The Dying Child

1. How the child will respond to his own death or the death of another will depend upon his developmental level, past experiences with death, family background, and religious orientation. (a) Below the age of 4 to 5 years, children have no understanding of death as an irreversible process even though they may use the word "dead." (b) Between the ages of 6 and 10 years, children develop a concept of death as a logical, biologic process which occurs according to a set of physical laws. Much of their knowledge of death is derived from active investigation of dead things. (c) The adolescent can conceptualize his own mortality and because this understanding can be anxiety provoking, he tends to deny the possibility of personal death and often experiments with danger. (d) Children learn about the emotions of loss (sadness, grief) by experiencing loss. Therefore, discussions with children about death must be appropriately geared to their developmental level and past experiences. Honest, straightforward answers which reflect reality, or the concrete tangible world of experience, will be understood most easily. Children who are unfamiliar with death may appear to react inappropriately or without emotion when, in fact, they feel deeply but are ignorant of what behavior is expected. Being allowed to experience loss (such as that of a pet) may be an important learning tool for the child in understanding death. 2. A family's response to the death of a child will be affected by the duration of the child's terminal illness. (a) Anticipatory grief, a characteristic of expected death, allows the survivors to experience fantasized feelings of loss while they have the consolation of the child's still being alive. (b) Sudden or unexpected death demands an immediate adjustment of the family to its loss. The family may protect itself from this overwhelming feeling by denial of many days' or weeks' duration. (c) The impact on the parents of a perinatal death may not be fully appreciated by the family or health care givers and the grief reaction may not be allowed the kind of expression necessary for its successful resolution. (d) The wished-for-death of a seriously ill or defective child may be an extremely guilt-provoking experience for the parents. Therefore, evaluation of a family's coping ability must take into consideration the opportunity the family has had to adjust itself to its loss. In normal grieving, tearful or other emotional outbursts are common during at least the first year after a death and at the time of special family anniversaries for several years thereafter. However, grief is usually considered pathologic if the family member is not moving toward functional adaptation to the loss after a period of four to six months. Support systems for the grieving family appear to come from groups of others who have sustained a similar loss. Hospital-based support networks, although important during the course of a fatal illness and in the immediate period after death, usually do not offer long-term support. Thus, families should be actively encouraged to transfer their reliance to a support system that is community-based at or around the time of the death. 3. The pediatrician or family physician has a major role to play throughout the child's illness and the period of bereavement. (a) At the time of a fatal diagnosis, the doctor is a familiar individual from whom the family should feel it is appropriate to seek explanation and advice. (b) Throughout the illness, the doctor should be an advocate for the child and family by helping to "smooth" the interface between the patient and the medical care system by making the system aware of the particular needs of the individual child. (c) At the time of death, the doctor should be a source of comfort and information regarding the appropriate way to discuss the child's death with others, especially other children in the family. (d) During bereavement the doctor should serve as a monitor of the family's adaptation, judging their present coping ability on the basis of their past experiences and responses to previous stresses. Therefore, the pediatrician and/or family physician should remain sensitive to the magnitude and permanency of the family's loss but also help them to tolerate and assimilate their void in constructive ways.