Death of a Child in the Emergency Department

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 2002.¹ 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.² 

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 life span–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 the following:

  •  ○ 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 life span–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; and

    •  ▪ 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 nonmedical 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 the following:

  •  ○ 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 after 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.

Patricia J. O’Malley, MD, FAAP

Isabel A. Barata, MD, FACEP, FAAP

Sally K. Snow, RN, BSN, CPEN, FAEN

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

Lee Benjamin, MD – American College of Emergency Physicians

Kim Bullock, MD – American Academy of Family Physicians

Elizabeth L. Robbins, 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

Angela Mickalide, PhD, MCHES – 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

Sue Tellez

Lee S. Benjamin, MD, FACEP, Chairperson

Isabel A. Barata, MD, FACEP, FAAP

Kiyetta Alade, MD

Joseph Arms, MD

Jahn T. Avarello, MD, FACEP

Steven Baldwin, MD

Kathleen Brown, MD, FACEP

Richard M. Cantor, MD, FACEP

Ariel Cohen, MD

Ann Marie Dietrich, MD, FACEP

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

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

W. Scott Russell, MD, FACEP

Mohsen Saidinejad, MD

Harold A. Sloas, DO

Gerald R. Schwartz, MD, FACEP

Orel Swenson, MD

Jonathan H. Valente, MD, FACEP

Muhammad Waseem, MD, MS

Paula J. Whiteman, MD, FACEP

Dale Woolridge, MD, PhD, FACEP

Carrie DeMoor, MD

James M. Dy, MD

Sean Fox, MD

Robert J. Hoffman, MD, FACEP

Mark Hostetler, MD, FACEP

David Markenson, MD, MBA, FACEP

Annalise Sorrentino, MD, FACEP

Michael Witt, MD, MPH, FACEP

Dan Sullivan

Stephanie Wauson

Joan Shook, MD, FACEP, FAAP – AAP Committee on Pediatric Emergency Medicine

Angela D. Mickalide, PhD, MCHES – EMSC National Resource Center

Elizabeth Edgerton, MD, MPH – Branch Chief, EMSC Injury and Violence Prevention

Sally K. Snow, BSN, RN, CPEN, FAEN – 2011 Chair & 2013 Board Liaison

Michael Vicioso, MSN, RN, CPEN, CCRN – 2012 Chair

Shari A. Herrin, MSN, MBA, RN, CEN – 2013 Chair

Jason T. Nagle, ADN, RN, CEN, CPEN, NREMT-P

Sue M. Cadwell, MSN, BSN, RN, NE-BC

Robin L. Goodman, MSN, RN, CPEN

Mindi L. Johnson, MSN, RN

Warren D. Frankenberger, MSN, RN, CCNS

Anne M. Renaker, DNP, RN, CNS, CPEN

Flora S. Tomoyasu, MSN, BSN, RN, CNS, PHRN

Deena Brecher, MSN, RN, APRN, CEN, CPEN, ACNS-BC

Kathy Szumanski, MSN, RN, NE-BC

Dale Wallerich, MBA, BSN, RN, CEN

Marlene Bokholdt, MS, RN, CPEN

Paula Karnick, PhD, CPNP, ANP-BC

Leslie Gates

Christine Siwik

AAP

American Academy of Pediatrics

ACEP

American College of Emergency Physicians

ED

emergency department

ENA

Emergency Nurses Association