Dundalk, Md., pediatrician Diana Fertsch recalls a 3-year-old patient who recently died in her sleep for no clear reason. Paramedics tried to resuscitate the child, but to no avail. When the hospital emergency department notified Fertsch the next morning, she was both shocked and flooded with guilt: "I had recently seen this child for his annual visit. Was there something different about this child? Something subtle we missed?"

But from such experiences, Fertsch has learned, it’s critical for her as a pediatrician to deal with her emotions and, in her words, "get centered" so she can be more available to the parents. So, before contacting the family Fertsch first tries to reach the hospital clinicians who cared for her patient to get as many details as possible about the child’s condition and death. She also solicits her colleagues’ thoughts. Then, when she contacts the family, she focuses on listening, not talking, and on being authentic and honest, more a person than a physician: "Families, given the opportunity, really do want to share the details of what happened. They’re upset, shocked, and they have their own guilt. I ask if it’s okay if we share together, and 95 percent of the time they say fine."

Fertsch also asks the family if she may attend the viewing, which supports both the family in grief and the role of the pediatrician’s office as a multi-generational medical home for families. Participating in the funeral, she adds, has a unique healing effect on the pediatrician: "I think it enriches you. It is a time of extreme sadness, but it also a time to reflect on the blessing that the child was in the world. Your being there makes a statement that you care and are available."

But Fertsch will admit that engaging families in such circumstances is challenging. She recalls caring for an acutely ill patient early in her practice, then finding herself devastated when the child succumbed despite her best efforts. She processed the events over and over again, searching for insights to learn from the tragedy. At the same time she stayed connected with the family and provided them with resources for bereavement counseling.

"Several years later the mother called to let me know she was pregnant and she wanted me to be the pediatrician because I knew what she and her family had been through," Fertsch says. "I still think of that infant 15 years later, but I was so grateful for the closure that comes from connecting with families."

So, how well do community pediatricians do with sharing bad news? Through Fertsch’s lens it’s highly variable but all pediatricians can get better at helping families, and themselves, through these tragedies. Some pediatricians may feel uncomfortable dealing with a patient’s death, and pull back from the family.

Pediatricians do need to recognize, Fertsch says, that they have established a relationship of trust with their patients and their families, in many cases over decades. Patients and families don’t perceive the pediatrician’s practice simply as a practice, but as a multi-generational medical home where they not only trust in the care of their children, but also willingly share their lives. In return pediatricians gain insights into families’ strengths, vulnerabilities and cultural beliefs, which allow them to better counsel the parents, especially when the news is bad.

"Even when I feel horrible about the pace of a chronic illness, I think parents still perceive us as therapeutic," Fertsch says. "Sometimes we don’t really get the importance of our therapeutic relationship, but we need to."