The Emotional Impact of Disaster on Children and Families

One of the most difficult experiences that a pediatrician will have during a disaster is notifying the family of a death, whether a child or parent has died. It is best to do this in person and not in a telephone call whenever possible, regardless of the time of day. It will also be preferable to deliver this news in a private place, away from the distractions of ongoing care to patients. The manual entitled Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians describes the notification process as follows:

“After notifying the survivor(s) of the death, pause to allow both the information to be processed and emotions to be expressed. Do not try to fill the silence, even though it may seem awkward. Listen more than you speak. Silence is often better than anything you can say. Stay with the family members as they are reacting to the news, even if they are not talking.

• Use clear and simple language. Avoid euphemisms such as terminated, expired, or passed away. State that the individual died or is dead.
• Don’t provide unnecessary graphic details. Begin by providing basic information and allow the individual to ask questions for more details.
• Don’t lie or speculate. If you do not know the answer to a question, say so. Try to get the answer if possible.
• Be conscious of nonverbal communication and cues, both those of the family as well as your own.
• Be aware of and sensitive to cultural differences. If you do not know how a particular culture deals with a death, it is fine to ask the family.
• Consider the use of limited physical contact (e.g., placing a hand on the family member’s shoulder or providing a shoulder to cry on). Monitor the individual’s body language and if at all in doubt whether such contact would be well received, ask first.
• Realize that the individual may initially appear to be in shock or denial. Expect additional reactions, such as sadness, anger, guilt, or blame. Acknowledge emotions and allow them to be expressed without judgment.
• Do not ignore or dismiss suicidal or homicidal statements or threats. Investigate any such statements (often this will be facilitated by the involvement of mental health professionals) and if concerns persist, take appropriate action.
• Just before and during the notification process, try to assess if the survivors have any physical (e.g., severe heart disease) or psychological (e.g., major depression) risk factors, and assess their status after notification has been completed.
• If possible, write down your name and contact information in case the family wants further information at a later time. If the situation is not appropriate for providing your name and contact information, then consider how the family may be able to obtain additional information in the future (even months later).
• Do not try to “cheer-up” survivors by making statements such as “I know it hurts very much right now, but I know you will feel better within a short period of time.” Instead, allow them their grief. Do not encourage them to be strong or to cover up their emotions by saying “You need to be strong for your children; you don’t want them to see you crying, do you?” Feel free to express your own feelings and to demonstrate empathy, but do not state you know exactly how family members feel. Comments such as “I realize this must be extremely difficult for you” or “I can only begin to imagine how painful this must be to hear” can demonstrate empathy. Avoid statements such as “I know exactly what you are going through” (you can’t know this) or “You must be angry” (let the individual express his or her own feelings; don’t tell the per son how to feel) or “Both my parents died when I was your age” (don’t compete with the survivor for sympathy). Provide whatever reassuring information you may be able to, such as “It appears your husband died immediately after the explosion. It is unlikely he was even aware of what happened and did not suffer before he died.” However, do not use such information as an attempt to cheer up family members (e.g.,”You should be happy, many people suffered painful burns or were trapped under rubble for an hour before they died. At least your husband didn’t experience that.”)
• Feel free to demonstrate that you are upset as well—it is fine to cry or become tearful. If you feel, though, that you are likely to become overwhelmed (e.g., sobbing or hysterical), then try to identify someone else to do the notification.
• After you have provided the information to the family and allowed adequate time for them to process the information, you may wish to ask questions to verify comprehension.
• Offer the family the opportunity to view the body of the deceased and to spend some time with their loved one. Before allowing the family to view the body, the health care team should prepare it for viewing by others. A member of the healthcare team should escort the family to the viewing and remain present, at least initially.
• Help families figure out what to do next. Offer to help them notify additional family members or close friends. Tell them what needs to be done regarding the disposition of the body. Check to see if they have a means to get home safely (if they have driven to the notification, they may not feel able to drive back safely), and inquire if they have someone they can be with when they return home.
• Help survivors identify potential sources of support within the community (e.g., member of the clergy, their pediatrician, family members, or close friends).
• In mass disasters it may be challenging to arrange for a dignified burial with appropriate and relevant religious or communal rituals. It is important that the family of a deceased child is supported to give their beloved one respectful and appropriate burial. In the chaos of mass disasters this may be difficult to realize and the pediatrician needs to support the family and may have to advocate within the humanitarian community to provide opportunities for dignified burials.
• Take care of yourself. Death notification can be very stressful to health care providers.