PEDIATRICS Vol. 116 No. 4 October 2005, pp. 1052-1053 (doi:10.1542/peds.2005-0253)
Primary Care Pediatricians and Child Deaths
William Marshall, MDDepartment of Pediatrics,
University of Arizona College of Medicine,
Tucson, AZ 85724
To the Editor.—
The article by Serwint and Nellis1 about deaths in the medical home reinforces my own experience in a primary care–training program and provides comparison data to our earlier finding that general pediatricians encounter deaths infrequently in their practices.2
Two important trends, both still evolving, must be considered in planning residency training and community health services with regards to child deaths. First, infant and child mortality rates are decreasing; from 1980 to 2001, the infant mortality rate has decreased 46%, and the rate for 1- to 4-year-olds has gone down 48%.3 Especially relevant for primary care pediatricians is the marked reduction in deaths from sudden infant death syndrome and acute bacterial infections in previously well infants and toddlers. An increased percentage of total deaths occur among children with cancer, congenital heart disease, and other chronic conditions.4 Second, pediatric physician specialization, not only in organ-specific disease treatment but in the setting and hours of pediatric physician practice, means less involvement of primary care pediatricians in care of dying children and support of their families. Oncologists and other pediatric subspecialists are often seen by families as the child's primary physician, and rightly so. More and more, urgent care and emergency physicians care for acute illness and injury, and hospitalists provide inpatient care. Although subspecialists, emergency physicians, and hospitalists do not wish to exclude primary care pediatricians, time and monetary factors work against their involvement.
Serwint and Nellis point to the need for better communication to inform primary care physicians of a child's death; this is difficult even within a single facility but may be especially pertinent for training programs. The increasing segmentation of care also requires community solutions to access expertise in helping the dying child and grieving family. Children's hospice and grief-counseling staff need an expanded mandate to coordinate and provide services to all community or metropolitan-area families who have a child who has died.
REFERENCES
1. Serwint JR, Nellis MF. Deaths of pediatric patients: relevance to their medical home, an urban primary care clinic.
Pediatrics. 2005;115
:57
–63
2. Bowen KA, Marshall WN Jr. Pediatric death certification.
Arch Pediatr Adolesc Med. 1998;152
:852
–854
3. United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Office of Analysis, Epidemiology, and Health Promotion. Compressed mortality file compiled from CMF 1968–1988, Series 20, No. 2A 2000; CMF 1989–1998, Series 20, No. 2E 2003; and CMF 1999–2001, Series 20, No. 2G 2004 on CDC WONDER on-line database. Available at: http://wonder.cdc.gov
4. Feudtner C, Christakis DA, Connell FA. Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980–1997.
Pediatrics. 2000;106
:205
–209
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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