BMJ  2004;328:890 (10 April), doi:10.1136/bmj.328.7444.890

Filler

Does your heart go on vacation?

Carlos, a quiet 7 year old with light brown tousled hair and big brown eyes, arrived with his mother for his yearly check up. He sat on the examination table, swinging his legs back and forth.

As I walked in, Carlos told me he had a question. "What is your question?" I asked.

"Can you check my mom to see if she can have another baby?" he asked with sincerity and thoughtfulness.

"Would you like another baby at your house?" I asked, watching his 2 year old sister climb on to his mother's lap. Carlos talked about his cousin, who had a new baby, and how he liked babies. We decided that the decision about whether his mother had another baby would be up to his parents. His mother smiled.

Satisfied, Carlos had another deep question. "Does your heart go on vacation?" he asked, becoming fidgety.

"Tell me more about that," I replied.

Carlos asked whether hearts stop beating and then start again, and what happens to your heart when you die. "Does it go on vacation then?" he asked.

Carlos's mother explained that Carlos was concerned about death, what happens at that time, and that he had been asking questions about death. I learnt that no one in his family or anyone he knew had died, and there were no recent losses. "It's a natural curiosity," I explained to his mother. "Children are curious about death at all ages. Younger children see death as transient, yet around Carlos's age they begin to understand, as they did not earlier, that death is permanent."

We continued to talk about answering children's questions about death, and then Carlos asked another question. "When do people die?" he asked, his small body now swaying from side to side on the examination table. I explained that people usually do not die until they are very old with white hair and wrinkles. Carlos talked about how he could make his hair white and paint wrinkles on his face. "Would I die then?" he asked me.

"No, you wouldn't die then," I replied. "Even if you made your hair white and drew wrinkles on your face, you would still be 7 years old." Carlos's shoulders relaxed, and he leaned back with quiet relief.

When we listen with acceptance and respect, we can hear our patients' concerns in their metaphors and stories. This holds true for patients of all ages.

Communication Skills Teaching Program, Harvard Medical School, Boston MA, USA

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