Friday, September 29, 2017

Coping With the Death of a Child in the ED


Health professionals often do not receive formal training in coping with pediatric deaths likely to be encountered in practice. Being unprepared for these intense experiences can negatively affect the health professional and the quality of care provided to survivors. 

After a young patient is pronounced dead in the emergency department (ED), surviving family members are in crisis. [5] Survivors can benefit from the engagement of the emergency physician who treated the family member. In addition to making medical decisions during resuscitation, the role of the emergency physician is seen as one of assisting in alleviation of suffering.

A patient's death in the ED, especially the death of a child, is often unexpected. The nature of ED practice is such that the emergency physician often does not have an ongoing professional relationship with the patient's family. Indeed, a patient's death often finds the emergency physician and the patient's family meeting each other for the very first time. This can be a difficult and emotional situation for both physician and family.

In an effort to assist certain care aspects of the child who is pronounced dead in the ED, this article's suggestions are meant only as guidelines to minimize errors. Each patient death is arguably unique. A standard "cookbook" approach by the physician is arguably inappropriate.
Information contained in this article is intended to provide general advice on the subject. As with other aspects of clinical medicine, general advice must be modified according to the individual patient and clinical circumstances. Nothing herein should be applied uncritically to the care of any individual patient or family.

This article is not intended to be encyclopedic. Healthcare professionals can anticipate being students of this topic for their entire professional lives. The author feels this strongly. Accordingly, readers are encouraged to share thoughts and experiences on this subject with the author via email. The opportunity for feedback from readers was a motivation for writing this article. A subject as emotional and potentially controversial as patient death in the ED has many facets. Like pieces of a jigsaw puzzle, each facet contributes to produce a complete clinical picture. Sharing thoughts and experiences is essential to the process of solving the puzzle.

Because a child's death may be viewed as especially tragic, ED personnel may have strong feelings of nonspecific sadness and loss. In the aftermath of a pediatric death, the emergency physician may have feelings that make it difficult to maintain composure. Natural psychological defenses are unconsciously summoned to assist the physician in maintaining composure. A problem may develop if the physician's defenses produce actions that are harmful to survivors of the dead child.

Survivors of a child who has recently died are likely to require emotional support. Every physician cannot be completely supportive of every family member at all times. However, it is reasonable to ask physicians to be aware of their defenses and to avoid actions that interfere with survivors' grief.

"First, do no harm" is a widely known and generally accepted clinical precept. In the care of a patient, the physician should avoid actions that cause harm or produce more harm than good.

Physicians with children may be especially vulnerable to an emotional response to a child's death. If physicians' children are nearly the same age as the deceased patient, physicians may realize suddenly, perhaps for the very first time, the possibility of losing their own children. Physicians with children may also identify with the parents' loss.

Because a child's death may be viewed as especially tragic, ED personnel may have strong feelings of nonspecific sadness and loss. In the aftermath of a pediatric death, the emergency physician may have feelings that make it difficult to maintain composure. Natural psychological defenses are unconsciously summoned to assist the physician in maintaining composure. A problem may develop if the physician's defenses produce actions that are harmful to survivors of the dead child.


Survivors of a child who has recently died are likely to require emotional support. Every physician cannot be completely supportive of every family member at all times. However, it is reasonable to ask physicians to be aware of their defenses and to avoid actions that interfere with survivors' grief.

"First, do no harm" is a widely known and generally accepted clinical precept. In the care of a patient, the physician should avoid actions that cause harm or produce more harm than good.

Physicians with children may be especially vulnerable to an emotional response to a child's death. If physicians' children are nearly the same age as the deceased patient, physicians may realize suddenly, perhaps for the very first time, the possibility of losing their own children. Physicians with children may also identify with the parents' loss.especially tragic.

Crisis

Crisis involves powerful and often uncontrollable emotions. Individuals in crisis may need assistance in moderating their emotions. Recruiting other family members, clergy, friends, and others to support an individual in crisis is often helpful. The physician should repeatedly recommend specific actions for the safety of the person in crisis (eg, "don't drive home, call a friend or cab").

Because individuals in crisis often behave illogically or have impaired decision-making abilities, responsibilities to dependents may be forgotten. Therefore, it is wise to inquire about other children or elderly family members who may require assistance. These individuals may forget about potentially unsafe conditions at home; inquire about safety items (eg, whether electricity to a stove or water to a bath was been left on). The physician should also ask whether the home was locked prior to coming to the hospital.

Grief

Grief is a natural reaction to the death of a child. The grief process begins with understanding that the child's death is real.

The physician should allow (not force) family members to see or hold their dead child. However, the family should be prepared for what will be seen and possibly misunderstood without prior explanation (eg, endotracheal tubes, chest tubes, other resuscitation equipment) when they enter the resuscitation area. Occasionally, offering the family the opportunity to take with them a memento (eg, a lock of hair) helps.

Suffering is a natural part of grief. The physician should accept a wide range of emotions of families suffering from the loss.

Families often feel guilty. If possible, reassure families that they did not contribute (either by acts of commission or omission) to the child's death. Reassuring families that every care procedure that could have been implemented in the ED was implemented is also important.

What are Advance Directives?

Advance directives center around the principles of your right to die and death with dignity. With an advance directive, you can express how much or how little you want done for you when you are no longer able to make these decisions.

  • Advance directives are a way of making your voice heard when you can no longer communicate. They allow you to appoint someone to make your health care decisions for you when you no longer can and to administer or withhold treatment and procedures based on your previously stated wishes. Advance directives are not just for the elderly. All people who desire to direct their medical care in the future should complete an advance directive.
  • All 50 states and the District of Columbia have laws regarding advance directives. Authorities also agree that no difference exists between withholding lifesaving treatment and withdrawing life-support treatment. This is especially important in a situation where someone is resuscitated despite his or her wishes because the advance directive could not be found and the person is put on life support. Once the advance directive is shown to health care professionals, life-support measures can be withdrawn according to the advance medical directive.
  • An advance directive does not mean "do not treat." This is a common misperception and not correct. Of course, if you want it to mean do not treat, then that is something that your surrogate needs to know.
  • Proper execution of an advance directive is a delicate task. A person should discuss this with loved ones and consider personal values and beliefs.
  • It is also impossible to think about all the possible medical and social scenarios that may happen in the future during the course of a disease and person's lifetime. Thus, people often change their minds contrary to their living wills while still capable of making their own decisions. Living wills can be modified to reflect any such changes.

Definitions Involved in Advance Directives


Advance directives: An advance directive is a written document or series of forms that must be signed to be binding. The documents indicate an individual's choices about medical treatment.
Two types of advance directives are generally completed: a living will and a medical power of attorney (also referred to as designation of a health care surrogate or health care proxy).
  • Living will: This written statement tells health care professionals what type of life-prolonging treatments or procedures to perform if someone has a terminal condition or is in a persistent vegetative state. Living wills should not be confused with a regular will. A living will addresses issues regarding your medical care while you are still living.
  • Medical power of attorney (or designation of a health care surrogate): This legal document allows you to select any person to make medical decisions for you if you should become temporarily or even permanently unable to make those decisions for yourself. This person is also referred to as your attorney-in-fact or durable power of attorney for health care. Most people choose a family member, a relative, or a close friend as their surrogate decision maker. It is important that the designated person knows and understands your wishes and preferences and has a written copy of either your living will or medical power of attorney.
Life-prolonging treatments: These are procedures that are not expected to cure your terminal condition. They generally are used to sustain life. Examples of life prolonging treatments include mechanical ventilator (breathing machine), kidney dialysis, and cardiopulmonary resuscitation (CPR).
Terminal condition: A terminal condition is an incurable (without cure) condition that is in its terminal stages.
Persistent vegetative state: This permanent coma or state of being unconscious is caused by injury, disease, or illness. No reasonable expectation of recovery exists.
Do not resuscitate (DNR): This document tells health care professionals and emergency personnel that if your heart stops beating (cardiac arrest) or if you stop breathing (respiratory arrest) that they are not to attempt to revive you by utilizing CPR, chest compressions, intubation, or shocking the heart.
Artificial nutrition and hydration: This procedure is the administration of nutrition and fluids through IV lines and feeding tubes. IV (intravenous) hydration is a common proactice in the hospital by which fluids are delivered into veins. Tube feeding introduces liquid food through a nasal or oral tube into the stomach. Sometimes intravenous (IV) antibiotics are also included in this category. The POLST form (Physician Orders for Life-Sustaining Treatment) addresses the patient's preferences regarding artificial hydration and nutrition. This form can be signed by the patient or their decision maker and the treating physician.

Thursday, September 28, 2017

Anticipatory Grief

What is Anticipatory Grief?

Patients and families facing terminal illness usually begin the grieving process prior to the actual loss. This is called “anticipatory grief.” Although it may be uncomfortable, anticipatory grief is sometimes helpful and may result in fewer grief complications later. Each person will experience grief in his or her own unique way. The same is true with anticipatory grief. It is a natural process that helps individuals prepare for emotional and physical closure. It is also a time when both patient and family prepare for change.

Things to Consider

Emotional and physical symptoms associated with grief may also be associated with anticipatory grieving. You may experience some of the following:
  • Loss of appetite
  • Tension and irritability
  • Fatigue and insomnia
  • Tearfulness
  • Restlessness
  • Indecision about what to do
  • Guilt or anger
  • Mood changes over small things, crying unexpectedly
Frequently, there may be a desire on the part of the patient to put his or her “affairs in order,” so that their wishes will be honored. This is sometimes referred to as completing “unfinished business.”
Often, there is a concern on the part of the patient about how loved ones will cope after the loss. The patient may wish to ensure that loved ones obtain practical life skills during this time, such as learning to balance the checkbook or learning how to cook.
The patient may also express the need to emotionally withdraw from others. Caregivers may observe “distancing” behavior, such as the patient becoming less conversational, losing interest in activities that once held meaning, and refusing to allow close friends and family to visit.

What to Do

  • Reach out to persons and groups that can offer you support and help.
  • Seek help through counseling with a therapist, minister, priest or rabbi.
  • Remind yourself that everyone needs adequate time to grieve.
  • Utilize any spiritual beliefs that bring you comfort or relief.
  • Express yourself through art, poetry, music, journaling, or gardening.
  • Engage in life review through photographs, music, conversation and writing.
  • Identify issues and concerns, which are important to address prior to the loss.
  • Talk about your feelings.
  • Address legal/financial/funeral issues as appropriate.
  • Discuss future plans as appropriate.
  • Identify whether or not your expectations are realistic.