Dealing with siblings

[nocturncal]

Hey!

This is my first of many posts to come! I just got accepted into a new grad program in the PICU! :-D. I worked in peds at the same hospital in a desk capacity, and I ran into something that really kept me up this past week.

A patient got admitted with an ICH and things weren't looking too good. I didn't know the exact details, but all the details I got through the 9 year old brother who was really mature for someone his age. He would talk about how he wanted to either be a doctor or nurse when he grew up because of how the staff cared for his sister.

Over the course of 2 days we got to know each other fairly well. I let him do simple tasks at the desk like stapling papers. We made him a name tag and gave him a disposable stethoscope because he wanted to be involved.

Then one day he came up to me and I asked him how everything was going. In the calmest voice he told me that his sister had died and that she was in a better place where she couldn't feel any pain anymore. I was devastated. It was the first time where I didn't know what to say, other than ask him how he was doing. I was at a loss of words.

I love working in the PICU and dealing with families (did my preceptorship in the same unit that I got hired), but I always wonder how I will deal with those times where I will have to help families at their time of loss. Has anyone experienced a time where they were at a loss for words? How do you help those cope with a loss of a loved one, especially a sibling?

[missnurse01, MSN, RN]

Well, I work adult ICU but have had kids die when I worked in the ER. Of course we didn't really know the siblings. In general I let the person grieving guide my response. Are they looking to talk? For a shoulder to cry on? Reassurance that the end wasn't painful? etc etc I usually ask them if I can do anything for them and let them know I am there for anything if they need me. I know it's different with kids. My son died when he was 8, he was the eldest. The kids for years would just randomly say things about him being dead, or how can we miss him when he is right there in the urn, etc. I think for kids they try to work thru their grief in a different way, so I would try to honestly answer their questions or reflect back their statements if that is what they were giving me. it's hard to know what to say-really there is no right thing. But we feel that we should say something. So I let them talk and know I am there.

[Double-Helix, BSN, RN]

Do you have a Child Life staff on your unit? Child life specialists are trained in communicating with children and doing medical teaching- including teaching about death. I highly suggest utilizing their expertise in these situations.

Like adults, children will have different ways of processing their grief. Of course, children of different ages/development levels will have different understandings of death and grieve differently, but even children of the same age/development will behave differently. It's important to follow the child's lead, and the parent's wishes in these situations. Sometimes the child will want to see the sibling after they have passed. In most cases, it's a good idea to let them. Many times parents or even staff feel that this will be traumatizing for the sibling and they try to shelter the sibling from the death. However, allowing the sibling to see the child that has passed can help provide closure and a more concrete understanding of the situation.

We had a little girl pass away on our unit who was about 5 or 6. She had a twin sister. After she passed away, the twin wanted to see her sister to say goodbye. She calmly walked into the room, climbed into bed with her twin and told her that she loved her, and that she would miss her. Being able to see her sister and say goodbye was actually very therapeutic for her.

Most of the time (just like with adults) the best thing you can do is listen to the child if they need to talk. Depending on their age/development, they may or may not want to talk about the death. Sometimes, especially older children will have very mixed emotions. They may be upset about the death, worried about their parents, worried about how their life will change now, and in some cases they can even feel relief. This is especially true if the sibling that passed away had a chronic illness that required a lot of the parent's time and attention. You can tell the sibling that it's okay to have lots of different feelings and to not know what to say or do. However they are feeling, it does not make them a bad brother or sister.

Often one of the major tasks you might have related to the death is helping the parents explain to the sibling. This can be very difficult, so I can't stress enough the importance of Child Life. If the parents have specific religious beliefs (i.e., the sibling is in Heaven), make sure you are aware of that so you can include that in your explanation to the child. Use simple language that they can understand. If they do want to see their sibling (and the parents agree) explain how the child will look and feel.

Finally, I want to stress that children, even young children, understand more than we give them credit for. It's rarely a good idea to try to hide illness and death from a child, even with the intention of protecting them. Children are intuitive. They know when something is wrong and, in most cases, it's better to explain the situation simply and honestly. Otherwise, the child will come up with their own explanation- and usually end up thinking that they did something wrong or somehow caused the problem.

I can best illustrate this intuitive knowledge through another example of twins. At about 20 months old, both boys (identical twins) had been very sick with the same chronic and fatal illness for over six months. One (A) was slightly healthier than the other (B) and able to be off of the monitoring equipment, go for walks, etc. B was more sick and really couldn't leave the hospital room that they shared. Both boys were very close to their father, who stayed with them 24/7, holding them, playing games, taking A for walks around the unit, etc. Like most siblings, they were jealous of each other and if daddy was spending time with B, A would often cry and fuss until he got the attention back. If daddy were in the room, A would refuse to allow any of the staff to hold him or remove him from the room.

Eventually, B got much sicker and it became obvious to us that he would not be with us much longer. In those final days, A's personality changed completely. He would sit quietly in his crib or stroller and let his daddy hold his brother. He never cried or demanded attention from his father those last days. He simply stayed quiet and watched. Shortly before B passed away, his parents wanted to be alone with him. A allowed the nurses to take him from the room without a peep. He hardly made a sound and never fussed to go back to his father until after his brother had passed away and the parents asked for him to come back in.

You can never tell me that A didn't know that his brother was very, very sick, and that B needed his daddy's attention. Nothing else can explain the sudden change in A's behavior.

I hope I helped answer some of your questions. Again, if you have Child Life available, please utilize them and, in your free time on the unit, sit down and ask them for some practical advice for these situations. As you care for children at the end of life, and in their death, you will become more experience with how to be with a grieving family. Helping families through their grief is a learned skill- and one that you will become more familiar with throughout your time in PICU.

[LoveSbux]

Oh Ashley. I have no idea how you do the job you do. I cannot even imagine having the strength to go to work and deal with the situations you speak of. You're a special, special person.

[umcRN, BSN, RN]

We had a little girl pass away on our unit who was about 5 or 6. She had a twin sister. After she passed away, the twin wanted to see her sister to say goodbye. She calmly walked into the room, climbed into bed with her twin and told her that she loved her, and that she would miss her. Being able to see her sister and say goodbye was actually very therapeutic for her.

Something about twins huh? We had a little guy who was going to have care withdrawn, he was 3 and had a twin sister. She wanted to see him so we got him cleaned and covered (his chest was open, on ecmo) best we could and she snuggled right up in bed with him to read and talk to him. Not a dry eye on the unit that day

[tryingtohaveitall]

Something about twins huh? We had a little guy who was going to have care withdrawn, he was 3 and had a twin sister. She wanted to see him so we got him cleaned and covered (his chest was open, on ecmo) best we could and she snuggled right up in bed with him to read and talk to him. Not a dry eye on the unit that day

Yes, there sure is. It always seems even more tragic when a twin is lost.