The primary goal of any patient/caregiver encounter is to develop a partnership that ultimately results in the best medical decisions for the patient. How well you communicate with patients and caregivers determines how successful you will be at achieving your goal. Good interpersonal relations and communication skills will help you deliver medical and systems-based information and provide good patient care. These skills will help you negotiate medical treatment. Because “difficult encounters” are so tenuous, they require a high degree of professionalism; a misstep can sabotage everything. When an unpredictable event occurs, such as the sudden death of a child, you do not have much time to accrue the medical knowledge or learn the systems-based practices; therefore it is important to learn about these beforehand. Medical knowledge about child abuse is especially important because this knowledge will help you recognize child abuse and neglect in the first place. During more slowly evolving situations, it is important to know the most current information about the disease or situation.

What defines a “difficult encounter”? For me, it is every time I have to deliver bad news or exchange emotionally charged information with a child’s caregiver or family or with an adolescent patient. Examples of these types of encounters are:

A more insidious type of difficult encounter occurs with parents of children with terminal, chronic, or fabricated disease (Munchausen syndrome by proxy). Over time the doctor–patient relationship may become strained because the parent becomes increasingly dissatisfied and demanding, despite tremendous effort by the doctor. In this case, almost every encounter with the parent is difficult.¹ Decision making in palliative care of a dying child may lead to difficult discussions about how much or how little treatment should be given.²

When a child dies suddenly, it is important to understand that sudden death is more common than anticipated death in this age-group. Unexpected child death may spark secondary reactions, such as posttraumatic stress disorder in parents, families, and health-care workers. Doctors should inform family members of this and encourage them to seek help if they develop symptoms. The same is true for involved members of the health-care team.

When a child is diagnosed with a terminal or chronic disease, caregivers need accurate, consistent information about the illness, treatment options, and prognosis. Caregivers/parents, and at times the child, need to be involved in the decision-making process. Their opinions need to be respected. Physicians caring for terminally ill children should be knowledgeable about palliative care and pain management. It is important to develop a care plan including directives about life-sustaining measures.² The goal is to keep the child comfortable and prevent unnecessary procedures and therapies.

Medical knowledge of risk factors, signs, symptoms, and physical examination findings about physical/sexual abuse and child neglect is the key to recognition. Heightened awareness leads to timely reporting to child protection agencies and law enforcement and can potentially save the child’s life or prevent future mental and physical disability in the child and his or her siblings.³