Before death
Often the death of a child can be anticipated. Although hospital admission is frequently necessary, most children and families wish to spend as much time as possible at home. With appropriate planning and support, most symptoms can be controlled effectively at home. Domiciliary medical care can be provided by the GP in consultation with hospital staff. Palliative care agencies can provide specialised nursing care and a range of other services. Parents may be reluctant to accept the assistance of such services because they associate the term ‘palliative care’ with imminent death, ‘giving up’ and hopelessness. Explaining palliative care as an approach that aims to improve the quality of life for children with life-limiting illness and their families may help overcome some of this resistance. Palliative care can be provided alongside ongoing attempts to modify or even cure disease. Parents do not have to abandon hope in order to receive support from a palliative care service.
Although home care offers many advantages to the family, it is not without difficulties and parents are subject to physical, emotional and financial stress. Re-admission to hospital or hospice should be easily and readily available. A letter detailing the child’s condition, plans in case of sudden deterioration and people to contact will facilitate appropriate care in an emergency.
Giving bad news to families: the interview in a hospital setting
The way in which difficult information is communicated sets the stage for the working relationship between staff and family. Staff need to be aware of how their own feelings of anxiety, sadness and impotence may influence this process. Most families appreciate honest information given in an empathic way and tempered with a sense of hope. Realistic hope may be offered in terms of ongoing support, attention to symptoms and help to maximise the child’s quality of life.
Personnel
The consistency of the healthcare team in a child’s final illness is essential. Medical interviews with families, in hospital, should be led by a senior doctor together with a junior doctor, nurse, social worker or pastoral care worker. The presence of more than two of these people at an interview may be difficult for the family. Other healthcare team members, especially the family doctor, community nurse and others outside the hospital, must be closely informed.
Comfort
Choose a physically comfortable location where interruptions can be avoided. The open ward or corridor are not the places for interviews. Whenever possible, divert phones and have someone answer pagers. Try to allow plenty of time for the discussion.
Giving clear and simple information
- Begin by asking the family to give their understanding of the situation.
- The prognosis is usually best given first.
- Give an explanation of the disease process.
- Try to determine what it is the family wish to know.
- Avoid the use of unexplained medical jargon.
- Avoid information overload. There is time to deal with complex medical issues at later interviews.
- Avoid ambiguous phrases such as ‘we might lose the battle’ or ‘he’s passed away’. The words death, die or dying should be used.
- Allow expression of emotion.
- Offer to help the parents tell important others such as grandparents and siblings.
- Initial shock may render parents unable to process detailed information, so multiple opportunities for discussion should be provided.
Respect silences
When bad news is delivered it is best to remain silent until the parent responds. This sometimes takes minutes and can be very uncomfortable. These are important moments; they should not be interrupted.
Responsibilities of the accompanying members of the healthcare team
At a medical interview, the accompanying members of the healthcare team need to be sensitive to the parents’ needs and to watch for misunderstandings. If they do not understand the medical message, it is unlikely that the parents will. At an appropriate time, the accompanying team member may ask the doctor to clarify some of the explanations given, but it is important not to interrupt a train of conversation or the silences that occur.
The senior doctor should inform the family that all possible reasonable measures will be taken to preserve their child’s life. It is not necessary to repeat this message.
When the senior doctor has concluded discussion with the family, other members of the health team may stay with the family for a time in order to offer their support and explore their understanding of the information provided.
Interpreters
The availability of trained interpreters for people with a language other than English is essential. Do not use other family members or friends as interpreters.
Adequate relief of pain and distress of the child
The most common reason for inadequate treatment of physical suffering is the failure to recognise it. It is important to actively ask about symptoms and consider potential contributing factors. For example, fatigue may be an expected part of terminal illness but it may also be due to factors such as anaemia and depression, which may be amenable to treatment.
Many parenteral medications (e.g. morphine, midazolam, and haloperidol) may be successfully administered subcutaneously rather than i.v. and this offers many advantages to children needing palliative care. Community palliative care teams are able to help establish and monitor subcutaneous infusions if the family wishes to be at home. Planning for symptom development and escalation is essential, such that appropriate medications are available for use in a crisis.
Parents and health professionals may be concerned about the use of opioids and benzodiazepines and fear they may hasten the death of the child. These concerns can result in needless suffering. There is no evidence that the appropriate use of medications such as morphine (i.e. when commenced at a conservative dose and titrated to effect, with the intention of relieving physical symptoms such as pain and dyspnoea) alters the timing of death. It is not ethical for a child to suffer as a result of misconceptions about the use of medications. Concerns about the treatment of physical symptoms should be directed to the child’s paediatrician, a children’s pain specialist or a palliative care specialist.
Communicating with children about death and dying
Parents may feel compelled to protect their children from ‘bad news’. Children often know a great deal about their disease and prognosis even when they have not been ‘told’. They may not reveal what they know, for fear of upsetting their parents who may (falsely) assume the child knows very little. Attempts to protect the child from accurate information may leave them feeling anxious and isolated as they sense distress in those around them and generate incorrect explanations for this such as ‘I have been bad’ or ‘Mummy and Daddy are angry with me’. In general, it is best to encourage parents to be honest with children, but information needs to be provided in a manner appropriate to their cognitive ability and developmental level. It may be helpful to anticipate questions and work with the family in planning responses.
It is important to listen to what the child is asking. The child who asks ‘Am I going to die?’ may actually not be concerned about dying as such but more about who will look after their parents, what their friends will think, or whether they will be in pain. A response such as ‘What makes you ask me that?’ will provide further information upon which to base an answer. Children may not wish to express themselves verbally or directly. Stories, artwork, music and play allow expression, build trust and facilitate communication.
Concepts of death
The child’s concept of death becomes more complete with development and life experience. A number of variables influence this process, so statistical averages serve as a guide only. Preschoolers typically view death as a reversible phenomenon (e.g. Snow White) and do not yet appreciate that people die as a consequence of age, illness or trauma. Magical thinking may lead them to believe they have caused death through bad behaviour or thoughts. By 7 years of age most children understand the concepts of irreversibility, causality, universality and cessation of bodily functions. Most 8 year olds also understand that dead people cannot feel pain or fear.
Siblings
Siblings of children with life-threatening conditions suffer not only the distress of having a brother or sister who is sick and dying, but the isolation of having parents who are frequently either physically or psychologically unavailable to them. They may feel guilty that they do not have the condition, or may fear for their own health. They may resent the attention given to the sick child. They may feel they have somehow caused the illness. Siblings often don’t want to burden their parents with their concerns and may express distress through developmental regression, school failure and physical symptoms.
Siblings benefit from inclusion in visits to the hospital and where possible, the care of the child. Staff can help by dedicating special time to children in which they may be given information and allowed to ask questions. Specific reassurance that the illness is not their fault may be needed, especially for siblings who have donated organs.
Preparations for death
Time and space
The healthcare team must not overwhelm families. Parents need to spend time alone together and with their child, either in the hospital ward, a quiet room, at home, or at a children’s hospice.
Arrangements
These may need to be made for baptism, religious advice, photographs, videos and other memories of the child.
Permission
Many families have specific needs and sometimes they are unsure whether these are permis-sible. If these issues can be anticipated and discussed, the family’s wishes may be facilitated.
The child
The preparation for death is largely dependent on the age and particular illness of the child. The older child with a chronic illness is often aware of impending death and the healthcare team needs to be sensitive to the family’s and child’s wishes in the delivery of information.
The place of death
Decisions need to be made about where the child will die. This largely depends on the family, but it may be at home, in a hospice or the hospital. When appropriate, the child may be included in this planning.
Taking the deceased child’s body home
Some families wish to take their child home after death. This may be for a brief period or several days. This allows family and friends to say goodbye and can be very helpful in facilitating the grieving process. The funeral may then commence from home, or the family may be happy to allow an undertaker to remove the deceased body earlier. Families should be advised to consult with a funeral director before taking the child home. In most cases parents can transport their child’s body from hospital to home, but it is important for the medical team to provide them with a brief document explaining the situation.
The sudden death of a child from a wide variety of causes may occur in the community, the emergency department, or a hospital ward. Sudden infant death syndrome (SIDS – see p. 219) is particularly traumatic because it is the unexpected and unexplained death of a previously well infant. Although most of the preceding guidelines are applicable, there are some additional considerations regarding sudden death.
Resuscitation
This is frequently attempted either at home or in hospital. Some parents may wish to be present and they should not be excluded, but an experienced health professional needs to be available to provide them with support.
When it becomes clear that further resuscitative attempts are futile, it is the responsibility of the senior hospital doctor, GP or senior ambulance officer to:
- Introduce themselves and explain their role in the child’s care.
- Explain to the family what happened and what treatments were attempted (this may need to be repeated).
- Listen to the family’s account of the events.
- Allow the family to express their emotions.
- Provide a non-judgemental understanding for any pre-existing difficult family relationships.
- Provide access to telephones for the notification of relatives.
- Facilitate the attendance of siblings and other important family members at the hospital.
- Encourage the family to see the child’s body, say their farewells and take as much time as required.
- Ensure the family can reach home safely.
The family response
The immediate responses to sudden death vary from emotional withdrawal to outbursts of profound grief. Unexpected reactions commonly occur; for example, anger towards healthcare providers who have done their best. Any response is appropriate, provided it does not threaten harm to self or other people.
Brain death
Brain death is defined as the irreversible cessation of all brain function including that of the brain stem. There are strict clinical criteria for the determination of brain death. Occasionally it becomes clear that a child who is dependent on mechanical ventilation is brain dead. In such a situation:
- The senior doctor needs to explain the meaning of brain death. Avoid using confusing words. The unambiguous message that death has occurred, together with the distinction between brain death and coma, needs to be clearly explained.
- It can be helpful to say that, although the child’s body is still alive, the brain is dead and therefore the person is dead.
- It frequently helps parents to understand that their child has died by encouraging them to witness some or all of the brain death tests.
- The request for organ donation generally requires a separate interview, made in a positive manner, without coercion and with the clear acknowledgement of the family’s vulnerability. Issues related to organ donation need to be discussed in order to receive an informed consent.
The moment of death
Although usually anticipated, the moment of death is an important event and needs medical confirmation.
Mementos
Offer to create the family mementos for the family such as photographs, locks of hair, hand-and footprints together with personal belongings. Families will vary in what mementos they would like and how involved they want to be in the process of creating these. Remember that:
- Black and white photographs of the dead child produce better-looking pictures.
- Some families may not want to take mementos with them on the day of the child’s death but may like to collect them at a later time.
Viewing the body
This can be valuable for family members. It may eliminate the disbelief that death really occurred or, in the case of stillbirth, that the child was profoundly abnormal.
- A private and comfortable area should be provided where the family can spend uninterrupted time with their child.
- Families should feel able to spend as long as they need with their child.
- Families should be offered the opportunity to wash and dress their child as a last act of love and care.
Autopsy
There has been a large amount of adverse publicity regarding the previous practice of organ retention without parental informed consent for autopsy procedures. Clear and accurate explanations need to be provided to families regarding the autopsy procedure and its purpose. Parents need to understand that the purpose of the autopsy is to seek full information regarding the cause of the child’s death, the nature of the illness and the risk of recurrence of the illness in other family members or future children. If you are concerned about your ability to do this, seek support and assistance from senior colleagues.
The autopsy may be limited to a system or area or be designated as a full autopsy. In particular, details need to be given regarding the removal, careful study and microscopic examination of tissues and organs, and that some organs such as the heart and brain may need to be retained for a period of time before a proper examination can be performed. Informed consent is essential if removed organs are to be disposed of or retained for teaching purposes.
The parents should be informed that the autopsy will be performed on the next working day after the child’s death and may interfere with the funeral arrangements. The full results of the autopsy are usually not available until approximately 6 weeks after the autopsy procedure and this needs to be made clear to the family. Written consent forms need to be completed before the autopsy can proceed.
Many parents decide against an autopsy. They need to be reassured that a hospital autopsy will not be performed without their consent. However, there are occasions where a death needs to be reported to the Coroner for further investigation and a Coroner’s autopsy can be performed without their consent.
Coroner’s cases
A doctor must report a death to the Coroner as soon as possible if:
- The cause of death is unable to be determined.
- The death appears to have been unexpected, unnatural or violent.
- The death appears to have resulted, directly or indirectly, from accident or injury.
- The death occurred during an anaesthetic and is not due to natural cause.
- The deceased person was held in care immediately before death.
- The deceased person’s identity is unknown.
The Coroner then decides whether or not an autopsy needs to be performed. Parents can request (on a special form) that the Coroner does not direct that an autopsy be performed. In many cases where the cause of death is not in doubt (e.g. severe head injury), the Coroner will respect the wish of the family.
Reviewable deaths
The second or subsequent death of a child with the same parent(s) must also be reported to the Coroner’s Court. The ensuing investigation may be limited to a review of medical files and contact with medical staff and family members or in some cases an autopsy.
Funeral options
These need to be discussed and the family assisted to make their own arrangements in their own time with a funeral director and religious personnel as appropriate. Encouragement is given to the family to involve siblings in this important ritual.
Sedation
Unless a parent has a well-defined psychiatric illness, sedation should be avoided for the acute stages of grief as it interferes with and suppresses the normal mourning process.
Breast-feeding
In the case of neonatal death or the death of an infant, advice needs to be given to the breast-feeding mother regarding suppression of lactation. Consultation with a specialist is recommended.
Surviving siblings
Children react in their own way to a sibling’s death. They may blame themselves and may fear their own death or that of others close to them. This fear is often unspoken. At times children may not appear to be grieving the death of their sibling as they often grieve in short bursts. Distress may be expressed by regression to an earlier stage, difficulties at school, acting out or in other ways. Parents often need help and support to understand the responses of their surviving children who may need repeated reassurance. Opportunities to talk as a family about the death, their feelings and their day-to-day challenges and achievements are important. A return to family routines can help them to feel more secure.
Availability of the healthcare team
The healthcare team should be available to the family after death and follow-up arranged. It is usually important to both families and team members that farewells are made.
Notification of other professionals
Notify the health professionals who have been and who will continue to be involved with the family following the child’s death, including the referring doctor or institution, the family’s GP and the maternal and child health nurse. This must be done as soon as possible.
Other families
The death of a child often affects the parents of other children in the hospital ward or local community. The acknowledgement of a child’s death with these families is very important.
Medical interview
Whether an autopsy is performed or not, it is essential that an appointment be made for the parents to see the child’s treating doctor. Some parents are reluctant to attend, but most see the interview as a ‘final farewell’. The discussion should include the autopsy results, the child’s period of illness, future childbearing and issues related to bereavement. If a family is reluctant to attend this important interview, alternative interviews with other healthcare providers should be arranged.
If the child has died in hospital, the child’s doctor should see the family for one or more follow-up visits, although they may not be the best person to conduct ongoing bereavement counselling. Families are more likely to attend if they receive both a written and a verbal invitation, and social workers may be helpful in both facilitating attendance and offering support during the visit. Parents may find it helpful to discuss the reactions of siblings and ways in which to support them. It is important the family be given information regarding potential sources of support and ongoing counselling if required.
Condolences
Communication such as a letter or card from the medical practitioner/team involved with the care of the child can be important.
Ongoing support
The course of parental grief following the death of a child may vary greatly. Many families manage their grief with the support of family and friends and may not utilise more formal supports. The grieving process changes over time, often intensifying after the initial period of shock, around important dates and sometimes unexpected triggers. Over time (usually years, not months) parents develop ways of living with their loss and are able to regain some sense of purpose and happiness in their lives. The death of a child is considered a risk factor for a more complicated and prolonged grieving process. Information needs to be provided to all families about the support groups that are available both at the hospital and in the community. Other factors to consider when assessing the risk of a more complicated grieving process include the preparedness of the family for their child’s death, their view of pre-death care, their perception of available supports, their own physical and mental health, substance use or addiction issues and life stressors. If someone is struggling more than expected, formal referral for psychotherapy should be considered. Medication is not a solution for grief.
Sudden unexpected death in infancy (SUDI) is a term used to describe all infants under the age of 1 year who die unexpectedly after they are placed to sleep.
Any unexpected death of an infant should be reported to the Coroner.
The causes of death for SUDI include:
- Sudden infant death syndrome (SIDS).
- Other sudden death, cause unknown (autopsy carried out).
- Other ill defined and unspecified causes of mortality (no autopsy).
- Suffocation while sleeping (including asphyxiation by bedclothes and overlaying).
- Explained: child abuse/homicide, infection, metabolic disorders, genetic disorders, other causes.
SIDS is only one of the causes of SUDI. The definition of SIDS was refined by Krous et al. (2004) as the sudden death of any infant or young child that is unexplained by history and in which a thorough post-mortem evaluation fails to demonstrate an adequate cause of death.
Key features include age <1 year, onset of the fatal episode apparently occurring during sleep, and the death remains unexplained after a thorough investigation, including a complete autopsy, review of the circumstances of death and the clinical history.
This definition has four main categories:
- Category IA SIDS: classic features of SIDS present and completely documented.
- Category IB SIDS: classic features of SIDS present but incompletely documented.
- Category II SIDS: infants meeting category I except for ≥1 factor(s).
- Unclassified sudden infant death.
Epidemiology
Until 1990, about 550 babies a year died of SIDS in Australia, approximately 140 of these in Victoria, which correlated with the national and international average of 2 SIDS cases per 1000 live births. Following the ‘Reducing the Risks’ campaign initiated in 1990 by the Sudden Infant Death Research Foundation (now SIDS and Kids), the number of infants dying from SIDS in Victoria has steadily fallen to 15 in 2005 (Consultative Council on Obstetric and Paediatric Morbidity and Mortality 2005). A drop in incidence has also been observed in Europe and New Zealand, where similar campaigns have been promoted.
The decline in SIDS rates is due to changing babies’ sleeping position from lying on their front to lying on their back.
SIDS is rare in the first 2 weeks of life and among babies over the age of 12 months. See Table 18.1 for further epidemiological features of SIDS.
The SIDS and Kids ‘Safe Sleeping Campaign’ recommends:
- Place baby on back to sleep from birth (not on side or face down).
- Baby should sleep with head uncovered.
- Avoid exposing baby to tobacco smoke before birth and afterwards.
- Place baby to sleep in a safe cot, safe mattress, safe bedding and safe sleeping environment.
Additional risk factors are discussed in Table 18.2. Further information on the campaign can be obtained from the appropriate SIDS organisations.
Apparent life-threatening episode
An apparent life-threatening episode (ALTE) is an event that is frightening to the observer, characterised by a combination of apnoea, colour change, marked change of muscle tone, choking or gagging. The terms ‘near-miss SIDS’ or ‘aborted cot death’ should not be used as they imply a close association between ALTE and SIDS.
- Up to 13% of infants who die from SIDS have a preceding history of an ALTE.
- No cause for the ALTE is found in over 50% of cases presenting under the age of 6 months.
Table 18.1 Epidemiological features of SIDS
| Parents of SIDS infants | Infants who die from SIDS |
| 1 Younger mothers and fathers | 1. Male (63%) |
| 2. Single and unsupported mothers | 2. Lower birthweight |
| 3. Higher maternal parity | 3. Lower gestation |
| 4. Lower family income | 4. Lower Apgar score |
| 5. Previous stillbirths | 5. Admitted to a special care unit |
| 6. Previous SIDS infant (∼1.6 times higher risk) | 6. Congenital abnormalities |
Data from the United Kingdom Confidential Enquiry for Stillbirths and Deaths in Infancy (CESDI) study into sudden unexpected deaths in infancy (SUDI) (Fleming et al. 2000).
Table 18.2 Risk factors for SIDS
| Risk factors for SIDS | Items that were not confirmed as risk or protective factors for SIDS |
| 1. Sleeping positions – face down or on the side. | 1. Breast-feeding – no independent factor found in the reduction of SIDS. |
| 2. Tobacco smoke – daily exposure of infant to smoke from either father, mother or other household members, is highly significant and dose related. | 2. Dummies (pacifiers) – no increased risk. |
| 3. The cot environment – infants dying from SIDS were found wrapped more warmly, wore hats, used quilts or ‘dooners’, had covers over their heads or were wrapped loosely. | 3. Aeroplane flights – no evidence of risk. |
| 4. Room sharing – evidence suggests that sharing a room with the baby in the first 6 months may be beneficial. | 4. Bed sharing – no apparent increased risk in the absence of cigarette smoke, alcohol or drug abuse. |
| 5. Bed sharing – when either parent has been smoking, drinking alcohol or using illegal drugs has been shown to be a risk factor. | 5. Cot bumpers – no increased risk or benefits. |
| 6. Sofa sharing – with an adult conveys a higher risk of SIDS. | 6. Apnoea monitors – no evidence of protection. |
| 7. Illness recognition – parents should be taught to recognise significant features of illness in babies. | 7. Mattress type or age – no relationship. |
| 8. Immunisation – infants who are fully immunised are at lower risk of SIDS than those who are not immunised. |
The United Kingdom Confidential Enquiry for Stillbirths and Deaths in Infancy (CESDI) study into sudden unexpected deaths in infancy (SUDI).
Reference: ‘Sudden unexpected deaths in infancy: the CESDI SUDI Studies’.
Editors: Peter Fleming, Pete Blair, Chris Bacon, Jem Berry.
Associations that have been found with ALTE are:
- Gastro-oesophageal reflux: a small number of infants with this common condition experience coughing and choking episodes and occasionally apnoea. These episodes occur most frequently when the infant is awake and are often recurrent. Most resolve within a month of onset but some persist for several weeks. The chest radiograph of these infants rarely shows signs of aspiration.
- Respiratory syncytial virus: can cause apnoea. Other upper airway viruses and pertussis can also be associated with apnoea.
- Upper airway obstruction: due to Pierre Robin syndrome, midnasal narrowing or adenoidal hypertrophy. It is usually suspected by a history of inspiratory stridor, snoring and sleep disturbance.
- Epilepsy: usually suggested by a good history. Investigations of ALTE by electroencepha-logram (EEG) are usually fruitless unless there is clinical suspicion of a seizure disorder.
- Cardiac arrhythmia: this is an uncommon cause but should be suspected in recurrent episodes. Obtain an electrocardiogram (ECG).
Most infants with ALTE need minimal resuscitation; however, some need cardiopulmonary resuscitation. These infants have at least a 10% chance of further episodes, which almost always occur in the first month after the previous episode.
A cause will often be found in infants presenting with ALTE over the age of 6 months. If no cause is found in this age group and the episodes are recurrent, formal investigation including sleep polysomnography should be done. Munchausen’s syndrome by proxy should be considered as a possibility, but this diagnosis is rare and in >50% no cause is found.
All infants presenting with ALTE should be admitted to hospital for monitoring, investigation and counselling of the parents. However minor the episode may appear to healthcare professionals, the parents usually believe that their infant’s life was endangered at the time.
No study has demonstrated that home apnoea monitoring programmes reduce the incidence of SIDS.
Home apnoea monitoring is not routinely recommended; however, there is a community awareness of its availability. Many baby goods stores sell monitors over the counter without any back-up or counselling. Advice regarding home monitoring should concentrate on the lack of its proven efficacy together with the positive message about the falling incidence of SIDS. Families may be given inaccurate advice regarding frequency of false alarms. Consider home apnoea monitoring in:
- Infants with a history of SIDS in the family.
- ALTE – particularly if cardiopulmonary resuscitation has been used.
There are families who demand monitors and in this situation they are best used under medical supervision after appropriate counselling. Some examples of these are:
- Siblings of a previous SIDS victim.
- Extremely low birthweight infants.
- Infants with minor ALTE.
- Previous family bereavement.
- Extreme family anxiety about apnoea and SIDS.
Counselling and instruction in cardiopulmonary resuscitation, together with complete medical and device back-up are essential to a home monitoring programme.
USEFUL RESOURCES
- www.rch.org.au/rch_palliative – Victorian Paediatric Palliative Care Program.
- www.vifm.org – Victorian Institute of Forensic Medicine.
- www.nalagvic.org.au – National Association for Loss and Grief (NALAG).
- www.vsk.org.au – Very Special Kids.
- www.sidsandkids.org – SIDS and Kids (1800 240 400 – 24 h consult). Usually for those affected by the sudden and unexpected death of a child ≤6 years old, but some rural area services take referrals for children up to 18 years old.
- www.sandsvic.org.au – Sudden and Neonatal Death Support (SANDS) Victoria.
- www.health.vic.gov.au/perinatal – Consultative Council on Obstetric and Paediatric Mortality and Morbidity. Annual Report for the Year 2005, incorporating the 44th Survey of Perinatal Deaths in Victoria. Melbourne, 2007.
- Fleming P, Blair P, Bacon C, Berry J. Sudden unexpected deaths in infancy: the CESDI SUDI studies 1993–1996. The Stationery Office, London, 2000.
- Krous HF, Beckwith JB, Byard RW. Sudden infant death syndrome and unclassified sudden infant deaths: a definitional and diagnostic approach. Pediatrics 2004; 114(1); 234–238.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
