A pregnant woman visits her obstetrician for her final examination before the birth of her new baby. She has waited nine long months for the baby’s arrival. The nursery is complete. Pastel pink bunnies and mint green lambs hover like guardians over her crib. Diapers are neatly stacked near the powder-scented wipes. Her tiny clothes sit patiently in the white dresser. The family purchased a Doppler so that every morning they could listen to her heartbeat. They have already named their little baby girl, Sarah. Sarah’s brother and sister sit patiently in the waiting room, their father already glowing with pride. It could be any moment that the new addition to their family changes their lives forever, and that it does.

Holding her swollen belly the woman emerges from the office into the waiting room. The smiling faces of the children and their father abruptly transform to confusion and concern. The woman is unable to hold back the tears. The obstetrical nurse hurries the family into a small room. The father awaits the news with baited breath. "What is going on?" he blurts, unable to contain the anxiety any longer. With tears streaming down her cheeks, her chest so tight she can scarcely breath, barely able to utter a sound, she quietly replies, "The doctor can’t find Sarah’s heartbeat. She is dead."

Sarah’s mother will endure hours of painful labor. She will give birth and death simultaneously. She will leave the hospital without her daughter, walking past a nursery of healthy newborns on her way out. In several days, her breast milk will flow for her dead child; a cruel reminder of her baby’s unjust death. She will wander her home subconsciously seeking to comfort and hold her newborn infant. Her arms will burn with an aching hunger. Inherent maternal instincts will drive her to the place where Sarah is buried. She will sit at the freshly dug mound of dirt, tears devoured into the merciless earth. Failure at her pretense of recovery will come frequently. She has a long, harrowing road ahead. The medical community will heavily influence the degree of her emotional imprisonment: Will she receive enough support to assist her through this life-changing event?

This scene plays out too often every day. The medical phenomenon, fetal demise or stillbirth, occurs to more than 25,000 families in the United States every year. Another 17,000 babies die within the first twenty-eight days of life; this is most often a result of premature birth or a congenital anomaly that is incompatible with life. Sudden Infant Death Syndrome (SIDS) steals the lives of another 3,000 babies per year. Almost every person in the United States knows someone who has experienced the death of a baby to one of these causes. The statistics are inescapable. The death of an infant is an inconceivable tragedy causing unrelenting guilt, anguish, and sorrow. It disrupts the family unit. It is the type of sorrow that knows no words. According to family therapist, Dr. Martin Keller, "The death of a child is the most profound loss a human can experience. As a society, we are more prepared to deal with other types of death…this causes deeper feelings of disorientation than any other type of loss" (SIDS Scoop, 1998).

While the death of a baby will never be experientially pleasant, the medical staff can minimize the horror of the experience with compassionate, ethical communication during the bereavement process. Unfortunately, very few are trained in the psychosocial impact of this type of loss. Many are unaware of their ethical responsibilities after fetal demise or sudden infant death. There are a plethora of health care workers who lack understanding of basic human compassion and empathy during crisis situations (Pancrazio, 1992). This lack of knowledge and fear causes many to abandon the family during crisis; and that lack of responsiveness is now being perceived as unconscionable in the medical community. Ethical standards in medicine are rapidly changing.

The latest research suggests that effective communication is a critical factor for the doctor-patient relationship. It is no longer acceptable for the nursing staff or physician to be inattentive to the patient’s emotional needs. Lesley Fallowfield, Director of the Cancer Research Campaign’s Psychosocial Oncology Group at University College London Medical School, understands the importance of good communication. "For Fallowfield, effective communication between doctor and patient is the key to achieving the best possible quality of life for people with cancer" (Bonn, 1999). Fallowfield’s studies strongly suggest that women are more likely to avoid unremitting anxiety and depression if they were satisfied with how their surgeon communicated with them (Bonn, 1999). Physicians involved with critically ill patients, in addition to bereaved parents, must employ an ethical protocol for communication. Qualities essential in these situations are compassion, honesty, empathy, patience, understanding, and communication.

While the number of SIDS deaths have declined exponentially, stillbirth and neonatal death are on the rise. There are practical, comprehensive methods for medical staff when faced with these circumstances. Ethics in communication begin by establishing rapport and trust with the family in crisis. Grieving parents should never feel that the staff has deserted them during this time. Interpersonal association will have a profound impact on their grief journey.

The acronym, L.A.S.T., is a simple way for a nurse or physician to recount the basic four steps to remarkable support. The acronym begins with the letter "L" to remind the support individual to listen. "Listening to a parent is a must. Provide an explanation for baby’s death when there is one. Allow them to explain their theological reasons. Encourage them to tell and retell their story. Listen and ask questions" (DeFrain, 1991). It is the most common need of the mourner to have someone available to listen. They need to tell their story (Rauen, 1985). A good listener knows that silence is not the enemy. Pauses between thoughts allow a person to organize his successive thoughts. That time may help the mourner articulate feelings into words. Open-ended questions are a wonderful way to encourage the flow of information and feelings. Rather than asking a question which can be answered with a yes or a no, ask an all-inclusive question. An example of a closed-ended question would be, "Are you feeling angry at your wife?" This does not allow latitude for an expression of deeper feelings. A more appropriate question would be, "What are you are feeling right now?" This abets further exploration of a griever’s emotions. Good listeners understand reflective conversation, a technique that encourages mirroring. For clarity and definition, the listener briefly repeats his understanding of the speaker’s meaning.

The "A" in L.A.S.T. represents acknowledgement. It is very important for a mourner to feel justified in the whirlwind of emotions they feel. A physician circumventing an undesirable outcome will compound the family’s disarray. Validation by the family’s physician can significantly reduce self-doubt and questioning for a mother or father. It is helpful for the physician to stress that it is never acceptable, under any circumstances, for a parent to have to bury their child. Bridging the professional-to-personal gap can be accomplished with ease when a physician removes his white coat and stethoscope. Entering the room in absentia of the white coast as a clinical symbol lessens intimidation when interacting with a family. Some physicians will share that they cannot imagine losing their own child, thus substantiating the grief of the parent. It is imperative that the support individual avoids trite aphorisms such as, "You’re young, you can have more children," "Everything happens for a reason," "At least you have other healthy children," or "Your child is in a better place now." These meaningless attempts at justification merely exacerbate a parent’s feelings of anger and isolation. Platitudes are unacceptable and have no place in ethical principles.

The third letter, "S" is for support. The intertwining of compassion and communication can have a monumental effect on the family in grief. It is the ethical responsibility of the medical staff to ensure comprehensive knowledge of local support groups available to parents after the death of their child. Some groups, such as the SIDS Alliance, the Compassionate Friends, and Parents of Murdered Children provide helpful brochures listing the times and locations of meetings. According to R.K. Limbo, Resolve Through Sharing Counselor (RTSC) and author of the book, "When a Baby Dies", the support group setting "provides a safe environment for parents to share their experience with others who have had a similar tragedy." Surrounding themselves with others in familiar situations is comforting to parents. It also helps to assuage feelings of isolation. As Thomas Jefferson said, "Who better to softly bind up the wound of one than he who has suffered the wound himself?"

Bereaved parents will manifest characteristics of the first stages of grief: denial, shock, disbelief, confusion, forgetfulness, apathy, disorientation, and overwhelming sorrow. During this period, it is critical that the medical provider remains available to offer support and respond to any concerns about the child’s death. Honesty is imperious to build trust and rapport with the family. The physician should share clinical information with the family in truthful, yet understandable language.

The final step in the L.A.S.T. communication process is a very meaningful form of non-verbal communication. The "T" represents touch. Touching is a cardinal piece of the bereavement support puzzle. Non-verbal communication accounts for more than ninety percent of the meaning received (Deep, Sussman, 1998). Voluminous messages can be conveyed with non-verbal communication such as body language, attitude, eye contact, tone of voice, facial expression, touch, and posture. However, in a recent survey by the Arizona SIDS Alliance, touch proved the most significant form of non-verbal communication. More than ninety percent of respondents said that they appreciated when a firefighter, physician, nurse, or social worker gave them a hug or held their hand. Parents reported feeling a connection to that individual; they felt the person was sharing in the experience with them. It lessened their sense of disconnection.