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Talking to children about death can be challenging
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Patient encounters often focus on future potential. Inevitably, discussion may center on death and dying. This is true for health care providers for patients of all ages. Given its unique nature, understanding how to talk to children about death and dying is a crucial part of oncologic practice.
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Children are often bombarded by mass media with manifestations of death — on television, in movies, in video games, etc. The real question becomes: What is their interpretation of these cues? Research has shown that by age 3 a child can recognize when something is dead, by age 6 a child can understand that all living creatures die, and by age 9 they begin to appreciate their own mortality. Four concepts listed in table 1 outline fundamental principles an individual should grasp to fully understand the finality of death.
A child’s appreciation of these concepts is primarily affected by the psychological phases they have attained (see table 2). Emotional and experiential factors also shape a child’s comprehension. Life-threatening illness has been shown to be a powerful accelerator of a child’s understanding of death. The “death culture” of the child’s family also plays a strong role in his understanding of death and response to a discussion about it.
The approach to discussing death with a child should be similar to that used to discuss bad news with any patient. Most importantly, provide accurate and helpful information. This can be accomplished by optimizing the discussion’s setting, learning what the child knows and what he/she wants to know, giving small amounts of information at a time and responding to the reactions and feelings. A straightforward approach is not always successful and sometimes one must use creative communications styles; flexibility is the key. Many children are more willing to communicate through nontraditional means such as drawing, telling a story or talking to stuffed animals. Respect the child’s need to be alone and desire to share; allow communication, don’t force it. Also, be specific and literal in explanations of death, ie, do not use euphemisms. In circumstances in which the child is the individual who is dying, acknowledge that life can be complete even if it is shortened; empower the child to take control of the situation and pursue goals.
Talking about death with a child can seem daunting, but understanding the characteristics of developmental stages in conjunction with the child’s experiences can prepare one for the conversation. Ultimately, as in all interactions, be honest, respond to cues from the patient and be flexible.
Christine Zawistowski, MD, is a Pediatric Palliative Care and Intensive Care Doctor at the Cancer Institute of New Jersey and Bristol-Myers Squibb Children’s Hospital at Robert Wood Johnson University Hospital, New Brunswick, N.J.