributed to traumatic causes. A child’s death significantly affects emergency service personnel (ESP) caring for children and families. This study explores the lived experience of ESP involved in unsuccessful pediatric resuscitation efforts and how this experience affects them professionally and personally.
A phenomenologic approach guided this study. Using an open-ended format, an interview was conducted with a purposive sample of ESP who experienced unexpected pediatric death. Eight ESP participated in semistructured, face-to-face interviews, ranging in length from 35 to 75 minutes. The research question asked: “What is it like for you when a child dies after an unsuccessful resuscitation attempt?” Data were analyzed using thematic analysis.
Van Manen’s 4 existentials guided this study, and 10 subthemes emerged that included: “what if,” “dying before my eyes,” “team,” “what if it was were my child?/being a parent,” “the environment,” “being trapped,” “wounded healer,” “education,” “anger,” and “coping.”
This study explores the experience of ESP involved in unsuccessful pediatric resuscitation that resulted in unexpected pediatric death and ESP’s perceptions of this experience: thoughts of loss, a sense of anger, and a lack of preparation to cope with unexpected pediatric death and the unknowns of life.
Neonatal Death in the Emergency Department: When End-of-Life Care Is Needed at the Beginning of Life
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The death of a neonate is devastating for all involved. Each year, critically ill neonates present to emergency departments across the United States. These infants require acute medical interventions with a goal of stabilization. Despite these efforts, hundreds of infants die every year in emergency departments across the United States. Emergency care providers, unaccustomed to providing neonatal end-of-life care, may feel unsure about how to best care for families during resuscitative measures and after neonates die. There is literature to suggest that increased knowledge and advance preparation can calm fears of providers caring for patients in such tragic situations. We aim to provide in this article a broad overview of a variety of topics related to neonatal death and bereavement care.
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There is also evidence that other types of patient death can have an adverse effect on HCPs professional and personal lives. Studies have included hospital deaths [19], still births and neonatal deaths [20], cancer deaths [21,22], pediatric deaths [23], primary care [24] and emergency ward deaths [23,25]. The pattern of effects is similar to those described for patient suicide and range from doubts over professional competency to a sense of loss, grief and personal mortality [25].
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Two hundred eleven HCPs were interviewed following suicide; 92 after sudden death. Suicide deaths were significantly more likely to impact upon the HCP's professional practice [suicide n= 79 (37.4%); sudden death n= 9 (9.9%); χ²= 22.06, P< .001] and personal life [suicide deaths n= 55 (26.1%); sudden death n= 12 (13.0%); χ²= 5.58, P= .018] than sudden deaths. Using multinomial logistic regression, being female and suicide within a week of the consultation predicted professional and personal impacts; having less than 5 years experience predicted professional impact and receipt of support/counseling predicted personal impact.
Suicide deaths have a greater impact than sudden deaths upon the life of HCPs. Clinical inexperience influences impacts on professional practice and availability of support impacts on personal life.
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Citation Excerpt :
Thus, it is important that providers whenever possible permit the expression of a variety of experiences rather than focusing only narrowly on medical issues.84-87 Pediatric palliative care and death in the ED are particularly challenging for families and health care providers.88 A multidisciplinary approach should include effective communication, empathy, allowing family presence, allowing a physical memento (such as a lock of hair or handprint), and follow-up communications.89-98
Palliative care is the physical, psychological, social, and spiritual care provided to patients from diagnosis to death or resolution of a life-threatening illness. Hospice care is a comprehensive program of care that is appropriate when patients with chronic, progressive, and eventually fatal illness are determined to have a prognosis of 6 months or fewer. Hospice and palliative medicine has now been recognized by the American Board of Medical Subspecialties as a field with a unique body of knowledge and practice. With 9 other specialty boards, the American Board of Emergency Medicine has cosponsored hospice and palliative medicine as an official subspecialty. As a result, board-certified emergency physicians may now pursue certification in hospice and palliative medicine through either fellowship training or, for a limited time, completing practice track requirements, followed by a written examination in the subspecialty.
As the practice of palliative medicine grows in hospitals, emergency physicians can develop a core of generalist palliative medicine skills for use with adults and children. These would include assessing and communicating prognoses, managing the relief of pain and other distressing symptoms, helping articulate goals of patient care, understanding ethical and legal requirements; and ensuring the provision of culturally appropriate spiritual care in the last hours of living. Front-line emergency physicians possessing these basic palliative medicine skills will be able to work collaboratively with subspecialty physicians who are dually certified in emergency medicine and hospice and palliative medicine. Together, generalist and specialist emergency physicians can advance research, education, and policy in this new field to reach the common goals of high-quality, efficient, evidence-based palliative care in the emergency department.

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Brief reportEmergency physicians' experience with pediatric death

Abstract

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Physicians attitudes and practice at the time of patient death

Arch Intern Med

Your child is dead

BMJ

Brief report
Emergency physicians' experience with pediatric death