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.

Childhood Emotional Neglect

In my experience, having helped many clients through many losses, one of the greatest prolongers of each of the 5 Stages is having grown up without enough emotional attention, validation and response from one’s parents: Childhood Emotional Neglect, or CEN.When your parents do not respond enough to your emotions as a child, you learn very early and well that your emotions and emotional needs are irrelevant (or even bad) and should be avoided. To adapt, you wall off your feelings and needs so that they will not burden your parents. Not surprisingly, when you are living with your feelings blocked off, it throws major obstacles into your path through the 5 Stages.How Childhood Emotional Neglect Blocks the 5 Stages of Grief
Makes it Hard to Move Past Denial: It’s only a short jump from denying one’s feelings to using denial as a general coping mechanism. It’s easy for a CEN person who has lost a loved one to end up prolonging his grief by refusing to feel the painful feelings that need to be accepted and processed. Alex, who stays busy to avoid his sadness and loss is a perfect example of that. Over time, avoiding your feelings of loss does nothing to process them. The result: you are stuck.
You Can’t Accept or Work With Your Anger: In phase 2, your anger is there to protect you. But if anger wasn’t allowed from you in your childhood home, you may have great difficulty allowing yourself to be angry as a grieving adult. You may be at risk of instead turn your anger inward at yourself, compounding your feeling of loss with even more pain.
Difficulty Accepting Help and Support: CEN makes you feel guilty or weak for having normal emotional needs. It’s hard for you to ask for help or accept comfort from others even in the best of times. When you’re grieving, there are few things that can help more than the love and support of someone who cares about you.
Depression Phase is Prolonged: With your emotions walled off, your anger directed at yourself, and the people most able to support you kept at bay, you are at great risk for getting stuck in a depression that won’t let go. How can Joanne move forward to the next phase, accept the painful reality of her loss and heal from it when her brain chemicals are thrown out of balance by depression?
Open up and talk to someone who can give you comfort. Ask for support and accept it. It will help.
Make a point to feel your feelings of grief, even if only for a brief period every day. Think about the one you’ve lost, and cry if you need to.
Pay attention to whether you are stuck in anger or depression. Might an anti-depressant give you a kick-start to deal with the genuine sad feelings that are waiting to be processed? Consult a professional, if needed.
Start addressing your Childhood Emotional Neglect. It’s important to begin to feel all of your feelings, not just your grief. Just as your grief is blocked in some way, so also is your joy. You need to feel all of your emotions in order to heal and move forward.

The whole point of the 5 Stages is to move through them. Experiencing one phase, allowing yourself to be in it and face it prepares you to move to the next phase. Moving through the phases allows your brain to process the reality, preparing you for acceptance. Acceptance must happen before you can turn your attention forward to rebuilding yourself and your life.If this is you, it’s important to re-direct and focus yourself.4 Ways to Manage Your CEN Through GriefWhen you are grieving something, it’s crucial to acknowledge that you only feel grief when you had something great to begin with. So a part of your grief must be appreciation and gratefulness for what you had.

Seek the Bereavement Counselor

How does a young child recover from the loss of a Father or Mother. In most case a young child does not and then goes into an adult full of abandonment, lack of parenting, Drug and Alcohol uses, and most case become homeless in the end. 

Dr. Nicholas Losito, Ph.D,CTS is there to provide Pre-Anticipatory losses and Prepare the young child from ever becoming lost, forgotten, and prepare them for Success.  

Grief Among Children

At one time, children were considered miniature adults, and their behaviors were expected to be modeled as such. Today there is a greater awareness of developmental differences between childhood and other developmental stages in the human life cycle. Differences between the grieving process for children and the grieving process for adults are recognized. It is now believed that the real issue for grieving children is not whether they grieve, but how they exhibit their grief and mourning.

The primary difference between bereaved adults and bereaved children is that intense emotional and behavioral expressions are not continuous in children. A child's grief may appear more intermittent and briefer than that of an adult, but in fact a child's grief usually lasts longer.

The work of mourning in childhood needs to be addressed repeatedly at different developmental and chronological milestones. Because bereavement is a process that continues over time, children will revisit the loss repeatedly, especially during significant life events (e.g., going to camp, graduating from school, marrying, and experiencing the births of their own children). Children must complete the grieving process, eventually achieving resolution of grief.

Although the experience of loss is unique and highly individualized, several factors can influence a child's grief:

·         Age.

·         Personality.

·         Stage of development.

·         Previous experiences with death.

·         Previous relationship with the deceased.

·         Environment.

·         Cause of death.

·         Patterns of interaction and communication within the family.

·         Stability of family life after the loss.

·         How the child's needs for sustained care are met.

·         Availability of opportunities to share and express feelings and memories.

·         Parental styles of coping with stress.

·         Availability of consistent relationships  with other adults.

Children do not react to loss in the same ways as adults and may not display their feelings as openly as adults do. In addition to verbal communication, grieving children may employ play, drama, art, school work, and stories. Bereaved children may not withdraw into preoccupation with thoughts of the deceased person; they often immerse themselves in activities (e.g., they may be sad one minute and then playing outside with friends the next). Families often incorrectly interpret this behavior to mean the child does not really understand or has already gotten over the death. Neither assumption may be true; children's minds protect them from thoughts and feelings that are too powerful for them to handle.

Grief and Grieving - Symptoms

Your experience of Grief is likely to be different from another person's. Similarly, you will probably grieve somewhat differently each time you experience a significant loss. Your reaction to loss is influenced by the relationship you had with the lost person and by your general coping style, personality, and life experiences. How you express grief is influenced in part by the cultural, religious, and social rules of your community.

Grief is expressed physically, emotionally, socially, and spiritually.

• Physical expressions of grief often include crying and sighing, headaches, loss of appetite, difficulty sleeping, weakness,fatigue, feelings of heaviness, aches, pains, and other stress-related ailments.
• Emotional expressions of grief include feelings of sadness and yearning. But feelings of worry,anxiety, frustration, anger, or guilt are also normal.
• Social expressions of grief may include feeling detached from others, isolating yourself from social contact, and behaving in ways that are not normal for you.
• Spiritual expressions of grief may include questioning the reason for your loss, the purpose of pain and suffering, the purpose of life, and the meaning of death. After a death, your greving process is influenced by how you view death..

Grief can cause prolonged and serious symptoms:

 including depression , anxiety, suicidal  thoughts and actions, physical illness, and PTSD.

Intense grief can bring on unusual experiences. After a death, you may have vivid dreams about your loved one, develop his or her behaviors or mannerisms, or see or hear your loved one. If you feel fearful or stressed by any of these experiences, talk to your doctor and a  mental health (Dr. Losito) professional or clergy person experienced in grief counseling

Age and emotional development influence the way a person grieves a death.

• Children younger than age 7 usually perceive death as separation. They may feel abandoned and scared. And they may fear being alone or leaving people they love. Grieving young children may not want to sleep alone at night, or they may refuse to go to day care or school. Children under age 7 usually are not able to verbally express their feelings. Instead, they tend to act out their feelings through behaviors, such as refusing to obey adults, having temper tantrums, or role-playing their lives in pretend play. Children younger than age 2 may refuse to talk. And they may be generally irritable. Children between the ages of 2 and 5 may develop eating, sleeping, or toileting and bed-wetting problems.
• Children between the ages of 7 and 12 often perceive death as a threat to their personal safety. They tend to fear that they will die also and may try to protect themselves from death. While some grieving children want to stay close to someone they think can protect them, others withdraw. Some children try to be very brave or behave extremely well. Others behave terribly. A grieving child may have problems concentrating on schoolwork, following directions, and doing daily tasks. Children in this age group need to be reassured that they are not responsible for the death they are grieving.
• TEENS perceive death much like adults do. But they may express their feelings in dramatic or unexpected ways. For example, they may join a religious group that defines death in a way that calms their feelings. They may try to defy death by participating in dangerous activities, such as reckless driving, Smoking cigarettes, drinking alcohol, taking illegal DRUGS, or having unprotected SEX. Like adults, preteens and teens can have suicidal thoughts when grieving. Warning signs of suicide in children and teens may include preoccupation with death or suicide or giving away belongings.

How can I help a child deal with the death of a loved one?

How can I help a child deal with the death of a loved one?

Children grieve just as adults do. Any child old enough to form a relationship will experience some form of grief when a relationship is severed. Adults may not view a child behavior as grief as it is often demonstrated in behavioral patterns which we misunderstand and do not appear to us to be grief such as "moody," "cranky," or "withdrawn." When a death occurs children need to be surrounded by feelings of warmth, acceptance and understanding. This may be a tall order to expect of the adults who are experiencing their own grief and upset. Caring adults can guide children through this time when the child is experiencing feelings for which they have no words and thus can not identify. In a very real way, this time can be a growth experience for the child, teaching about love and relationships. The first task is to create an atmosphere in which the child's thoughts, fears and wishes are recognized. This means that they should be allowed to participate in any of the arrangements, ceremonies and gatherings which are comfortable for them. First, explain what will be happening and why it is happening at a level the child can understand. A child may not be able to speak at a grandparent's funeral but would benefit greatly from the opportunity to draw a picture to be placed in the casket or displayed at the service. Be aware that children will probably have short attention spans and may need to leave a service or gathering before the adults are ready. Many families provide a non-family attendant to care for the children in this event. The key is to allow the participation, not to force it. Forced participation can be harmful. Children instinctively have a good sense of how involved they wish to be. They should be listened to carefully.

How can I help an adult friend or family member deal with the death of a loved one?

Someone you know may be experiencing grief - perhaps the loss of a loved one, perhaps another type of loss - and you want to help. The fear of making things worse may encourage you to do nothing. Yet you do not wish to appear to be uncaring. Remember that it is better to try to do something, inadequate as you may feel, than to do nothing at all. Don't attempt to sooth or stifle the emotions of the griever. Tears and anger are an important part of the healing process. Grief is not a sign of weakness. It is the result of a strong relationship and deserves the honor of strong emotion. When supporting someone in their grief the most important thing is to simply listen. Grief is a very confusing process, expressions of logic are lost on the griever. The question "tell me how you are feeling" followed by a patient and attentive ear will seem like a major blessing to the grief stricken. Be present, reveal your caring, listen. Your desire is to assist your friend down the path of healing. They will find their own way down that path, but they need a helping hand, an assurance that they are not entirely alone on their journey. It does not matter that you do not understand the details, your presence is enough. Risk a visit, it need not be long. The mourner may need time to be alone but will surely appreciate the effort you made to visit. Do some act of kindness. There are always ways to help. Run errands, answer the phone, prepare meals, mow the lawn, care for the children, shop for groceries, meet incoming planes or provide lodging for out of town relatives. The smallest good deed is better than the grandest good intention.

How can I deal with the death of a loved one?

Bereavement is a powerful, life-changing experience that most people find overwhelming the first time. Although grief is a natural process of human life, most of us are not inherently able to manage it alone. At the same time, others are often unable to provide aid or insight because of discomfort with the situation and the desire to avoid making things worse. The following passage explains how some of our "normal" assumptions about grief may make it more difficult to deal with.

Five Assumptions That May Complicate

1. Life prepares us for loss. More is learned about loss through experience than through preparation. Living may not provide preparation for survival. Handling grief resulting from the death of a loved one is a process that takes hard work. The fortunate experience of a happy life may not have built a complete foundation for handling loss. Healing is built through perseverance, support and understanding. The bereaved need others: Find others who are empathetic.
2. Family and friends will understand. If a spouse dies children lose a parent, a sibling loses a sibling, a parent loses a child and a friend loses a friend. Only one loses a spouse. Each response is different according to the relationship. Family and friends may not be capable of understanding each other thoroughly. Consider the story of Job's grief in the Bible. Job's wife did not understand his grief. His friends did their best work the first week when they just sat and did not speak. It was when they began to share their judgements of Job and his life that they complicated Job's grief. Allowance must be made so that grief may be experienced and processed over time. The bereaved need others: Find others who are accepting.
3. The bereaved should be finished with their grief within one year or something is wrong. During the first year the bereaved will experience one of everything for the first time alone: anniversaries, birthdays, occasions, etc. Therefore grief will last for at least one year. The cliche, "the healing hands of time," does not go far enough to explain what must take place. The key to handling grief is in what work is done over time. It takes time and work to decide what to do and where to go with the new and changed life that is left behind. The bereaved need others: Find others who are patient.
4. Along with the end of grief's pain comes the end of the memories. At times, the bereaved may embrace the pain of grief believing it is all they have left. The lingering close bond to the deceased is sometimes thought to maintain the memories while, in fact, just the opposite is true. In learning to let go and live a new and changed life memories tend to come back more clearly. Growth and healing comes in learning to enjoy memories. The bereaved need others: Find new friends and interests.
5. The bereaved should grieve alone. After the funeral service is over the bereaved may find themselves alone. They may feel as though they are going crazy, painfully uncertain in their world of thoughts and emotions. The bereaved begin to feel normal again when the experience is shared with others who have lost a loved one. Then, in reaching out, the focus of life becomes forward. The bereaved need others: Find others who are experienced.

How Children are Involved in Grief and Loss

Children often are disenfranchised in their grief. Well-meaning adults try to protect them from the enormousness of loss by distracting them, telling them half-truths, even lying to them about the death of someone they loved. Some adults, perhaps to protect themselves from having to manage the full impact of a child’s grief, fool themselves into believing that children are “too young” to know what is going on. As noted children’s psychologist, Alan Wolfelt (1991), has said, “Anyone old enough to love is old enough to grieve.”

Children need avenues for safe expression of feelings that may include fear, sadness, guilt, and anger. Children’s play is their “work.” Provide a child-friendly environment where a child may choose the avenue best suited to his or her self-expression. For some children, it may be drawing or writing, for others, it may be puppetry, music, or physical activity. Keep in mind that a child’s reactions to grief will not appear the same as those seen in adults; as a result, children often are misunderstood. They may appear disinterested or respond as if they don’t understand the significance of what has happened.

For example, upon being told that her mother might soon die from metastatic cancer, a 10-year-old responded by asking, “When we go to dinner tonight, can I order extra pickles?” She was letting the adults know that she had heard enough for the moment. A four-year-old was told that his father died. He continued to ask, “When will he be back?” At this age, children don’t understand that death is permanent, final, and irreversible. Adults need to understand what is appropriate and expectable with children at different ages and stages of development and to recognize that children grieve in their own way and in their own time. Adults who tend to these children must focus on the children’s individual needs as well as their own.

When a child is denied the opportunity for grieving, there may be adverse consequences. At the D’Esopo Resource Center for Loss and Transition, located in Wethersfield, Conn., we regularly receive calls from parents who are worried about their children’s response to loss.

Recently, a mother called to say that she was very concerned about her three-year-old daughter. The child’s grandmother had died the previous month. The mother explained that she had consulted with the child’s pediatrician who told her that three-year-olds are too young to go to a funeral service because they do not understand death. The parents had therefore not included the child in any of the family’s commemorative rituals. Ever since, the little girl had been afraid to go to sleep and, when she did go to sleep, she experiencednightmares. During the day she was uncharacteristically anxious and clingy.

Fortunately this child, like most young children, is remarkably resilient. The problem was corrected by giving her a simple, direct, child-centered, age-appropriate explanation. She was told what happens to the body upon death (“It stops working”). And she was also given an explanation of the type of ritual that the family chose based on their religion and culture. She responded by sleeping well, having no more nightmares, and returning to her usual outgoing behavior.

While it is true that three-year-olds don’t understand that death is permanent, final, and irreversible, they do understand that something terribly sad has happened. They will miss the presence of people who have died, and they will worry about the sadness they feel around them. Lying to children or hiding the truth increases their anxiety. They are better observers of adults than most people recognize. You can’t fool them. They are remarkably perceptive.

When children of any age are not given proper explanations, their powerful imaginations will fill in the blanks in the information they have picked up from those around them. Unfortunately, their imaginations often come up with things that are far worse than the simple truth would have been. If, for example, they don’t understand the concept of “burial,” they may create images of dead loved ones being buried alive, gasping for air and trying to claw out of the ground. In the case of cremation, they may imagine their loved one being burned alive and suffering horribly.

It is far better to give them a clear idea about what is going on than to leave them to the mercy of their own imaginations. Children need to know not only what happens to the body upon death, they also need an explanation of what happens to the spirit or the soul, based on the family’s religious, spiritual, and cultural beliefs. It is essential to offer a detailed description of everything they likely will see and experience. At least one responsible adult should be present to support the child during the funeral and any other rituals.

One of the first workshops I attended regarding children and death began with the statement, “Anyone old enough to die is old enough to go to a funeral.” Participants gasped until the presenter went on to say, “as long as they are properly prepared and given the option — never forced — to attend.”

Children thrive when they are told what to expect and are allowed to participate in the commemoration of loved ones. When children and adults are encouraged to develop creative, personalized rituals, it helps everyone find comfort during the sad times. At the Resource Center, we ask children to draw or write a description of their favorite memory of the person who died. They love to share their memories and place the pictures, stories, and other items they have made into the casket to be buried or cremated along with their loved one. These kinds of activities can help the rituals around death become a meaningful family bonding experience rather than a continuing source of fear and pain.

Shakespeare said it best: “Give sorrow words. The grief that does not speak whispers the o’er fraught heart and bids it . . . break.” (Macbeth, Act IV, Scene 1)

Holy Innocents -

A Prayer To The Holy Innocents

Holy Innocents, you died before you were old enough to know what life means, pray for all children who die young that God may gather them into His loving arms.

Holy Innocents, you were killed because one man was filled with hatred, pray for those who hate that God may touch their hearts and fill them with love.

Holy Innocents, you experienced a violent death, pray for all who are affected by violence that they may find peace and love.

Holy Innocents, your parents grieved for you with deep and lasting sorrow, pray for all parents who have lost young children that God may wrap a warm blanket of comfort around them.

Holy Innocents, those around you certainly felt helpless to prevent your deaths, pray for all who feel helpless in their circumstances that they may cling to God for courage and hope.

Holy Innocents, you who are now in Heaven, pray for all of us that one day we may join you there to bask in God's love forever.

Amen.