Heart of EM: Coping with the Loss of a Pediatric Patient in the ED

I will never forget my first pediatric death as a resident.

It was around 5:45 am, and our shift was beginning to wrap up. I had a disposition plan for most of my patients and could almost taste the fresh air when we got the call: “10-day-old, CPR in progress, 4 minutes out.” We quickly prepped the Panda warmer, the pediatric code cart, and the team. Then we waited.

As emergency physicians, we are trained to carry out complex tasks. We mentally rehearse, read, practice, and teach so that when difficult cases arise, we think clearly and concisely. We thrive in hectic environments. We feed off of medical crises and interesting cases. We bury emotions in order to offer the best care possible. However, often we forget we are human too.

Our team coded the patient just long enough for the infant’s parents to see our efforts. Just long enough for them to be part of the decision to stop. Their wails echoed in the halls of the 70-bed ED and resonated in our hearts. I still hear their cries to this day.

I went home that morning and broke down. I had never felt so alone. I did not want to share this story with anyone because I did not want to make my loved ones sad. I felt guilty for crying, because they were not my tears to shed. They were the family’s tears, and the baby’s tears; that beautiful baby. I felt weak. I felt like it was not very “EM” of me to cry. I should be stronger.

This case was a reminder that I am human and that it is OK to feel emotions. My attending, during our debrief a few days later, told me something that has resonated ever since: “The moment you stop feeling like this, it is time to pick another career.”

Although rare, the specialty of EM is peppered with heartbreaking pediatric cases. Coping with death in the ED is challenging – and pediatric losses are more powerful. It helps to know what to do when a child dies, as well as what resources are available to you.

Incidence and Management
Of the thousands of pediatric deaths that occur each year, approximately 20% happen in the ED.¹ These events are tragic, and an appropriately trained medical provider can make a significant difference to parents and staff.

The American Academy of Pediatrics (AAP) recommends that parents and guardians be offered the option to be present with their child during medical procedures.² Although they do not make recommendations on their presence during resuscitation efforts, the Emergency Nurses Association (ENA) and American Heart Association (AHA) both recommend that family members be offered the opportunity to be present during cardiopulmonary resuscitation.^3,4 Families tend to feel that being present is helpful in their grieving process.⁵

It is also essential to use a team-based approach. Examples of team members include social workers, child-life workers, chaplains, spiritual leaders, mental health professionals, emergency medical technicians, paramedics, nurses, and physicians. The team must have open communication, know their roles, and be sensitive to the desires of the family.

Effective counseling has a positive impact on the family’s ability to cope.⁶ One member of the team should be assigned to be with the family continuously during the resuscitation to answer questions, explains procedures, and if possible, let the family know the child did not suffer.⁷

The emergency physician ultimately has the responsibility of notifying the family of the child’s death and the circumstances around it. When this falls to you, take these steps:

• Ensure the appropriate family members are gathered in a safe, quiet area with enough space.
• Sit at eye level with the family and introduce yourself as the physician who cared for their loved one.
• Determine what the family members know before explaining what happened.
• Inform the family of the child’s death in a direct statement, such as “we did everything but [child’s name] died.” It is important to know and use the child’s name in the conversation.
• Answer any questions, and (when possible) reassure the family that their child did not suffer. If possible, they may reassure the family that they did nothing that contributed to the event.⁸

It is important to offer family members time to be with their child after death, as this is a critical part of the bereavement process.⁹ Care should be taken to clean the resuscitation area and make the child presentable. Cover any disfiguring wounds as much as possible with clean towels or sheets. Parents also find that collecting small mementos from their child helps with bereavement. Kits can be kept in the ED to make imprints of the child’s hands or feet, and bags can be stored for taking their belongings.

The ED team must also notify the patient’s pediatrician, as they will be a vital source of support for the bereaved family. Offer support and know what resources your ED has for bereaving families. Most important, the emergency physician and every other member of the care team must remember that compassion in communicating bad news is a crucial therapeutic tool. Surveys show that parents value health care providers who are honest, caring, and approachable and who speak in lay terms that match the pace of the parents’ processing and understanding.⁸

Finally, it is important to provide emotional support to the health care team involved in the event. This is often done via a debriefing; however, mental health services should be available for staff members as well. A debriefing is any meeting held following a critical event in order to review and discuss event outcomes, team performance, medical management, errors, and emotional response. The attending physician often initiates it, but any member of the team should feel comfortable doing so. Although it may seem difficult to carve out time during a busy shift, it is crucial to the healing process.¹⁰ Staff should be encouraged to share their worries, feelings, and successes. Just as the family needs a safe space to mourn the loss of their child, the health care team needs space to grieve.

As difficult as it may be to cope with death, research shows that providers who care for dying patients find more satisfaction in their work. When given the opportunity to incorporate their experiences caring for the dying into their personal and professional lives, emergency doctors find their work more meaningful.¹¹ As such, it is important to share your stories with colleagues, family, and friends. Higher levels of grief are associated with coping strategies that involve emotional distancing as opposed to actively dealing with stressors.¹² Take the time to share. Our EM community is vast in size and in support. Remember you are never alone and it is OK to feel emotions.

Lastly, be mindful in practicing self-care. Often in medicine we focus so much on our patients that we forget to care for ourselves. Make sure to get adequate sleep. Exercise and eat a well-balanced diet. Take time to do the things you love, and remember it is important to experience joy again. Finally, remember you are your own person, and there is no one-size-fits all for coping strategies.

Take-Home Points
Although the first pediatric death I experienced was heartbreaking, it was essential to shaping my practice today.

• It reminded me to learn and remember the steps to take both inside and outside the ED when dealing with a pediatric death.
• It inspired me to practice and perfect my communication with family members and the entire care team, and to create mental and physical space for the family and health care team to grieve.
• It reminded me that we as physicians are allowed to feel emotion and practice self-care.

That death will stay with me forever. The child’s memory encourages me to learn, grow, and succeed as an emergency physician, and I hope that it will do the same for you.

References

1. Institute of Medicine, Committee on Palliative and End-of-Life Care for Children and Their Families. In: Field MJ, Behrman RE, eds. When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families. Washington, DC: National Academy Press; 2003:41–71. Available at: www.chcr.brown.edu.dying.htm.
2. American Academy of Pediatrics, Committee on Hospital Care. Family-centered care and the pediatrician’s role. 2003;112:691–694. 

3. Emergency Nurses Association, Department of Nursing Resources. Presenting the Option for Family Presence. Dallas, TX: Emergency Nurses 
Association; 1995.

4. American Heart Association. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 2: ethical aspects of 
CPR and ECC. 2000;102(8 suppl):i1–i21. 

5. Clark AP, Calvin AO, Meyers TA, Eichhorn DJ, Guzzetta CE. Family 
presence during cardiopulmonary resuscitation and invasive procedures. A research-based intervention. Crit Care Nurs Clin North Am. 2001;13:569 –575.

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