ditionally, departments of pediatrics have
been unwilling to accept this as a
commit-ment. I wonder how many departments
really are willing to hire pediatricians who
wish to devote their full efforts to the
psychological and social aspects of
pediat-rics. So often the department turns to the
child psychiatrist to come in, consult,
and then go away. He often is not an
inte-gral part of the pediatric department.
I’m hoping that more pediatricians will
view it as “legitimate” to be interested in
what might be termed “psychological or
be-havioral pediatrics,” from the service and
teaching points of view, and also with an
interest in research. Perhaps I should
un-derline research. So many of us have strong
feelings without supporting data. I would
certainly include my own thoughts in this
matter. Perhaps it should be tile
depart-ments of pediatrics who would do research
investigation in this area and not wait for the cllild psyciliatrists necessarily to help
us, though indeed I would hope that they
would.
Dii. MCCLELLAND: I would share Dr.
Friedman’s feelings of inadequacy
concern-ing dying children, but I’m not sure that the
problem a pediatric house officer faces with
dying children is greatly different than with
children who are retarded. The finality is
more abrupt, but it’s the same kind of
cop-ing problem of handling an ongoing,
unto-ward long-term, or short-term relationship.
At Western Reserve we’ve seen the very
interesting, spontaneous development of
patterns of house officer involvement.
We’ve also been concerned with how house
officers will acquire a vertical 2- or 3-year
follow-up with patients to have some idea
of continuity of care. We’ve been strongly
committed to the idea that a house officer
follows several patients during the entire
time that he’s in the program.
DR. WuLIA1 SHERMAN: I would like to
make one brief comment. Dr. Rothenberg
said in passing that we psychiatrists need to
involve ourselves at the level of work
rounds. In trying to teach liaison to
pediat-ric house staff at the University Hospital I
have found that this simple maneuver is
more effective than any other: if a
psy-chiatrist will unbend himself and appear at
7:30 in the morning once a week or so and
just walk around the ward for an hour,
throwing back and forth the issues coming
up with each child in the ward, more
mean-ingful teaching transactions take place in
that hour than in 10 hours of formal
confer-ence.
Panel
Discussion
EFFECTIVELY USING THE TEAM
DR. LOREN MACKINNEY: The pluralistic
approach that Dr. Green has described
im-poses severe demands on the time,
emo-tions, and skills of the physician who is not
part of a well organized single-purpose
can-cer team. Incidentally, such teams exist in
only a few medical centers at the present
time. How can the consulting pediatrician
in a medical center cope with the problems
inilerent with caring for such a patient and
his family? What aspects of the many
prob-lems can he delegate to others? After this,
which the physician must do ilimself, he
can begin to ask others to help him. As the
parents come out of their initial shock and
daze and begin to take stock, it is very
helpful to have a sympathetic,
non-authori-tarian figure make a relationship with the
family and the physician. This person can
be a social worker in the hospital, the
fam-ily’s minister, a hospital chaplain, or
a friend. The physician may have to
active-ly look for such a person to serve as a
buffer and an informant. From this time on
it is important for the physician to try to
maintain good lines of communication
be-tween himself, the patient, and the
par-ents. The social worker can be of great help
in reviewing with the parents what the
phy-sician has said and reinterpreting it for
SUPPLEMENT
the physician the progress that the family is
making in adapting to this new situation.
The second common problem is helping
the parents to begin thinking constructively
and positively about the child’s remaining
lifetime. The extent to which the family can
be helped to permit and encourage the
usual and normal activities for the patient
commensurate with his state of physical
well-being represents the best possible
compromise. This actually involves two
fac-tors: first, the physician helping the parents
to see the child as he really is from day to
day and to react appropriately to his needs;
second, the physician reassuring the parents
that he will always be standing behind
them to help and advise.
The third problem is that of maintaining
the family and the patient during periods of
relapse. When the child’s normal activities
are curtailed, both the child and his parents
need certain props to help them
accommo-date to the unnatural situation. Putting a
few quiet, living things in the child’s
envi-ronment can be of great help. Plants that
the child can tend and watch grow, a
goldfish aquarium, or one of these
fascinat-ing ant colonies are representative
exam-ples. The physician should organize his
team of helpers to minimize the traumatic
situations. Physical trauma can be
de-creased by carefully planning blood counts
and having the same technician and
person-nel deal with the child when he comes to
the clinic or is in the hospital. The
physi-cian may find it helpful to have meetings of
the various people involved in caring for
this child, orienting them to the child’s
problems and to the parents’ problems in
order to avoid unfortunate faux pas.
Spiri-tual support can also be very important.
The minister from home or other parents
with the same problems in the
hospital-each may fill an important role.
The fourth problem is the parents’
read-justment following the death of the child.
This is most commonly overlooked. Not
in-frequently, severe reactions set in at this
time particularly involving siblings and the
way in which the family sets about to
preserve the memory of the loved one.
Preserving the child’s room as it was should
be firmly discouraged.
In summary, caring for the child with
cancer requires a very broad range of skills
on the part of the managing physician.
Each of us has different aptitudes in
var-ious categories of skills required. It requires
great honesty on the part of the physician
to recognize his deficiencies and to seek out
the best supportive help to shore up the
comprehensive care of the patient. He can
often finds ways of reducing the large
amounts of time that both the patient and
the parents require by the intelligent use of
ancillary personnel.
AGE AND TUMOR TYPES
DR. WAYNE BORGES: I would like to talk
about two aspects of the problem. What
age groups are we talking about? Leukemia
has a distinct age peak incidence in the
Caucasian population in this country and
the age of that peak doubles at 3 to 4 years
of age, going from around three per
hundred thousand incidence from birth on
up to 73 and then sharply descending again
to the previous level. Therefore, the
majori-ty of children with malignancies will be
in-fants or young children and not
adoles-cents. The same holds for the two most
common solid tumors-neuroblastoma and
Wilms’ tumor. They do not have a sharp
peak, but nevertheless they are elevated in
the younger age groups and, therefore,
again we are dealing with the young child
and usually the young family.
The other large group of solid tumors are
the lymphomas. They have no age peak and
have a lower incidence, approximately one
per hundred thousand. Tumors such as
os-teogenic sarcoma and brain tumors increase
in incidence with age. So, in the older child
we are dealing primarily with the solid
tumor whose initial therapy and subsequent
course involves surgical procedures, such as
amputation in the case of osteogenic
sarco-ma. Other specialists than the ones we have
been talking about, such as the surgeon, the
the scene. So, the picture gets complicated,
but I think the older child has more signals
going when he has a severe condition than
the young infant and young child. So much
for the etiopathology of malignancy in
childhood.
This morning I have been impressed
that when the word cancer was mentioned,
it was invariably assumed that the child
would die of that disease, or at least
with that disease. This brings up two
points, about prognosis and subsequent
course. Prognosis is applying our past
expe-rience to our prophetic role as physicians.
Notoriously, physicians are not prophets.
We can only talk about what has happened
in the past; this may not be true for what is
going to happen in the future. Tile fact is
there has been a startling reversal of what
may be true in the future to what was once
true in the past. In the case of one of the
two common solid tumors, namely,
meta-static Wilms’ tumor, the outlook has
changed greatly in the very recent past; so,
we would be erroneously hanging crepe, I
think, if we applied only past statistics in
talking with parents of the children or with
the child with metastatic Wilms’ tumor.
The same, but not so dramatically, holds in
leukemia, the single most common
malig-nancy of childhood. We know now, with
the accumulation of well over a hundred
so-called long term responders, that some
of these children can win in a sense.
There-fore, equating the diagnosis with the
prog-nosis of death due to disease is no longer
possible.
This brings me to the other point;
name-ly, that many of the children, particularly
with leukemia or neuroblastoma, do not die
of their disease, but with it. They die of
complications of the disease and of therapy.
Therefore, when speaking about home care
or terminal home care of children, we should
be cognizant that sometimes, in fact quite
frequently, all the forces of the
comprehen-sive children’s hospital are required to deal
with the complications of such an
exacerba-tion, which may be followed by another
remission. In our own thinking as
physi-cians we should be precise about the past
experience in these diseases, and in our
prognosis, recognize the changing
experi-ences that are going on in the care of
pa-tients with malignant disease.
TEACHING MEDICAL STUDENTS AND HOUSE OFFICERS
DR. OLMsrim: I would like to make a
few comments about teaching. In relation
to the medical students, we have heard this
morning a great deal about the teaching of
comprehensive pediatrics, and about the
importance of psychiatric pediatrics. But
one thing we haven’t heard very much
about is the relationship of the medical
stu-dent to his teacher; namely, the person who
is the staff man on the inpatient service and
the preceptor in the outpatient clinic. All
the things that have been talked about this
morning are very important, but perhaps
the core of the whole thing is what the
medical student learns from the one
indi-vidual to whom he responds most deeply. If
we all look at our own experience as
teach-ers, the one thing that we probably rarely
do is discuss the situation with the medical
student and actually involve him with us as
we in turn handle the situation, but this in
itself may be its strength. If the medical
student can see that we are not infallible,
that we have problems handling a dying
child, then he is going to give deeper
thought to ways he can devise to meet the
situation.
Another thing about the teaching of the
medical student is again to realize who it is
that he is learning from. We tell our
medi-cal school students that they’re going to
learn mostly from the residents and in
gen-eral this is true. In the matter of the dying
child, though, I’m not so certain that the
medical student is going to learn from the
resident, because the resident is still
hop-ing to learn himself. As I said, in general
the staff men will completely divorce
them-selves from the situation and the student
rarely gets the opportunity to sit and
dis-cuss the case with the older, more revered
Another area that we should look to is the
possibility of getting the medical student
involved with the child in some way other
than the medical setting. This may sound
extremely simple, but if a medical student
can visit a child in a home or if he can take
a child who is in the hospital out to the zoo,
or for a walk, or almost anything but be
in-volved with the child in a medical setting,
something is going to penetrate to this
medical student that he will not get in any
other way. This is an indefinable
some-thing, but something I think we should
con-sider in our efforts to try to teach medical
students.
This next comment applies to residents as
well as students; that is, the reaction and
orientation about the pathological findings
when a child dies. Naturally, and rightly,
the resident and students are tremendously
interested in the findings of the
postmor-tem examination and their attention goes
into this. Once the final report has come in,
whether you like it or not, oftentimes the
resident’s and student’s involvement ends
and the case is sort of finished. I think this
would be the ideal time for us somewhat
older people to point out that this is not the
end, and to begin to describe and to discuss
other aspects of the case. I think we’re
fre-quently guilty of backing out at this point,
too.
FAMILY FUNCTIONING
DR. Jom’ WALLACE: As a child
psychia-trist part time in academic work and private
practice, and more recently consultant to
the Hematology Clinic at Children’s
Hos-pital, I see the care of the child with cancer
in the context of family process and
func-tioning. The question of diagnosis,
prog-IlOsiS, and what and how to tell the family
has come up several times. We often put it
in terms of what to tell the family. That is
of course a valid concern but it is only part
of a larger question. That is, what sort of
relationship does this family need with the
physician? As the victims of an
overwhelm-ing assault on their parental identities as
protectors and providers, they need to be
helped to cope, to become active in dealing
with their reality. As a first step, then, the
doctor needs to help the parents recognize
what and how they feel and recognize the
doctor as someone who will help try to
un-derstand and not avoid the painful reality.
In the course of listening to parents talk
about a “leukemic child” it may become
ap-parent that this child has a special meaning
or place in the family-one that antedates
the frequent “perfect child” overevaluation
by parents in anticipatory mourning.
As an example, not long ago a child with
leukemia died here and both before and
after there was much dissension in the
fam-ily. Much of it wasn’t recognized, partly
be-cause the parents were denying themselves
the impact that this child’s dying was
hav-ing. But, looking back in this family a story
unfolds. These parents were married as
teenagers. The mother began having
chil-dren when she was 16; she had three girls.
When the youngest one entered school, she
became pregnant again, producing a boy.
This mother’s identity was solely that of a
mother; she’s “always had babies.” It was
the youngest child who developed leukemia
at 4 years. Now the oldest child “should
have been a boy; her father called her
‘ju-nior’,” quoting the mother. When the
youngest child developed leukemia, many
things started to happen in this family. The
mother practically moved into the hospital,
not only to the distress of the hospital staff,
but also to the distress of the family. The
oldest daughter was then left, at 14, in a
very tenuous conflicted relationship with
her father. Simultaneously she became the
woman of the house in role and physical
appearance. Father became increasingly
irritated with her, and she ran away from
home. This accomplished what it was
ap-parently intended to, a temporary return of
mother to the family, but when the boy
be-came terminally ill, the mother again
moved into the hospital and the child of
course died. Since that time, the mother has
functioned better, accepting the reality
slowly and painfully. The father tried to
don’t need fathers-only boys do-and the
oldest girl became involved in some very
serious delinquent behavior. I do not know
how much of this could have been
prevent-ed, but I would say tilat some of it might
have been. I think here the model is akin
to that of crisis intervention. Several crises
occur, one at the time of diagnosis, again at
tile time of relapse, and then finally when
the child is terminally ill. At these times
shifts occur within the family, and one must
have an intimate knowledge of what is
going on in the family and tile meaning of
the critically ill child to the various family
members, including the siblings. This all
becomes extremely important in enabling
one to carry on an effective therapeutic
program with its psychosocial aspects.
Responding to Dr. Rothenberg’s
discus-sion of the avoidance reaction, a doctor and
the rest of his staff need to have a feeling
that they can do something and that there
is an area of competence open to them. As
far as we know now, the area of
compe-tence is not the absolute prevention of
death from leukemia, but can be that of
amelioration of family reactions. I think all
of you are more familiar than I with stories
of family upsets that have occurred in var-ious clinic and private practice populations.
If we are to prolong lives we must accept
some responsibility for helping to deal with
the side effects.
The early speakers might have
empha-sized a little more vigorously the initial
stunned reaction to the diagnosis. In the
families that I have talked to, this is an
in-variable experience. They are stunned,
shocked, or numbed, and some suggest that
this lasts from a period of hours, in a very
few, to weeks in some, during which one or
more family members are literally “out of
it” as far as carrying on their customary
roles. This has to be recognized by the
phy-sician trying to communicate with them.
They won’t hear much of what you
say-you will have to say it again and again. Try
to determine what they think, what they
feel, also what they have read. Begin to find
out what they know or what they think they
know, which half the time is much more
important than the facts. This also indicates
to them your willingness to become
in-volved and that something is going to occur
between you and them on a long-range
basis. I think a useful technique for the
pri-vate physician and the house physician, for
that matter, is the family interview. In my
opinion, the family in which leukemia
oc-curs, where there is at least one child 8 or 9
years of age or older, should, at some point,
be interviewed as a family. This may be the
only time some families will sit down
to-gether and recognize verbally each other’s
distress. This is a difficult thing for them to
do. It is difficult for the physician, the
nurse, social worker, or whoever is willing
to become involved, but it has a powerful
effect in bringing the family members
to-gether and avoiding an activation in them
of the kind of communication conflict that
Dr. Rothenberg has described to us. Special
attention to what is going on in the siblings
may be in some families the best indicator
of a creeping pathologic adjustment or
fail-ure to cope with fatal illness in the family.
Often the first sign may be running away
by one of the children, delinquent behavior,
or sudden eruption of a behavior disorder
in a previously well adjusted child. The
symptoms may be a good barometer to
what is happening in that family. I wish Dr.
Green’s modesty had not prevented him
from discussing his “vulnerable child
syn-drome.”1 This work represents clinical
pediatrics at its best. The diagnosis of
po-tentially fatal illness in a child is one of the
situations that not uncommonly leads to
displacement of anxiety from, eventually,
the lost child to a remaining child or to
se-vere emotional problems in the child who
survives a life-threatening illness.
The area of group therapy has been
men-tioned, and I too have some views. I really
question whether there is a place for group
therapy as such in the hematology clinic or
in the private practice of cancer physicians,
group meetings and group process. I do not
think it is useful to most parents who are
experiencing this kind of repetitive crisis or
prolonged crisis to identify them as
psycho-logically ill, unless of course there is no
choice and events have activated a
patho-logic preexisting personality disturbance. I
think it is more in the interest of their
over-all coping needs to provide a group setting
in which they can share experiences and
where they can, if necessary, put the
physi-cian on the spot and make him be specific. I
think there is a real place for this!
Finally, I would like to identify a
“spe-cial problem”-the adolescent with
leu-kemia or a fatal illness. At least here in our
clinic this is an especially touchy situation.
What do you do with the adolescent of at
least average intelligence who reads the
newspaper and magazines and can rather
rapidly diagnose himself as leukemic,
al-though his parents are determined that he
has nothing worse than a common cold?
This situation comes up from time to time,
and I unfortunately have no pat answers. I
would like to know what some of the other
panel members tilrnk or, perhaps, what are
some of the experiences of those in the
audience.
INITIAL SHOCK REACTION
DR. BERGMAN: I would like briefly to
comment on Dr. Wallace’s description of
the initial shock reaction of parents where
they describe visceral sensations. We see
this regularly in parents of victims of “crib
death.” This acute grief reaction is similar
to receiving the diagnosis of a fatal illness.
\Ve often get the comments like “I’m going
insane,” “I’m losing touch,” etc., and I think it’s very important to recognize this
occur-ring along with various somatic sensations
and assure families that this is a normal
reaction.
UNDERSTANDING FAMILIAL STRENGTHS
DR. FRIEDMAN: I would just like to add
to what Dr. Bergman said. We also have
heard parents speak of “losing their minds.”
Sometimes having heard the diagnosis,
par-ents will come back and say “Now I’ve
heard the worst, I know I can go on from
here.”
I also would like to comment on some of
the things Dr. Wallace has said. For one
thing, I think he is entirely correct about
the group therapy versus group sessions.
We deliberately went out of our way to call
these group sessions and I think the
distinc-tion is a valuable one. I might add that
group therapy might mean something
different to a psychiatrist and to a
non-psy-chiatrist. The informal groups in the
solari-um, without the benefit of a physician, are
also group therapy to some extent. Family
interviews also call for a great deal of skill.
As a pediatrician, I have been overwhelmed
at times in trying to carry out family
inter-views where one has to not only concern
himself with the parents and the children,
but also with the interactions between
them. This takes a fair amount of
experi-ence.
All of these issues discussed thus far are
difficult to answer. It really is not so much
coming up with the answers but trying to
reexamine some of the questions. I will use
an example: “What to tell the child
re-garding his illness?” I, for one, do not
pre-tend to know the answer, but I do not think
we should be satisfied in relying, as Dr.
Green indicated, upon intuition. I think this
is a subject worthy of systematic
evalua-tion. Though we all have strong feelings, I
believe we really cannot point to very
much data.
I would like to say a few more words
about telling children their diagnoses. One
extreme is to say that no child should be
told his diagnosis; I think only the younger
child would fit into this category. Dr. Green
covered this well in discussing the child’s
concept of death and that the younger child
is more afraid of separation and pain, and
not so much of death itself.
Even though teen-agers represent a
mi-nority of cancer cases, they are the very
518
us. I do not think all teen-agers should be
told-all we are suggesting is the rejection
of the old adage that none of them should
be told. Furthermore, discussion of
diag-nosis or prognosis with the child must be in
the context of parental permission and
cooperation.
I would not give the diagnosis to the
child who is still struggling through his first
remission or is on a downhill course. I
would reserve the telling of the diagnosis
for those patients who have managed to
overcome the first crisis in their illness.
Then one can point to past success in
han-dling the disease, particularly therapeutic successes.
Perhaps the most important point is that
the discussion should be tied in with some
hope. I think the physician should point to
the most optimistic aspects of the disease.
As was touched on in the opening remarks,
the prognosis is changing. Though we
should not deny to the child the fact that he
Ilas a serious illness, I believe one can say
such things as, “You know every case is
different,” “You are responding and there is
no reason we shouldn’t expect you to
re-spond to future drugs.” The diagnosis
should be tied to hopes of getting home,
being able to resume normal activities, etc.
In this setting, the child is much more able
to understand what is being said and to
ac-cept it. Along with this, and this has been
touched on also, is the need to listen to
what the child is asking. “Do I have
leukemia?” may be merely a way of asking
the doctor do I have a blood disease. That
is quite different from the child asking, “Do
I have a fatal disease?” Often by merely lis-tening and examining what the child is
ask-ing, one can accomplish a great deal. It
would be only in this context that some of
us question whether or not older children should be told their diagnosis.
I would like to end these comments by
responding to what Dr. Wallace said about
family disintegration. The psychiatrist is
more apt to see this side of the problem. All
of us who have treated fatally ill children
and their families realize that to a large
de-gree these families do succeed in meeting
the crisis. Therefore, we must look at some
of their psychological strengths to
under-stand how the successful ones go about it.
The overall approach should not be looking
only at failures in adjustment in families of
fatally ill children but examination of
suc-cessful adaptation to family crises and
trag-edies.
DISCUSSING THE DIAGNOSIS WITH CHILDREN
DR. ROTHENBERG: Jack Wallace asked,
“What about adolescents who appear to
know their diagnosis?” It is obviously not
an easy thing to talk about in a couple of
minutes. We have, in our particular
institu-tion, over the past 10 years accumulated a
fair amount of straightforward clinical
ex-perience with just this sort of a situation.
There seems to be two major groups: one is
a relatively smaller group in which an
ex-tremely bright child may actually confront
either a physician or some paramedical
per-son with his own diagnosis. Not only with
his diagnosis, but also with the manner at
which it was arrived. In other words, he
eventually says, “Look, the last time I was
home I went to the library and I read this,
this, and this, and I know I have leukemia.
Why hasn’t someone said something about
it, for I know I have it.” Or, they will quote
Dr. Kildare or some other such “scientific”
source. The other group is a larger group.
They do not actually confront the health
worker directly by naming the diagnosis
it-self but begin to ask a series of questions or
make a series of comments, or a mixture of
the two, which make it very obvious. If you
are able to listen as well as hear, they really
have come up at least with a tentative
diag-nosis. What they want to do is explore it.
Then you run into the situation where the
most important thing to do, and we very
often forget this, is to find out what the
child is really asking. Secondly, what does
he really want to hear? In other words,
what are his total needs at this time? Does
he need to hear the word or does he need
ask-SUPPLEMENT
ing you not to say it. This is why we cannot
give you a simple formula.
Every time we have a case conference in
the pediatric ward that has to do with the
dying child, whatever the cause, everybody
wants to focus right away on do you or
don’t you tell the child he is dying. Nobody
wants to talk about the
circumstances-what is the child really saying to you, what
is he really asking for, and so forth and so
on-because this means that you have to
make much more contact with what is
real-ly going on in the child and in the family,
and even in yourself.
When this larger group of children begin
to talk about or ask questions or make
statements that make it clear to us that they
really want to talk about the diagnosis,
what we do is start out using the third
per-son technique. We first get the child to
ver-balize spontaneously as much as he will or
can. We then begin to talk about “lots of
times children who have been through what
you have been through in the last week or
month (or however long it has been) begin
to feel .“ Then we start listing the
kinds of reactions, the kinds of questions
that children raise. It is obvious that this
method has to be custom-tailored to each
child. When it has become clear to you that
the child desperately wants to talk about it
and wants to use the word, what you do
first is to see if you can get him to be able
to say it, then use the third person
tech-nique and then you use the word. It has
been our clinical experience that there is a
great relief for these children if you say,
“Lots of children have been through what
you just went through last night” (i.e.,
bleeding episode, transfusions, etc.) and,
when this happens, one thing a child thinks
about is, “Do I have leukemia?” Depending
upon the circumstance, he may say, “Am I
going to die, or was I dying last night when
that happened?” What you are doing, in my
terminology, is giving the child a chance
to “run the option.” He can opt in or opt
out, and you can say, “Does that sound
out-landish to you,” and he may say
“Absolute-ly,” or he may say, “No, it doesn’t sound
outlandish, but it certainly has nothing to
do with my feelings,” or he may opt in at
that point, when his readiness has reached
that point, and say “Whew, I have seen it
happen and that is what I was thinking and
I was afraid to talk about it.” It is the old
story-the pediatric patient begins to get
the idea that the doctor is afraid to talk
about his illness, whatever it may be, by the
way. The patient concludes that it must be
so bad that even the physician is afraid to
talk about it, and “I am not going to talk
about it if he doesn’t want to.”
I just want to make one comment about
the role of a social worker and the role of
the ant farm. I agree, and I do not wish to
offend my social worker friends by
equat-ing social work and ant farms. What I do
mean is this: while the use of paramedical
personnel and the use of live animals or
particularly exciting games or skills or
what-ever can be enormously helpful, I
person-ally have been burned very badly. My
ex-perience in the last 10 years in pediatric
wards has been seeing these things used
more often as a defense on the physician’s
part than as a proper, rational, useful
ad-junct in his role. Unfortunately, I have seen
too many people hiding behind social
work-ers and hiding behind ant farms and guinea
pigs and you name it. These people and
these things lend themselves beautifully to
the physician avoiding his, albeit painful,
responsibility.
REFERENCE
1.Green, M., and Solnit, A. J.: Reactions to the threatened loss of a child: A vulnerable child syndrome. Pediatric management of the
