Published online September 30, 2005
PEDIATRICS
Vol. 116
No. 4
October 2005, pp.
1053
(doi:10.1542/peds.2005-1598)
Primary Care Pediatricians and Child Deaths: In Reply
Janet R. Serwint, MD
Johns Hopkins University School of Medicine,
Baltimore, MD 21287
Marianne E. Nellis, MD
Department of Pediatrics,
New York Presbyterian Hospital,
Weill Cornell Campus,
New York, NY 10021
In Reply.—
We appreciate the opportunity to respond to the thoughtful letter from Dr Marshall. Although we agree that infant and child mortality rates are decreasing, the death of a pediatric patient remains a powerful experience for pediatricians, perhaps because it is an infrequent event. A recent study at an academic institution documented that pediatric residents experienced a mean of 4.6 deaths during the latter half of their residency, ranging from 0 to 19 deaths.1 Thirty-one percent of residents expressed guilt about at least 1 of the deaths, suggesting that this significant experience must be acknowledged and discussed.
Subspecialists do hold a very important place for families with children with life-threatening illnesses. A serious illness in a child can often lead to a very close relationship between the parents and child and the pediatrician, regardless of whether he or she is a pediatric subspecialist or the primary care provider. Although the family may rightly see the subspecialist as the primary care provider during their child's illness, they may not have a continued relationship with him or her after the child dies. Both the subspecialists and generalists need to be informed of the patient's death. This is relevant to consider, because 50% of the deaths reported in our study occurred at an outside hospital, and 14% occurred in the emergency department.2 Physicians who have known the child before the life-altering diagnosis often have a longitudinal relationship with the family and may continue to have a relationship through the care of the child's siblings. In addition, the death rate from sudden unintentional injuries remains high; thus, the primary care provider may be an important source of support both at the time of the death and during the bereavement period.
Because the notification of patient deaths is critical yet difficult, community solutions do need to be developed, as Dr Marshall suggests. City-wide tracking systems, mortality reviews, and involvement of hospice and funeral home directors may all have a role. The Institute of Medicine report When Children Die: Improving Palliative Care for Children and Their Families stresses the importance of continuity of care for families. Even when the primary responsibility for a child shifts, as with a life-altering disease, those who have cared for a child still may seek ways to have continued communication and involvement.3 We as health care professionals need to be committed to facilitate that communication in whatever ways we can.
REFERENCES
- Serwint JR. One method of coping: resident debriefing after the death of a patient.
J Pediatr. 2004;145
:229
–234[Medline]
- Serwint JR, Nellis MF. Deaths of pediatric patients: relevance to their medical home, an urban primary care clinic.
Pediatrics. 2005;115
:57
–63[Abstract/Free Full Text]
- Institute of Medicine, Committee on Palliative and End-of-Life Care for Children and Their Families, Board of Health Sciences Policy. In: Feld MJ, Behrman RE, eds.
When Children Die: Improving Palliative Care for Children and Their Families. Washington, DC: National Academies Press; 2003
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
