Managing paediatric death in the emergency department Matthew O’Meara1,2 and Susan Trethewie1 1

Pain and Palliative Care and 2Paediatric Emergency Department, Sydney Children’s Hospital, Sydney, New South Wales, Australia

Abstract: Death of a child in an emergency department is a rare occurrence, but one with significant impact on the family and staff involved. The rarity means few emergency department clinicians feel ‘expert’ in the overall management process. However, most have some knowledge and experience which can be augmented by collaborating with other health professionals. By exploring some of the main management issues and challenges for the emergency department, key aspects of care are identified for emergency department clinicians to consider in reviewing local procedures and guidelines. Key words: child, death, emergency department, paediatric.

The death of a child is an increasingly uncommon event. In 2013, 1582 infants and children aged less than 15 years died in Australia. Of these, two-thirds were infants less than 1 year of age.1 Injuries account for one-third of deaths in children aged 1–14 years. There are no currently published data on how many children die in Australian emergency departments (ED). Individual hospitals may have local data, but detail of location of death within a hospital is not routinely collected through current central reporting processes of deaths. North American data estimate that there is one death of a child per 15 000 ED visits.2 It is fair to say that death of a child in the ED is a rare event, and thus, few clinicians will feel experienced in managing the death of a child. However, most have access to other staff and resources to assist in the provision of appropriate and compassionate care to the bereaved parents and family. While some areas of paediatric medicine and acute management of an unwell child have quite clear (and mandatory) Key Points 1 The death of a child in an emergency department is rare. 2 There are a number of legal requirements in documenting of death and care of the body. 3 Care of the family by the health-care team requires skills from medical, nursing and allied health staff. Correspondence: Dr Susan Trethewie, Paediatric Palliative Medicine, Pain and Palliative Care Department, Sydney Children’s Hospital, High Street, Randwick, NSW 2031, Australia. Fax: +61 29382 7946; email: [email protected] Conflict of interest: None declared. Further Reading (communication skills). Waldman E and Wolfe J. Nature Reviews Clinical Oncology 2013; 10: 100– 107 Levetown M and Committee on Bioethics. Communicating With Children and Families: From Everyday Interactions to Skill in Conveying Distressing Information. Pediatrics 2008; 121: e1441–1460. Accepted for publication 29 May 2015.


training requirements, care of a dying child and management of paediatric deaths is a topic less well covered, and training tends to be more ad hoc and voluntary. Increasingly, end of life care is being recognised as a critical part of health care and is now included in quality standards for accreditation of Australian hospitals.3

Case Study The ambulance call came just before 09:00 h. A 1-year-old boy had been found face-down in the bath and was floppy and unresponsive. It was at least 5 min before Jack had any basic life support. A paramedic team arrived after 10 min and found him in asystolic arrest. Positive pressure ventilation by bag and mask was commenced, with cardiac compressions and eight doses of intravenous adrenaline over 35 min. In the minutes before Jack’s arrival, the ED team prepared equipment to intubate, monitor and deliver further doses of medication. Roles were allocated, including someone to be with his family in the resuscitation room. We discussed that while we would do our best to resuscitate him, it was likely that Jack would not survive. Jack arrived in asystolic arrest. Jack’s mother arrived shortly afterwards and stayed with him in the resuscitation room, accompanied by the social worker. Jack was intubated and ventilated and had a further three doses of adrenaline with continuing cardiac compressions. We described what we were doing and explained that everything that the ambulance and hospital teams were doing had not been able to make his heart beat again. We encouraged Jack’s mother to touch him and talk to him. After a further 20 min of resuscitation (1 h in total), we ceased resuscitation then confirmed that Jack had died. In place of activity and noise of the team and monitoring there was stillness and soft cries from Jack’s mother. Jack’s mother had been with the ambulance team and in the resuscitation room watching everything. She also heard everything the ED team said as we described that he did not have a

Journal of Paediatrics and Child Health 52 (2016) 164–167 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

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pulse after each cycle of resuscitation and that the time from commencement of resuscitation without recovery was growing longer. Jack’s father arrived after we had ceased resuscitation. The ED specialist, a registrar and the social worker sat down in a quiet room, briefly found out what he knew and outlined the events, then told him that Jack had died. We asked him if he wanted to go in and see Jack and explained how Jack would look. We had wrapped Jack up in a blanket and kept all the tubes and cannulas in place due to coronial requirements. His parents sat with him, held him, and cried. We advised the family of the need for the coroner to review Jack’s death. The police would come later and ask his mother or father to identify Jack’s body and ask them some questions, but we would defer doing that until the family was more ready. We asked if they wanted other family to join them. An hour after the resuscitation we asked all the team members and the paramedics to meet. We started with each clinician talking about what happened, what was difficult, and discussed whether we felt the decision to cease resuscitation occurred at the right time. The conversation then turned to how people felt, how difficult it was to be in the room after resuscitation was ceased, to be so close to a parent’s grief, and to have no activity to distract oneself from one’s own emotion. The family’s general practitioner was contacted and asked to see them soon. The social worker remained in close contact with the family. About 2 months after Jack died, the ED specialist met with the family to enable them to ask questions and discuss the results of the coronial post-mortem examination.

Paediatric Deaths in the ED Death of a child in the ED may occur in a variety of situations. The ED may see children with new and acute medical problems requiring intensive treatment, children who have suffered physical trauma (e.g. accidents and immersions), and also sudden unexpected death in infancy. In addition to this, children with chronic medical diagnoses may present with acute deterioration needing immediate and intensive management. In circumstances where death has occurred in the ED, the family may have been present during resuscitation and supported by a staff member. This approach may be of benefit for family bereavement.4 In general, the family should be offered the opportunity to be present.5

Confirming Death Although it may appear obvious that a child has died, there is a formality to establishing that death has, in fact, occurred. The examination should include all of the following: no palpable carotid pulse, no heart sounds heard for 30 s, no breath sounds heard for 30 s, no response to centralised stimuli and fixed dilated pupils. Additional confirmation may be asystole on electrocardiography, absence of pulsatile flow with intraarterial monitoring or absence of cardiac contraction on echocardiography.6 In the rare situation of extreme hypothermia, resuscitation should be withheld only if the cause of a cardiac arrest is clearly attributable to a lethal injury, fatal illness, prolonged asphyxia or

Paediatric death in the ED

if the chest is not compressible. In all other patients, the traditional guiding principle that ‘no one is dead until warm and dead’ should be considered.7 Resuscitation should continue until warmth is achieved or is unattainable.

Informing the Family One of the most difficult tasks is informing the family that their child has died. Taking a few moments to prepare can help with managing your own feelings; clarify what you are going to say and how you will proceed.8 In cases where family are present during resuscitation, it may be helpful for the Resuscitation Team Leader to periodically summarise the resuscitation efforts and clinical response, and give guidance on ongoing management. You may have strong feelings after a child has died – inadequacy or guilt that resuscitation was not successful; sadness or anger of the loss of life. Acknowledge them; you may briefly want to share these with a colleague, and then set them aside as the family will be looking for your calmness, empathy and genuine care for their child and them. Find an appropriate place that has the adequate space and privacy, with enough seats for everyone. Turn off distractions such as phones and pagers so you can give the family your full attention. Ensure that the right family members are present. Organise the staff you need – social worker, chaplain and interpreter before you start. Have tissues and water available. Check that you know and can explain what happens next. Make sure you know the child’s name and use it. A brief description of events leading up to the child’s death may help give the family some context and make sense of what happened. Consider what words you will use – ‘die’ and ‘death’ are clear and honest. Be prepared to sit quietly and allow the family to respond. Discussion about organ or tissue donation should be separated from informing the family that their child has died.

Documentation In non-coronial deaths, medical certification of cause of death should be completed as soon as practicable, along with cremation forms in case they are required. Legislation relating to coronial deaths varies slightly between states; however, compliance with it is mandatory. Coronial cases will generally require certification that life is extinct and a report of death to the coroner. Where organ or tissue donation is being considered in coronial cases, contact the coroner urgently to seek approval.

Investigations If tissue or body fluid testing is required, this need to be done quickly as sampling may be time sensitive. In coronial cases, the coroner should be contacted urgently to seek approval.

Care of the Body After the death of a child, the family may wish to spend time with their child. Adequate space and privacy are essential.

Journal of Paediatrics and Child Health 52 (2016) 164–167 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)


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Memory-making at this time may consist of hand/foot prints and sometimes photographs. In circumstances where death is expected, these may be important activities for families prior to death. Washing and dressing the child may be important, and families may wish for assistance from staff in carrying this out. In coronial cases, discussion and negotiation of these aspects with the coroner is needed to ensure compliance with legislative requirements, and a staff member should be present at all times.

Spiritual and Cultural Aspects In Australia’s multicultural society, there is considerable variation in what is required and/or desired by parents and families regarding their cultural and religious circumstances and death. Rather than making assumptions based on previous experience or general information, it is best to enquire about what is needed for this particular child and family, and where possible, facilitate the processes to achieve the goals and wishes. In coronial cases, these should be conveyed to the coroner as soon as possible.

Bereavement Support, Funeral Arrangements and Counselling Specialised psychosocial support (where available) may complement the emergency staff in supporting the family after the death of a child. Such staff presence for difficult conversations and breaking bad news as well as support for asking questions is helpful for the family as well as the medical and nursing staff. Managing parent and family distress, assistance with notifying other family and friends and identification of short-/mediumterm needs is essential. Psychosocial support staff can assist the family with navigating the immediate arrangements such as funeral and will identify who is available for ongoing support over the first few days/week, as well as options on bereavement support and counselling in the ensuing weeks/months. A follow-up meeting with an appropriate medical practitioner at a later date provides an opportunity to discuss medical information that may have become available (particularly postmortem or other investigation results) and allow another opportunity for questions from parents and family. In some circumstances this may involve the ED physician.

Health Professional Communication Communication to current/previously involved health professionals of the details of the child’s presentation to the ED, management and outcome is important. Identify who needs to be notified (remembering the general practitioner and community care providers), and clarify who will carry out the task. In some circumstances this can be done via electronic methods, however, personal communication may be preferred to enable discussion and provide an opportunity to answer questions as well as determine any capacity for family follow-up.

Paediatric Palliative Care Patients in the ED With increasing awareness of palliative care and relevance to paediatrics, it is likely that EDs will increasingly see patients 166

who are known to a palliative care team. Often it is a sudden change in the child’s condition that triggers attendance to an ED. Advance care planning is relevant to some paediatric patients – those with clearly terminal diagnoses,9 and those with chronic conditions where issues of quality of life may direct which resuscitative measures are appropriate in the event of deterioration. When a child attends an ED with any type of advance care documentation, the clinician must quickly and sensitively clarify that parents remain in agreement with the documented plan.10 A formally documented resuscitation plan reflects the agreed wishes and goals of the family; however, the legal status may vary between states.11 Not all patients known to palliative care have a documented plan regarding resuscitation, as this is determined on an individual basis depending on disease trajectory. If there is no advanced care plan and the child with a terminal disease or end-stage organ failure is unstable, the ED team needs to promptly determine which treatments should be initiated. Using language that focuses on withholding resuscitation, for example ‘do you want us to intubate’, or ‘we won’t resuscitate your child’ misses the opportunity to understand the child and family’s goals of care. An alternative approach, suggested by Shreves,10 is to start exploring the issue by asking about the family’s thoughts and preferences about the use of life support at the end of their child’s life, describing the procedures and your concerns, then suggesting a plan that maximises comfort and control of symptoms. In most cases, terminal care symptoms can be well managed with a small selection of medications and advice from a specialist paediatric palliative care team.

Challenges in the Emergency Environment Managing the death of a child in an ED is particularly challenging. The activity in most EDs is relentless. Staff involved in resuscitation and care of the family need to resume routine duties and care for other patients. It may be necessary to call in additional staff to maintain an adequate emergency service while the staff fulfil their roles to the child who has died and have an opportunity to reflect on the situation and their feelings. Few EDs will have a dedicated area to care for the child and family after death. A relatively quiet and private area may need to temporarily become the place where the family can spend time with their child. Patients and families in the ED and staff not directly involved will often know that a child has died. This impact should be acknowledged without providing specific details.

Death Review and Staff Support While there is often a significant focus on reviewing the medical management of the deteriorating child who dies, it is also important to review the interdisciplinary management of the death itself (mortality management). This may include issues relating to symptom management, psychosocial support of the family, adequacy of the environment and privacy/space and bereavement follow-up processes.

Journal of Paediatrics and Child Health 52 (2016) 164–167 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

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As the team involved in the care of the child may be formed from departments across the hospital or be rostered differently the best time to gather the team together to reflect and debrief may be soon after the event. In this type of ‘hot debrief’, inclusion of ambulance officers may also be relevant. This activity provides staff support and an opportunity to identify immediate issues from a staff management perspective. This review should include how well the team the team used or withheld medical interventions, how well the team cared for the family and how the team supported each other. This type of review should be voluntary, non-intrusive and directed at support rather than psychological counselling.12 Staff should also be made aware of any staff support services available through the health employer. In addition, formally reviewing paediatric deaths at a later date may have benefits in identifying areas for improvement and opportunities to acknowledge aspects that were well managed.

Summary The rarity of death of a child in the ED means few clinicians feel ‘expert’ in the overall management process. However, most have some knowledge and experience that can be augmented by collaborating with other health professionals. There is a dual responsibility for ED clinicians to provide optimal care to the child and family, as well as appropriate education and support for their staff. As in many circumstances where an event or situation is uncommon, it is helpful to share experiences (good and bad) to assist in providing opportunities for improvement in both our own and other organisations.

Paediatric death in the ED


9 10 11 12

accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010; 81: 1400–33. O’Malley P, Barata I, Snow S, American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Emergency Medicine Committee, and Emergency Nurses Association Pediatric Committee. Death of a child in the emergency department. Pediatrics 2014; 134: e313–30. Clark JD, Dudzinski DM. The culture of dysthanasia: attempting CPR in terminally ill children. Pediatrics 2013; 131: 572–80. Shreves A, Marcolini E. End of life/palliative care/ethics. Emerg. Med. Clin. North Am. 2014; 32: 955–74. NSW Health. Using Resuscitation Plans in End of Life Decisions. 2014 Reynolds F. How doctors cope with death. Arch. Dis. Child. 2006; 91: 727.

Appendix Checklist: Death of a child in the Emergency Department □

Life extinct

□ □ □

Social worker, spiritual/ cultural support Inform family Coronial deaths



Inform health professionals

References 1 Australian Bureau of Statistics. Deaths, Australia 2013 http://www[email protected]/mf/3302.0. 2 United States Agency for Healthcare Research and Quality. Health Care Cost and Utilization Project 2012 http://www.hcup-us 3 Australian Commission for Safety and Quality in Healthcare. National Safety and Quality Health Service (NSQHS) Standards 2012 -safety-and-quality-health-service-standards/. 4 Dudley NC, Hansen KW, Furnival RA et al. The effect of family presence on the efficiency of pediatric trauma resuscitations. Ann. Emerg. Med. 2009; 53: 777–84. 5 Kleinman ME, de Caen AR, Chameides L et al. Part 10: pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2010; 122 (Suppl. 2): S466–515. 6 NSW Health. Life extinct form NSW. Available from: http://www.ecinsw [accessed June 2015]. 7 Soar J, Perkins GD, Abbas G et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning,

Assess; document (details, location and time)

Local procedures Explain to family Contact police Leave all attachments; do not bathe body Complete report to coroner DO NOT complete Medical Certificate of Cause of Death Medical Certificate of Cause of Death; Cremation form Determine if post-mortem required Consider tissue donation Hand/foot prints; lock of hair; photos (Coronial death – confirm allowed with coroner) Paediatrician General practitioner Other specialists (obstetrician if

Managing paediatric death in the emergency department.

Death of a child in an emergency department is a rare occurrence, but one with significant impact on the family and staff involved. The rarity means f...
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