7 FAM 200 APPENDIX C
DEATH OF CHILDREN, STILLBIRTHS, and MISCARRIAGES
(Office of Origin: CA/OCS)
7 FAM 210 appendix c INTRODUCTION
a. One of the most difficult situations a consular officer may encounter in assisting U.S. citizens abroad is the death of a child. This appendix provides guidance to help you aid families.
b. A child's death is often viewed as particularly tragic. Unlike an adult's death, a child's death is often felt to be especially unnatural or unfair. The following thoughts are common when dealing with the death of a child:
Children aren't supposed to die. It's not natural.
The child never had an opportunity to experience a full life.
The child was innocent and didn't deserve to die.
The child was helpless to intervene or change the outcome. (This thought may be particularly strong if child abuse is suspected.)
c. This appendix also includes guidance on assisting families who suffer a miscarriage or stillbirth abroad.
7 FAM 220 appendix C GRIEVING FAMILIES
a. Most consular officers have no formal training in coping with pediatric deaths. Being unprepared for these intense experiences can negatively affect consular officers and the quality of assistance provided to families.
b. After the death of a child, families commonly have very strong crisis and grief reactions.
(1) Crisis: Crisis involves powerful and often uncontrollable emotions. Individuals in crisis may need assistance in handling their emotions. Recruiting other family members, clergy, friends, and others to support an individual in crisis is often helpful.
(a) Consular officers should repeatedly recommend specific actions for the safety of the person in crisis (e.g., "Don’t drive.” “Let me call a friend to take you home.”)
(b) Because individuals in crisis often behave illogically or have impaired decision-making abilities, responsibilities to dependents may be forgotten. Therefore, it is wise to inquire about other children or elderly family members who may require assistance.
(2) Grief: Grief is a natural reaction to the death of a child. The grief process begins with understanding that the child's death is real. 7 FAM 200 Appendix B provides guidance about grief and bereavement. Confer with Locally Employed Staff or other local resources, including as appropriate the Regional Psychiatrist, to ensure cultural sensitivity.
(a) Host country practices may differ from those of the United States regarding bereavement (see 7 FAM 200 Appendix B).
(b) The attending physician may allow (not force) family members to see or hold their dead child. However, the family should be prepared for what will be seen and possibly misunderstood without prior explanation (e.g., endotracheal tubes, chest tubes, other resuscitation equipment) when they enter the resuscitation area. Occasionally, offering the family the opportunity to take with them a memento (e.g., a lock of hair) helps.
(c) Suffering is a natural part of grief. Consular officers should expect and accept a wide range of emotions of families suffering from the loss. As appropriate, consular officers may wish to provide families information on local psychologists or other counseling services. If the family members are in the United States, victim assistance specialists in CA/OCS/L (ASK-OCS-L@state.gov.) may assist in connecting the family to local grief and bereavement specialists.
(d) Families often feel guilty. If possible, reassure families that they did not contribute (either by acts of commission or omission) to the child's death. This may best be done by attending physicians and other medical staff, clergy, or social workers. Reassuring families that they did everything they could is important.
(e) Do not give false hope while respecting the family members’ religious beliefs or lack thereof.
(f) It is extremely helpful for consular officers to remain with families as they deal with local officials. An understanding of local medical examiner, police, funeral home, and hospital policies and procedures is necessary to provide a road map to survivors.
(g) Families should not be placed in the position of consoling the health professional or consular officer.
(h) Violent reactions from survivors are rare. However, be aware of this possibility and protect yourself. As with a potentially violent psychiatric patient, do not allow your access to the room exit to become blocked. If possible, arrange for others to accompany you.
(i) Often, family members already suspect that their loved one is dead. When interacting with the family after death, consider the following suggestions:
When talking to families …
Use the child's name when speaking with family members.
Speak in short sentences; use plain language (avoid medical jargon).
Avoid euphemisms for death (e.g., "gone to a better place"); use culturally sensitive appropriate words such as “passed away” or “died”.
Try to make eye contact and speak to all family members, not just the most vocal ones.
Look for nonverbal communication from family members. Be aware of your body language. Try to sit. Touching an arm or shoulder can be appropriate.
If expressions of anger are directed at you or health professionals, try to accept them without fighting back. The family member may just be venting. If family members have gross misconceptions, attempts at education are reasonable. If resistance is encountered, it is probably wise to return to the subject at another time and place.
Do not "hit and run." If you say something hard, remain with family members long enough for them to absorb it emotionally.
Try to be comfortable with silence. Sometimes doing nothing is actually doing something. Your presence alone can help family members.
Accept the family's discomfort. You can support family members in their pain, but removal of the pain is not within your abilities as a consular officer.
Do not attempt to find a silver lining in discussing the death.
Deeply religious families may find great solace in prayer, religious observance, or a philosophical conversation. Consular officers may attend such services if invited by the family, and may assist in directing the family to religious organizations in the host country, preferably in the family’s denomination.
(3) Victim Assistance: If the child’s death was the result of a crime; 7 FAM 230 ,7 FAM 1900, and the consular victims of crime resource notebook available on the CA/OCS Intranet (Specific Types of Crimes) provides guidance: Guidelines for Victim Assistance in Homicide Cases; Homicide Background Reading; Homicide Case Referrals. If the death occurred as a result of an act of terrorism; 7 FAM 1800 provides guidance. Deaths resulting from violence can be even more difficult than a death due to disease or accident.
(4) Organ Donation: Families may inquire about the possibility of organ donation. The host country may not have a tradition of organ donation, particularly of children. Consular officers should assist families in talking to local authorities about this subject. The generosity of one family whose child was killed in Italy prompted a marked increase in organ donation.
The Nicholas Green Foundation
NOTE: This is a very compassionate, but emotional Web site.
7 FAM 230 appendix C STRESS ON CONSULAR OFFICERS ASSISTING FAMILIES WHO HAVE LOST A CHILD
a. Because a child's death may be viewed as especially tragic, consular officers may have strong feelings of nonspecific sadness and loss. In the aftermath of a pediatric death, you may have feelings that make it difficult to maintain composure. Natural psychological defenses are unconsciously summoned to assist you in maintaining composure. While maintaining a professional demeanor, you should also avoid appearing to be remote, distant, or cold.
b. Consular officers with children may be especially vulnerable to an emotional response to a child's death. If their children are nearly the same age as the deceased, consular officers may realize suddenly, perhaps for the very first time, the possibility of losing their own children. Consular officers with children may also identify closely with the parents' loss. This is also true for consular officers who do not have children of their own, but have nieces or nephews or friends with children.
c. Consular officers need not be embarrassed if a pediatric death produces strong feelings within them. It is uncommon for a person to be totally dispassionate in the circumstances of a child's death. Do not hesitate to seek assistance from family, friends, clergy, and other professionals in helping to manage your own feelings. (See 7 FAM 1800 Appendix A, Managing Stress and Consular Crisis Work.)
d. If consular officers feel angry because the death is due to abuse or neglect, it may be helpful to remember the limits of the consular role. Others (i.e., police, courts, juries) have the responsibility to conduct an investigation, adjudicate, and assign guilt. Directing anger at the situation, but not at any individual, can avoid the possibility of causing great harm by placing guilt on the wrong person.
7 FAM 240 APPENDIX C REFERENCE AND RESOURCES FOR PARENTS WHO HAVE LOST A CHILD
a. Consular officers should be familiar with resources in the host country for families in these tragic circumstances.
BBC Coping With Grief Childhood Death
U.K. Child Death Helpline
b. The following are selected on-line material that may be useful. Do not provide such referrals in your initial conversations with surviving family members.
The Death of a Child the Grief of the Parents A Lifetime Journey
National Funeral Directors Association Discussing Death With a Child
Hospice Talking to Children About Death
National Center for Grieving Children and Families
American Cancer Society Discussing Death With a Dying Child
American Heart Association Coping With the Death of a Child
Pregnancy Loss and Infant Death Alliance
Death of an Infant, Child, Grandchild
American SIDS Institute (Sudden Infant Death Syndrome)
MEDLINE PLUS SIDS
Parents of Murdered Children
7 FAM 250 APPENDIX C STILLBIRTHS AND MISCARRIAGES
a. Posts may be called upon to assist U.S. citizen families abroad when birth results in stillborn infants, miscarriages, or when infants die shortly after birth. Different countries have different standards regarding this distinction, which can determine the host country policy on the issuance of a birth or death certificate and release of remains to the family.
b. Report of Death: In the case of a stillborn child, the consular officer may issue a report of death, provided local authorities have issued a death certificate or the attending physician provides a statement regarding the stillbirth, and the parents submit required evidence of their own identity and citizenship. The remarks section of the report of death should reflect the circumstances. Reports of Death are not generally issued for a miscarriage, but if it is a late term miscarriage which would be considered a stillbirth in the United States and the family asks for such a document, consular officers should e-mail ASK-OCS-L@state.gov., which will provide immediate guidance. (See 7 FAM 270.)
c. Report of Birth or Stillbirth: 7 FAM 1470 provides guidance regarding issuance of Reports of Birth and Reports of Stillbirth.
d. Consular Mortuary Certificate - Disposition of Remains: Posts should assist parents wishing to bring the remains to the United States. A consular mortuary certificate should be modified accordingly. CA/OCS is aware that some countries use terms such as “medical waste” to describe a miscarriage. Do not use such terminology in any consular documentation or in any conversations with families. If no local death certificate is issued (due to host country interpretation of the definition of miscarriage v. stillbirth), posts may assist families in communication with local authorities to obtain release of remains on a humanitarian basis. Host country authorities should be asked to execute some certification as to the contents of the hermetically sealed container and the fact that no communicable disease is involved. (See 7 FAM 250.)
e. Bereavement Assistance: If the family is residing in the host country, you may direct them to local resources for bereavement assistance.
International Stillbirth Alliance
Compassionate Friends Stillbirth
SANDS Stillbirth and Neonatal Death Society U.K.
The MISS Foundation
Missing Angels Foundation – Legislative Reference Site
Bereavement and Childbirth in Ireland