When aiming to do good does harm #WILTW

This is the 187th #WILTW

The nature of working in paediatric medicine means the joy of ‘high-fiving’ a four year old after fixing their broken arm comes with the utter despair of telling parents their child is dead.

Death is not a regular event for many who work in child health but your actions may have a huge impact on families or carers. You can’t make grief better but you can certainly make it worse.

The impact of an unexpected death in a child is also profound for those involved in the final moments of their care. Many will have never seen an adult, let alone a child, die before. There may be completely unwarranted feelings of guilt from the ambulance crew (“did I do CPR effectively?“), to the nursing staff (“did I give the right dose of drugs“), to the doctors (“did I make the right decisions?“) and there is often a visceral urge for senior staff to hold others grief and suffering. This commonly occurs in the form of a debrief, an open forum to discuss the tragedy that has just occurred. This may be ‘hot’, taking place immediately, or ‘cold’ arranged in the days or weeks afterwards.

The role of debrief has always been debated and contested. Is reliving the detail of a traumatic event, traumatic in itself? A recent study (in print this week) of over 300 paediatric trainees experience of child death adds to evidence in this area. The survey’s response rate was only 50% and it wasn’t possible to control for responses i.e. those completing the survey having stronger feelings in this emotive area than those not. Or conversely those not responding having potentially been more adversely affected by the events. Non-withstanding this limitation there was much food for thought:

  • About 15% of respondents had only experienced 1-2 deaths in their training. Less than 30% had a been a team leader during the resuscitation of a child who died.
  • An acute stress response occurred in up to 9% of trainees and Post Traumatic Stress Disorder (PTSD), as measured by a questionnaire, developed in 5%.
  • These reactions were not associated with age, gender or working patterns but there did seem to be a relationship with debrief – with those attending debrief more likely to develop PTSD than those who didn’t.

Association is not causation. This work in itself does not mean that debrief is always harmful and there may be many other factors which haven’t been measured which may be significant. But this study adds to others that have hinted at the same thing. So why should it be that debrief, a powerful educational technique, may cause suffering rather than take it away?

These are not frequent events and are unpredictable in their nature. By definition they are highly emotive events where staff are acting at the height of physiological stress. Importantly many will never have experienced this pressure before, and critically, those leading the debrief may never have had to facilitate a discussion like this. In fact training in this area is almost non-existent. Learning through watching others is how many will develop skills they may deploy for the first time as a consultant.

The public deserve the best and most appropriate care, especially in the most tragic of circumstances. But so do staff who need the research to guide the best way to deal with these catastrophic events and training in how to help others recover from what may well be their most significant life event to date.

What have you learning this week? #WILTW

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