Communication tips with parents and children?

Pediatric Critical Care Columnist · Jan 20, 2008

What do you say when a parent is frustrated that the doctor is taking to long to visit them?

I have to know if they're talking about their pediatrician, who may or may not have much input into the in-hospital care of the child, or the hospital attending. I usually start by explaining that their pediatrician also sees patients in the office most days, and that s/he times hospital rounds depending on what kind of day it was in the office. Many will make a quick round really early in the morning before they go to their office, if their office is close enough to the hospital to make that practical. Most of them though round at the end of their office day, the timing of which will vary. Unless we're waiting for discharge orders, that usually isn't a huge concern and most of the time no news is good news. The same basic principle goes for specialists. If they're talking about the hospitalist, I try to guesstimate an approximate time to expect them based on what I know about what's going on with the rest of the floor. If there's something really important that they want to discuss, I will sometimes offer to contact the doc and see if we can pinpoint a time for a chat. If they are waiting around and not going for lunch "in case" then I promise them I'll either call them on their cell or page them overhead when the doc is available.

What do you say when a child is scared about getting an IV inserted?

First I acknowledge that there will be an owie factor. If your hospital allows the use of topical anesthesia like EMLA or Maxilene, explain how it works, but don't tell them that it will completely eliminate the pain, because it doesn't quite. The developmental stage of your patient will influence how you say things and the choice of words you use. Tell them that you'll pick the very best vein to use and that you'll tell them before you do anything that will hurt. Remind them that the worst part will be going through the skin. Don't use the word "needle", but say "tube" instead. If you use a lot of friction when cleansing the skin, it desensitizes it to a degree and makes the process less painful... if you have everything else ready and are talking to them the whole time they may not even be aware that you're doing it until it's done. When you're done tell them how helpful they were, what a great job they did at staying still, how brave they were, whatever will give them some positive feedback. I sometimes will say, "Now, was that totally horrible?" when the last piece of tape is in place, and am usually rewarded with a "Nah, not really."

What do you say to parents when their child seems to be on the brink of death? I had clinicals and a trisomey 18 baby was a month old. The parents thought the baby had a cold but she was obviously struggling to stay alive. It is amazing that she lived past the first week. How can you explain to the parents how critical the child is in a theraputic manner?

This one is a little tougher. You have to be honest but not too negative. No matter whether the child has something potentially reversible or not, I always praise the parents for how obviously they love their child, what a good job they've done at caring for the child and how lucky the child is to have them as parents. If they're feeling guilt about something, I try to reassure them (if appropriate) that they did everything right based on their knowledge of their child... and who knows a child better than a parent? Then I tell them that I know they're struggling with all the information they've been given about their child's condition, trying to sort it all out and make sense of it. I encourage them to ask questions. If they ask specifically about their child's impending death and the progression of changes, I usually start with, "In my experience" and then describe how things will happen. If we're taking a child off life support, all the information I have about the child will be important to what I tell them. Some children die within minutes, others will continue to breathe for hours, days, weeks... I assure them that although the focus of our care has changed, the care itself will not. The child will continue to receive comfort care and whatever other nursing care is ordered. And I offer them pastoral care, social work supports and whatever else I can think of that might be of practical use to them. It's a crucially important but difficult to acquire skill in pediatrics to be able to provide the right words at the right time. If you can identify role models in your workplace, listen to how they talk to families, pay attention to their choice of words, and tone of voice, their use of body language and touch. It'll help.

kristenncrn · Jan 29, 2008

I absolutely agree with everything janfrn says!

If you are a floor nurse, like I am a lot of the time, getting the docs in to the room can sometimes take forever! We are a teaching hospital, so the residents and attending round on everyone, plus the kids ED plus the PICU. If the parents are really upset, irritable or honestly just don't understand, I just make sure that they know that. And to be honest, I sometimes throw a little dig in there (all in the name of education) when if they are responding to a peds trauma or intubating or something like that, I explain how they have to triage. Then I say something like "when my son was here I just kept telling myself how fortunate we were that we weren't the family that everyone was waiting on. This is one situation where I didn't mind being lower on the waiting list." With a smile, of course!

Sometimes it works, sometimes it doesn't. But if their kid is essentially WELL, it may help put things in perspective. I also have no problem paging if the docs take too long, though.

About the IV - I do have one tip that really does seem to work. After about age 5, I always tell kids with no IV experience that some kids say that it doesn't hurt much at all and some kids say it's a bigger ouch. Then I make them promise to tell me afterwards what they thought. I always, always, always try and give kids a job or task that makes them my partner somehow. Child Life Specialists are also great to have around.

About the baby - I actually wouldn't give a diagnosis without the support of the entire care team. Don't get me wrong - I don't think it is the "doctor's job" or anything. But I may not know the whole story (much like they may not.) In a situation where the parents seem to have no idea that their babe is "not meant to live a long life," I offer my support, my assurance that we are doing everything that we can to care for their baby and I explain everything that is going on to the best of my ability. I tread carefully about pulling the rug out from under them - no matter how shocking I find their denial.

Congrats on clinicals! Peds is awesome, by the way!

Kristen