1. Chapter 34:
The Dying Child

2. The Nurse’s Reaction to Death and Dying
Nurses and other health care workers are often uncomfortable with dying clients because they are afraid that the clients will ask questions they cannot or should not answer.
In addition, death reminds us of our own mortality, a thought with which many of us are uncomfortable.
It is important to examine your own feelings about death and the reasons for these feelings.

3. I am a student nurse. I am dying
I am a student nurse. I am dying. I write this to you who are and will become nurses in the hope that by sharing my feelings with you, you may someday be better able to help those who share my experience…. You slip in and out of my room, give me medications, and check my blood pressure.
Is it because I am a student nurse myself, or just a human being, that I sense your fright? And your fears enhance mine. Why are you afraid? I am the one who is dying! I know you feel insecure, don’t know what to say, don’t know what to do. But please believe me, if you care, you can’t go wrong. Just admit that you care…. Don’t run away—wait—all I want to know is that there will be someone to hold my hand when I need it….
If only we could be honest, both admit our fears, touch one another. If you really care, would you lose so much of your valuable professionalism if you even cried with me? Just person to person? Then it might not be so hard to die in a hospital—with friends close by.
(American Journal of Nursing, 1970)

4. Prepare To Care For Dying Children
You can personally prepare to care for dying children by exploring your own feelings about life and death.
Attending a workshop, conference, or seminar in which one's own feelings about death are explored can be helpful.
Talking with other professionals, sharing concerns, comforting each other in stressful times, and reading studies about death to discover how dying clients feel about the situation can also be helpful in preparing to work with dying clients.

5. The Child’s Understanding of Death
Factors that affect the child's understanding of death include his or her stage of development, cognitive ability, experiences, and how the family deals with death.
Most children do not understand the finality of death until they near preadolescence.

6. The Child’s Understanding of Death (cont.)
Infants and toddlers have little understanding of death; the toddler may fear separation but has no recognition of the fact that death is nearing and irreversible.
The preschool child may believe that death happens because of angry thoughts.
Magical thinking about death and thinking of death as a kind of sleep are seen in preschool-aged children until about 8 or 9 years of age.

7. The Child’s Understanding of Death (cont.)
After age 9, children gain the concept that death is universal and irreversible.
Adolescents have an adult understanding of death, but feel that they are immortal—that is, death will happen to others but not to them

8. Question
An 8-year-old child is actively dying from leukemia. What could you, as the nurse, do to help this child and his or her family?
a. Recognize that vocal aggression is an expression of the child’s fear
b. Recognize that vocal aggression is an expression of the child’s sadness
c. Teach the family to maintain discipline with the child
d. Teach the family to give the child whatever they want

9. Answer
a. Recognize that vocal aggression is an expression of the child’s fear
Rationale: Children may fear the loss of control that death represents to them and express this fear through vocal aggression. Family caregivers and nurses must recognize this as an expression of their fear and avoid scolding or disciplining them for this behavior.

10. Anticipatory Grief
When death is expected, as in a terminal illness, the family begins to mourn in anticipation of the death, a phenomenon called anticipatory grief.
Anticipatory grief shortens the period of acute grief and loss after the child's death.

11. The Family’s Reaction to Dying and Death
When a child has a terminal illness, family caregivers go through anticipatory grieving.
Families have the opportunity to complete unfinished business by spending time with the dying child, helping siblings understand the child's illness and impending death, and giving family members a chance to share their love with the child.

12. The Family’s Reaction to Dying and Death (cont.)
When a child dies suddenly, a family may suffer excessive grief and guilt for something they felt they left unsaid or undone.
When a sibling dies, possible reactions seen in children depend on the stage of development of that sibling.
Young siblings find death impossible to understand.
School-aged siblings may have classroom problems, behavioral disorders, and feelings of guilt about the death of their sibling.
Dealing with the realities of the brother's or sister's death openly is likely to be more beneficial than avoiding the issue.

13. Question Tell whether the following statement is true or false.
Health care staff can meet the dying child’s needs more effectively if the family caregiver allows the child to know that he or she is dying.

14. Answer
True
Rationale: If caregivers permit openness and honesty in communication with a dying child, the health care staff can meet the child’s needs more effectively, dispel misunderstandings, and see that the child and the family are able to resolve any problems or unfinished business.

15. Settings for Care of the Dying Child
Settings for caring for the dying child include the home, hospice, and hospital settings.
The home provides a loving, caring environment and may decrease costs and family separations.
Home settings may prevent some expenses from being covered and may be difficult emotionally and physically for the family..

16. Settings for Care of the Dying Child (cont.)
Hospice principles of care include relief of pain, attention to the needs of the total person, and absence of heroic life-saving measures.

17. Settings for the Dying Child (cont.)
In the hospital setting, the child and the family may find support from others in the same situation, support from the hospital staff, and technologically advanced treatment.
Hospital care is much more expensive, but this may not be important to some families.
The hospital is still the culturally accepted place to die, but having a child in the hospital can contribute to family separation, a feeling of loss of control, and a sense of isolation

18. The Role of the Nurse
Nursing care for the dying child focuses on minimizing pain, diminishing feelings of abandonment by the child's peers and friends, and relieving anxiety about the future.
Care also aims to help the family find ways to cope with the impending death and to identify feelings of powerlessness.

19. Question Tell whether the following statement is true or false.
The assessment is performed by the health care team and only covers the family’s support system, present indications of grieving (e.g., anticipatory grief), and interactions among family members.

20. Answer
False
Rationale: The assessment is performed by the health care team and covers the child’s developmental level, the influence of cultural and spiritual concerns and the family’s support system, present indications of grieving (e.g., anticipatory grief), interactions among family members, and unfinished business.