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Death of a Child in the Emergency Department

Revised and approved by the American Academy of Pediatrics April 2014; the Emergency Nurses Association October 2012 and the ACEP Board of Directors March 2013

Reaffirmed by ACEP Board of Directors and the American Academy of Pediatrics 
October 2008

Originally approved by ACEP Board of Directors 
February 2002 and the American Academy of Pediatrics Board of Directors June 2002

This policy statement is accompanied by a Technical Report titled, “Death of a Child in the Emergency Department

 

Death of a Child Technical Report Download

 

ABSTRACT. The American Academy of Pediatrics (AAP), American College of Emergency Physicians (ACEP), and Emergency Nurses Association (ENA) have collaborated to identify practices and principles to guide the care of children, families, and staff in the challenging and uncommon event of the death of a child in the emergency department.

Key words: emergency department, death, child, pediatrician, nurse.
ABBREVIATIONS: ED, emergency department; AAP, American Academy of Pediatrics; ACEP, American College of Emergency Physicians; ENA, Emergency Nurses Association.

INTRODUCTION
The death of a child in the emergency department (ED) is an event with emotional, cultural, procedural, and legal challenges. The original policy statement, “Death of a Child in the Emergency Department; Joint Statement by the American Academy of Pediatrics and the American College of Emergency Physicians,” was first published in 2002. It represented a groundbreaking collaboration between general and pediatric emergency practitioners regarding their professional obligations in managing the death of a child in the ED, recognized as one of the most difficult challenges in emergency care. This revised statement expands that collaboration to include emergency nursing and is issued jointly by the American Academy of Pediatrics (AAP), the American College of Emergency Physicians (ACEP), and the Emergency Nurses Association (ENA).

The infrequency of child death in the ED and the enormity of the tragedy magnify the challenges in simultaneously providing clinical care, holistic support for families, and care of the team delivering care while attending to significant operational, legal, ethical, and spiritual issues. The evidence basis for these recommendations is detailed in the accompanying technical report of the same title.1

 

RECOMMENDATIONS
The AAP, ACEP, and ENA support the following principles:

  • The ED health care team uses a patient-centered, family-focused, and team-oriented approach when a child dies in the ED.
  • The ED health care team provides personal, compassionate, and individualized support to families while respecting social, spiritual, and cultural diversity.
  • The ED health care team provides effective, timely, attentive, and sensitive palliative care to patients with lifespan-limiting conditions and anticipated death presenting to the ED for end-of-life care.
  • The ED health care team clarifies with the family the child’s medical home and promptly notifies the child’s primary care provider and appropriate subspecialty providers of the death and, as appropriate, coordinates with the medical home and primary care provider in follow-up of any postmortem examination.
  • ED procedures provide a coordinated response to a child’s death including:
    • Written protocols regarding:
      • family member presence during and after attempted resuscitation
      • preterm delivery resuscitation
      • end-of-life care/anticipated death in the ED of a child with a lifespan-limiting condition
      • collaboration with law enforcement staff to address forensic concerns while providing compassionate care
      • institutional position on permitting the practice of procedures involving the newly deceased
      • best practice-outlining procedures after the death of a child (eg, a “death packet” with guidelines for completion of a death certificate, organ donation, etc)
    • Processes for notification of primary care and subspecialty providers and medical home of the impending death or death of their patient
    • Identification of resources, including other individuals and organizations, that can respond to the ED to assist staff and bereaved families, such as child life, chaplaincy, social work, behavioral health, hospice, or palliative care staff
    • Identification and notification of medical examiner/coroner regarding all deaths, as directed by applicable law
    • Routine offering of postmortem autopsy to families for all non-medical examiner-coroner cases
    • Clear processes for organ and tissue procurement
    • Identification and reporting of cases of suspected child maltreatment
    • Formal voluntary support and programs for ED staff and trainees, out-of-hospital providers, and others who are experiencing distress
    • Support of child death review activities to understand causes of preventable child death

 

  • Emergency medicine, pediatric resident, and emergency nurse training includes specific education regarding the difficult issues raised by the death of a child in the ED, such as:
    • Evidence for supporting family presence during attempted resuscitation
    • Best palliative care practices for imminently dying pediatric patients
  • Communicating the news of the death of a child in the ED to parents and family
  • Best practice in discussion of organ donation or autopsy
  • Filing the report of suspected child abuse or neglect in the setting of a child death
  • Medical-legal issues and best practice surrounding completion of death certificates
  • Optimal documentation and collaboration with state and local child death review teams to identify strategies to prevent future child deaths
  • Self-care following difficult or troubling ED cases
  • The ED health care team routinely considers care for the bereaved members of the patient’s family that may include information and arrangements for bereavement care services, condolence cards, and follow-up with family to address any concerns or questions.

______________________________
This document is copyrighted and is property of the American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association, and their Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics and have declared no conflicts. None of the authoring groups have neither solicited nor accepted any commercial involvement in the development of the content of this publication.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.


Lead Authors 
Patricia J. O’Malley, MD, FAAP
Isabel A. Barata, MD, FACEP, FAAP
Sally K. Snow, RN, BSN, CPEN, FAEN

American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, 2012-2013 
Joan E. Shook, MD, MBA, FAAP, Chairperson
Alice D. Ackerman, MD, MBA, FAAP
Thomas H. Chun, MD, MPH, FAAP
Gregory P. Conners, MD, MPH, MBA, FAAP
Nanette C. Dudley, MD, FAAP
Susan M. Fuchs, MD, FAAP

 

Marc H. Gorelick, MD, MSCE, FAAP
Natalie E. Lane, MD, FAAP
Brian R. Moore, MD, FAAP
Joseph L. Wright, MD, MPH, FAAP

Liaisons 
Isabel A. Barata, MD - American College of Emergency Physicians
Kim Bullock, MD - American Academy of Family Physicians
Jennifer Daru, MD, FAAP - AAP Section on Hospital Medicine
Toni K. Gross, MD, MPH, FAAP - National Association of EMS Physicians
Elizabeth Edgerton, MD, MPH, FAAP - Maternal and Child Health Bureau
Tamar Magarik Haro - AAP Department of Federal Affairs
Jaclynn S. Haymon, MPA, RN - EMSC National Resource Center
Cynthia Wright, MSN, RNC - National Association of State EMS Officials
Lou E. Romig, MD, FAAP - National Association of Emergency Medical Technicians
Sally K. Snow, RN, BSN, CPEN, FAEN - Emergency Nurses Association
David W. Tuggle, MD, FAAP - American College of Surgeons

Staff 
Sue Tellez

American College of Emergency Physicians, Pediatric Emergency Medicine Committee, 2012-2013 
Isabel A. Barata, MD, FACEP, FAAP, Chairperson
Kiyetta Alade, MD
Jahn T. Avarello, MD, FACEP
Lee S. Benjamin, MD, FACEP
Kathleen Brown, MD, FACEP
Richard M. Cantor, MD, FACEP
Ann Marie Dietrich, MD, FACEP
James M. Dy, MD
Paul J. Eakin, MD
Marianne Gausche-Hill, MD, FACEP, FAAP
Michael Gerardi, MD, FACEP, FAAP
Charles J. Graham, MD, FACEP
Doug K. Holtzman, MD, FACEP
Mark Hostetler, MD, FACEP
Jeffrey Hom, MD, FACEP
Paul Ishimine, MD, FACEP
Hasmig Jinivizian, MD
Madeline Joseph, MD, FACEP
Sanjay Mehta, MD, Med, FACEP
Aderonke Ojo, MD, MBBS
Audrey Z. Paul, MD, PhD
Denis R. Pauze, MD, FACEP
Nadia M. Pearson, DO
Brett Rosen, MD
Mohsen Saidinejad, MD
Gerald R. Schwartz, MD, FACEP
Annalise Sorrentino, MD, FACEP
Jonathan H. Valente, MD, FACEP
Muhammad Waseem, MD, MS
Paula J. Whiteman, MD, FACEP
Michael Witt, MD, MPH, FACEP

Liaisons 
Joan Shook, MD, FACEP, FAAP - AAP Committee on Pediatric Emergency Medicine
Jaclynn S. Haymon, MPA, RN - EMSC National Resource Center
Elizabeth Edgerton, MD, MPH - EMSC Injury and Violence Prevention

Staff
Stephanie Wauson

Emergency Nurses Association, Pediatric Committee, 2011-2012
Sally K. Snow, BSN, RN, CPEN, FAEN - 2011 Chair
Michael Vicioso, MSN, RN, CPEN, CCRN - 2012 Chair
Jason T. Nagle, ADN, RN, EMT-P, CEN, CPEN
Anne M. Renaker, DNP, RN, CNS, CPEN
Flora Tomoyasu, MSN, RN, CNS
Sue Cadwell, MSN, BSN, RN, NE-BC
Shari Herrin, MSB, MBA, RN, CEN
Deena Brecher, MSN, RN, APRN, CEN, CPEN, ACNS-BC, Board Liaison

Staff Liaisons
Kathy Szumanski, MSN, RN, NE-BC
Dale Wallerich, MBA, BSN, RN, CEN
Christine Siwik


REFERENCE

  • American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians, Pediatric Committee; Emergency Nurses Association; Pediatric Committee. Technical report: death of a child in the emergency department. Pediatrics. 2014; in press

SELECTED RESOURCES 
American Academy of Pediatrics, Committee on Pediatric Emergency Medicine;
American College of Emergency Physicians, Emergency Medicine Committee. 
Death of a Child in the emergency department; joint statement by the American Academy of Pediatrics and the American College of Emergency Physicians. Pediatrics. 2002;110(4):839-840

Atwood DA. To hold her hand: family presence during patient resuscitation. JONAS Healthc Law Ethics Regul. 2008;10(1):12-16
Browning DM, Meyer EC, Truog RD, Solomon MZ. Difficult conversations in health care: cultivating relational learning to address the hidden curriculum. Acad Med. 2007;82(9):905-913

American Academy of Pediatrics, Committee on Child Abuse and Neglect, Committee on Injury, Violence, and Poison Prevention, Council on Community Pediatrics. Child fatality review. Pediatrics. 2010;126(3):592

Covington TM, Rich SK, Gardner JD. Effective models of review that work to prevent child deaths. In: Alexander R, ed. Child Fatality Review: An Interdisciplinary Guide and Photographic Reference. St. Louis, MO: GW Medical Publishing Inc; 2007:429-457 

Dingeman RS, Mitchel EA, Meyer EC, Curley MA. Parent presence during complex invasive procedures and cardiopulmonary resuscitation: a systematic review of the literature. Pediatrics. 2007;120(4):842-854

Dudley N, Hansen K, Furnival R, Donalson A, Van Wagenen K, Scaife E. The effect of family presence on the efficiency of pediatric trauma resuscitations. Ann Emerg Med. 2008;53(6):777.e3-784.e3
Emergency Nurses Association. Position Statement: Emergency Nursing Resource: Family Presence During Invasive Procedures and Resuscitation in the Emergency Department. Des Plaines, IL: Emergency Nurses Association; 2010. Available at:http://www.ena.org/SiteCollectionDocuments/Position%20Statements/FamilyPresence.pdf. Accessed July 19, 2012

Levetown M; American Academy of Pediatrics, Committee on Bioethics. Communicating with children and families: from everyday interactions to skill in conveying distressing information. Pediatrics. 2008;121(5):e1441- e1460
Meyer EC, Sellers DE, Browning DM, McGuffie K, Solomon MZ, Truog RD. Difficult conversations: improving communication skills and relational abilities in health care. Pediatr Crit Care Med. 2009;10(3):352-359
Overly F, Sudikoof SN, Duffy S, Anderson A, Kobayashi L. Three scenarios to teach difficult discussions in pediatric emergency medicine: sudden infant death, child abuse with domestic violence, and medication error. Simul Healthc. 2009;4(2):114-130
Sekula LK. The advance practice forensic nurse in the emergency room setting. Top Emerg Med. 2005;27(1):5-14

Truog RD, Christ G, Browning DM, Meyer EC. Sudden traumatic death in children: we did everything, but your child didn't survive. JAMA. 2006;295(22):2646-2654

Wisten A, Zingmark K. Supportive needs of parents confronted with sudden cardiac death—a qualitatitive study. Resuscitation. 2007;74(1):68-74
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