P 22 Opinion

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Opinion
P E D I AT R I C N E W S • M a rch 2 0 0 8
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How to Discuss a Death With Children
P
You may be consulted regarding the
icture this: It is a winter Monday afternoon and you are working your children’s participation in the wake, fuway through seeing all the children neral, burial, and other mourning rituals.
who have become sick since your office The Smiths had made their decision, and
closed on Saturday. You have a first-year on Saturday they brought the boys to the
medical student observing you (through funeral but not to the burial. In my expethe clinical introduction course), and your rience, children are very honest and will
nurse whispers that Mr. and Mrs. tell you to what extent they want to be in“Smith”—who are waiting with their chil- volved in the ceremonies that surround a
dren in the next exam room—want to talk death. I would allow a child to go to the
funeral if she wants to. But
to you privately before you
the child should be supergo in to see the children.
vised by a less-involved
When this was my Monadult, who can leave with
day afternoon, I told the
the child if the experience
nurse to have one of the
becomes too much for her.
parents meet me briefly outOn the other hand, I would
side the exam room, as I
never force a child to attend.
don’t like to conspicuously
We certainly hope that, in
leave the children alone
the expected order of things,
while they know we are talkour children will live to ating about them. What was
tend our funerals without
the problem? Dad’s brother,
BY DEBORAH
us there to take care of
Uncle John—a police offiT O L C H I N , M . D.
them. The experience they
cer—died from a gunshot
have with funerals of more
from his own gun on
Wednesday night, and they wanted me to distant connections can be considered a
make sure that the children were doing all rehearsal: They learn what gets done,
how people express themselves, and that
right.
What are the points you have to cover people do manage to get through the
when dealing with a death in a child’s fam- mourning process.
We need to see the experience through
ily?
Of course, you need to start the discus- the eyes of the child in order to know what
sion by expressing your sympathy for the concerns each child might have; a child’s
family’s loss, and when the child is present, experience may be very different from
that of a grownup. Children of different
specifically on his loss.
You inquire about the relationship be- ages will certainly have different reactions.
tween the child and the deceased. In this Young children may not act as if they
case, he was a favorite uncle of “Joey” (9 take a death very seriously; they are used
to playing “bang, bang, you’re dead,” and
years old) and “Tom” (5 years old).
You learn if the death was sudden or an- then getting up and playing another game.
ticipated, and, if anticipated, how the chil- When an adult dies, both young and olddren were prepared for it. In this case, the er children need to be reassured that someuncle was in his room, his wife and moth- one will be there to take care of them.
People from different backgrounds have
er were elsewhere in the house, his gun
went off, and he was found dead. The case different understandings about death. Ceris still under investigation. The Smiths are tainly parents will teach their children
sure the death was accidental, not self-in- their own beliefs of what happens when
flicted, and that is what the children have someone dies. But what I stress is the
need to dwell on the existential aspect of
been told.
L
E T T E R S
Ensuring Continuity in Your Practice
I am doing some research for a pediatrician and I noticed that Dr. Charles A.
Scott has written numerous articles for
PEDIATRIC NEWS.
The pediatrician, who is 53 years old, is
a bit concerned that his practice is shrinking as new parents select doctors who
will be available for their children throughout their entire childhood. Does Dr. Scott
have any suggestions?
Bonnie Grosshans
Memphis
Dr. Scott replies:
The pediatrician who is in his or her prime
(by my standards) should first consider
whether the practice can afford a younger
colleague. That guarantees continuity
when the senior physician retires. If there
is not enough patient flow or revenue to
support even a part-time younger pedia-
trician, then the 53-year-old in this case has
to assure his patients that a younger pediatrician will join the practice in a few
years as he begins to wind down—but that
he fully anticipates going for another 10 or
12 years and can see most patients through
the throes of childhood.
I am in the same boat. I have been
telling my patients that I will be around for
another 10 years (I’m 56) and I’m not
thinking about slowing down anytime
soon. Obviously, it is predicated upon my
good health, which I hope will continue.
Parents feel relieved that I will be able
to care for their children for at least that
many years. But I have younger associate
doctors who will carry on after I retire. Dr.
53 needs to think about this as well.
AAP Had Better Stick to Science
The American Academy of Pediatrics’
stand on adolescent sexuality is unscientific
the death, what we experience here and
now: We know Uncle John is gone and is
not coming back; we miss him and we feel
sad because of that.
We can think of all the nice things we
did with Uncle John and remember what
he was like. The boys tell me that Uncle
John was a prankster, a comedian. Everyone enjoyed his company and liked him.
We can even remember a couple of things
that we did not like when Uncle John did
them. We do not have to feel guilty about
such thoughts; after all, he was a real person, and no human being is perfect. If we
have a picture or some gift that Uncle John
might have given us, we can keep it in a
special place, as a reminder of him.
We feel sad when someone we know
and love has died. Even grownups, even fathers, may cry over the loss of someone
they were close with. A parent who acts
as if everything is fine after someone dies
might convey a subliminal message to the
child that the parent does not experience
strong love, possibly giving the child the
feeling that “it might not even upset them
if I died.”
In general, everyone processes a death
at a different rate. I remember a young
couple who lost a baby to crib death,
years before the “back to sleep” campaign.
When he wanted to go to the cemetery
she was not ready to go, and when she
wanted to go, he wouldn’t go with her.
Fortunately, the marriage survived, and together they decided to have another child.
Joey, the 9-year-old, was able to talk
about good memories of his uncle and his
joking around. He was overwhelmed by
the constant crowd of people who came
to pay their respects. We talked about his
new worry: When his father is out, Joey
frets about his father’s returning home
safely. He expresses concern about his
aunt.
Tom, the 5-year-old, also was confused
by so many people being around. He reported that the day before he had felt his
heart beating (“going bump”).
and impractical (“AAP Updates Policy on
Adolescent Contraception,” December
2007, p. 6).
Pontification is no way to address a biologic phenomenon governed by various
hormones and neurotransmitters responsible for propagation and survival of the
species.
Twenty thousand years ago the average
life expectancy of human beings was 20
years, and if they did not reproduce we
wouldn’t be here.
Times, values, requirements, societal
structure, and ways to survive have
changed over the millennia but biology
has stayed the same. Abstinence as a recommended means of contraception is a
religion-based value system with total disregard for biology. In addition, the sense
of guilt associated with a breach of a religion-based value system is capable of
causing conflicts and depression in young
people. I am not sure we as professionals
know what the adolescents understand of
We concluded that—with all the visitors
at the house and all the soda that was set
out (and with nobody free to supervise
how much he drank)—Tom had had a caffeine overdose and some PVCs (premature
ventricular contractions); he was reassured
when he learned that all he had to do was
stop drinking soda and he would be fine.
We ended the visit by agreeing that we
would talk again as issues came up. The
parents told me that the school was going
to offer counseling to the children.
Several weeks later, Ms. Smith was back
in the office with both boys to deal with
strep, and I took the opportunity to ask
how things were going for the family. Mr.
and Ms. Smith have good days and bad
days, as do the children, more so the older boy. The boys have pictures of Uncle
John. They are sad when they see any wedding picture, because they remember Uncle John’s wedding. Both are doing okay in
school; the 9-year-old is into sports; the 5year-old likes to read and joke around.
On Sundays after church, if the weather is good, the family goes to the cemetery,
which is an emotional experience. They
tidy up the grave; then the older boy reads
from the Bible and the younger one recites
a children’s prayer. I acknowledged that
this was a meaningful thing for them to
do, and further suggested that as time goes
by, it would be normal to decrease the frequency of the visits and to go instead on
special occasions and anniversaries.
I asked the mother whether our discussion at the time of the death had been
helpful to the family. She replied that it definitely was. She told me that the family
had felt great relief afterwards. They recognized that they were together and they
have someone to go to if they have a problem, and their overall reaction was “it’s going to be okay.”
■
DR. TOLCHIN is an attending physician at
Montefiore Medical Center, New York. She is
also a member of the PEDIATRIC NEWS
Editorial Advisory Board.
the emotional and physical consequences
of sex. Preaching abstinence to such an organism will generate distrust, self-doubt,
and guilt
Contraception and sex education are
the best scientific answers we have, and we
must utilize them wisely. And the AAP as
a scientific organization must follow rigorous scientific standards in its recommendations.
Amar Dave, M.D.
Ottawa, Ill.
Agreed: MRSA Is a Superbug
Dr. Christopher J. Harrison might be a bit
too casual in his outlook regarding methicillin-resistant Staphylococcus aureus
(“MRSA Panic Unwarranted,” ID Consult, November 2007, p. 16).
First, the two most disturbing aspects of
MRSA are its resistance to many (and
sometimes all) of the standard antibiotics
and its production of molecules which
Continued on page 24
24
Opinion
Continued from page 22
puncture and injure the immune cells trying to contain the infection.
Regarding the second point, Michael
Otto, Ph.D., of the National Institute of
Allergy and Infectious Diseases, has shown
that community-associated MRSA (CAMRSA) has a considerable amount of phenol-soluble modulin.
This complex destroys neutrophils by
forming pores on these white blood cells,
greatly contributing to the organism’s
deadly potential.
Although Dr. Harrison hates the terminology, this trait of MRSA does make it a
“superbug” with “flesh-eating” potential.
Secondly, although many of the pharmaceutical giants are able to develop new
antibiotics for these new strains of bacteria, costs are inhibitory.
In 2000, a report in the Journal of
Health Economics indicated a cost of
more than $800 million to develop (and
get Food and Drug Administration approval for) a novel drug with a new molecular structure.
That figure has been revised, to adjust
for inflation, to $1.3 billion. One must also
add the probable legal costs, given the penchant by lawyers to initiate lawsuits, especially when dealing with virulent organisms.
As the government pays more of the
cost for pharmaceuticals, including innovative drugs, this issue of development of
new antibiotics is woven into many aspects
of health care policy. As with most national health issues, there is not a quick solution to CA-MRSA.
Craig G. Burkhart, M.D.
Sylvania, Ohio
Dr. Harrison replies:
I thank Dr. Burkhart for his comments,
and I would stress that my outlook toward
E DITORIAL
A DVISORY BOARD
LILLIAN M. BEARD, M.D., George
Washington University, Washington
LEE SAVIO BEERS, M.D., George
Washington University, Washington
SUZANNE C. BOULTER, M.D., Dartmouth
Medical School, Hanover, N.H.
KAREN E. BREACH, M.D., private
practice, Charlotte, N.C.
STUART A. COHEN, M.D., M.P.H.,
University of California, San Diego
H. GARRY GARDNER, M.D.,
Northwestern University, Chicago
THOMAS W. MAUSBACH, M.D.,
University of North Dakota, Fargo
KEVIN T. POWELL, M.D., PH.D.,
pediatric hospitalist at St. Louis
Children’s Hospital
KEITH S. REISINGER, M.D., M.P.H.,
private practice and research at
Primary Physicians Research Inc.,
Pittsburgh
CHARLES A. SCOTT, M.D., private
practice, Medford, N.J.
JACK T. SWANSON, M.D., University of
Iowa, Iowa City
DEBORAH TOLCHIN, M.D., Albert
Einstein College of Medicine, New York
P E D I AT R I C N E W S • M a rch 2 0 0 8
MRSA is not casual. CA-MRSA has become an increasing problem in the office,
clinic, and hospital.
A recent report defines a USA300 lineage for most isolates of this strain of CAMRSA that seems to have appeared approximately 10 years ago.
It has acquired multiple antibiotic resistance genes and multiple virulence genes.
My column mentioned some such factors: “ ... most S. aureus can ‘eat flesh’ using coagulase and other enzymes.”
Dr. Burkhart points out that phenol-soluble modulin (PSM) was reported by Dr.
Otto’s group to be a candidate factor for
increased virulence, suggesting it to be
more important than Panton-Valentine
leukocidin (PVL).
However, Dr. Otto himself, commenting on the same report, did not claim that
that PSM was the single virulence gene
that determines the outcome of community-acquired MRSA infections.
PSM is a pleiotropic factor with multiple effects.
For example, PSM has long been noted
to be a factor in producing biofilm associated with Staphylococcus epidermidis, not a
highly virulent or aggressive pathogen.
Biofilm, however, reduces penetration of
even effective antibiotics to target bacteria.
Biofilm also provides an environment that
allows staphylococci of any species to adhere well to foreign bodies or even to human tissue.
When a pathogen combines PSM with
antibiotic resistance and other virulence
factors, it can be more difficult to treat,
particularly late in invasive disease. So
PSM’s major impact may not relate only
to the injury of the immune cells trying to
contain the infection, as noted by Dr.
Burkhart, but to other effects and their interaction with more than a dozen factors
or enzymes which have accumulated in
this MRSA strain.
These include some that most clinicians
may recognize, for example, staphylococ-
Opinion
M a r c h 2 0 0 8 • w w w. p e d i a t r i c n e w s . c o m
cus protein A (a super antigen), leukocidins, and coagulase itself.
Most of these same virulence factors
also occur (with less frequency) in methicillin-susceptible S. aureus.
So MRSA is not the only staphylococcus
capable of producing severe or lethal disease.
The USA300 CA-MRSA strain owes its
potential for severe disease to a constellation of factors together with a universal resistance to current b-lactams, macrolides,
an increasing resistance to quinolones,
and occasional although potentially increasing resistance to clindamycin.
This combination can, in selected hosts
or with delayed/inadequate therapy, lead
to serious outcomes.
However, current data still indicate that
the overwhelming majority of CA-MRSA
infections are mild and can be treated on
an outpatient basis with trimethoprimsulfamethoxazole or clindamycin.
Most CA-MRSA strains are also susceptible to doxycycline and rifampin. Almost
all are susceptible to linezolid and all have
been susceptible to vancomycin. Our current tools to treat CA-MRSA are still adequate.
Many new drugs aimed at resistant
gram-positive pathogens including CAMRSA are in the pipeline.
These include the fourth-generation
cephalosporins, ceftobiprole, and cerexa,
as well as the once weekly-dosed drug, dalbavancin.
These drugs are more than halfway
through the expensive regulatory and testing phases noted by Dr. Burkhart.
We still need to be vigilant in detecting
CA-MRSA in our patients and treat it appropriately before it produces severe outcomes. Our other role is to provide practical advice on measures to attempt
prevention.
Neither adding to the panic nor recommending excessive interventions will likely be useful.
25
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