Going straight to the source: A pilot study of bereaved parent-facilitated communication training for pediatric subspecialty fellows

The New Oncologic Diagnosis Discussion: Perspectives of Pediatric Oncologists

PURPOSE

We aimed to understand how new diagnosis discussions are conducted in pediatric oncology, and the training provided for their conduct.

METHODS

This mixed-methods study used a sequential exploratory design. Qualitative interviews (n = 20) were conducted with pediatric oncologists (n = 15) and fellows (n = 5) at a single institution, focusing on the process used to convey the diagnosis and treatment plan to the family. Accreditation Council for Graduate Medical Education-accredited pediatric oncology fellowship program directors (n = 38) and fellows (n = 70) were subsequently surveyed to confirm qualitative results and elucidate the training that fellows receive in conducting new diagnosis discussions.

RESULTS

Our findings suggest that new diagnosis discussions in pediatric oncology are typically conducted in three stages: (1) concern for cancer; (2) confirmation of diagnosis; and (3) treatment plan/consent, and are fundamentally similar across settings; however, pediatric oncologists skillfully tailor their approach on the basis of clinical circumstances and parental needs. Decisions regarding inclusion of the child are primarily determined by parental preference, whereas inclusion of health care team members is driven by physician role (ie, trainee v program director) and health care organization-related factors. Physician preparation for discussions involves logistical, intellectual, and emotional components. Disclosure of prognosis is nuanced. There is variability across pediatric oncology fellowship programs in the provision of training for these discussions.

CONCLUSION

We identified common practices of pediatric oncologists as they prepare for and lead new diagnosis discussions in pediatric oncology. We found variability in the training that pediatric oncology fellows receive regarding how to conduct these discussions, highlighting a need for standardized training curricula.

Parental Perspectives on Life-Altering News in Emergency Settings: A Qualitative Evaluation

INTRODUCTION

Delivering life-altering news is a difficult task that is frequently the responsibility of emergency physicians. However, the existing frameworks for guiding such interactions fail to address the physician-parent-patient dynamic of pediatric emergency encounters. To date, no study has investigated the parental perspective, limiting the ability to provide evidence-based recommendations. This study describes how parents experience receiving life-altering news about their child in emergency settings.

METHODS

This qualitative study used virtual asynchronous focus groups. Through purposeful sampling of virtual support and advocacy groups, we recruited parents of children diagnosed with either malignancy or type 1 diabetes in an emergency department. Participants were then assigned to private Facebook groups established solely for this study. Questions were posted to these groups over the course of 5 days. At their convenience, participants could post responses, replies, or new questions. Three members of the research team performed thematic analysis and used team consensus to ensure validity.

RESULTS

Four focus groups were conducted with a total of 28 participants. Parents described their experiences receiving life-altering news as a process with 4 primary emergent themes: lens through which they view the experience, the ED encounter, the immediate response, and the long-term impact. Each parent entered into the ED encounter with a unique collection of personal experiences, circumstances, and knowledge. These factors shaped the lens through which they perceived the events of the ED encounter. Ultimately, this determined participants' response to the life-altering news, leading to many long-term impacts on the various dynamics within each parent's life.

CONCLUSIONS

The words used to disclose life-altering news are only a small piece of the experience for parents. Personal lenses changed how encounters were perceived, resulting in variable and long-lasting implications. We recommend the following framework for providers: understand the lens, control encounters, manage responses, and respect long-term impacts.

Patient references in the 2005 and 2015 CanMEDS frameworks

Background

Patient involvement in postgraduate medical education (PGME) can help residents improve their communication, professionalism, and collaboration. The CanMEDS Framework defines such competencies for physicians and informs teaching and assessment activities in PGME. However, it is unclear how patients are referenced in the CanMEDS Framework and if these references encourage the active involvement of patients in PGME. To inform how patients are referenced in the revisions of the CanMEDS Framework, scheduled for publication in 2025, our aim was to determine how patients are referenced in each the 2005 and 2015 CanMEDS Frameworks.

Methods

We used document analysis to examine how the term 'patient(s)' is referenced in the 2005 and 2015 CanMEDS Frameworks.

Results

Several 2005 and 2015 CanMEDS Roles include patients in the descriptions but do not reference them in the competencies. Others do not reference patients in the descriptions or competencies, potentially detracting from the importance of involving patients. As it stands, the 2015 Health Advocate is the only Role that describes and references patients working with physicians as partners in care, facilitating potential opportunities for patient involvement in PGME.

Conclusion

There are inconsistencies in how patients are described and referenced as potential partners in PGME throughout past and present CanMEDS Frameworks. Understanding these inconsistencies can inform the revision of CanMEDS that is scheduled for publication in 2025.

Novel approaches to communication skills development: The untapped potential of qualitative research immersion

Objective

Participation in qualitative research, particularly analysis of recorded medical dialogue, offers real-time, longitudinal immersion that can strengthen clinical trainee communication skills. The study objective was to explore how qualitative research participation impacts clinical trainees' self-perceived communication skills development and practice.

Methods

In this study, a 17-member multidisciplinary working group of child life specialists, advanced practice providers, undergraduate/medical students, residents, fellows, attending physicians, social scientists, and career researchers with recent qualitative and communication research experience assembled to discuss this topic using a structured discussion guide. Content analysis was used to identify concepts and themes.

Results

Three key themes characterizing the impact of qualitative research participation on aspiring clinicians' communication skills development and practice arose - the 3Cs: (1) Connection, therapeutic alliance, and accompaniment; (2) Clarity and prognostic communication; (3) Compassion, empathy, and understanding. Participants emphasized that qualitative research learning improved their understanding of patient/family lived experiences, preparing them for future clinical encounters, strengthening their emotional intelligence, and promoting self-care, resilience, and professional affirmation.

Conclusions

Immersion in clinical communication through participation in qualitative research is an under-utilized resource for supporting clinical trainees in communication skills development.

Innovation

The process of collaborative knowledge production through the collective exploration of an a priori question related to group members' collective experiences is methodologically innovative. Further, re-thinking qualitative research participation as an underutilized educational opportunity is pedagogically novel, and leaders in medical education and qualitative research should collaborate to realize the potential of this teaching tool.

Pediatric End-of-Life Care Skills Workshop: A Novel, Deliberate Practice Approach

INTRODUCTION

Pediatric end of life (EOL) care skills are a high acuity, low occurrence skill set required by pediatric clinicians. Gaps in education and competence for this specialized care can lead to suboptimal patient care and clinician distress when caring for dying patients and their families.

METHODS

A half-day workshop using a deliberate practice approach was designed by an inter-professional workgroup including bereaved parent consultants. Pediatric fellows (neonatal-perinatal medicine, critical care, hematology oncology, blood and marrow transplant) and advanced practice providers learned and practiced EOL skills in a safe simulation environment with instruction from interprofessional facilitators and standardized patients. Participant perceived competence (self-efficacy) was measured before, immediately-post, and 3 months post workshop.

RESULTS

There were 28 first-time (of 34 total) participants in 4 pilot workshops. Participants reported significantly increased self-efficacy post-workshop for 6 of 9 ratings, which was sustained 3 months afterwards. Most (92%, n = 22 of 24 respondents) reported incorporating the workshop training into clinical practice at 3-month follow-up.

CONCLUSIONS

With early success of the pilot workshops, future iterative work includes expanding workshops to earlier, interprofessional learners and collecting validity evidence for a competency-based performance checklist tool. A project website (https://z.umn.edu/PECS) was developed for local and collaborative efforts.

"I Didn't Want My Baby to Pass, But I Didn't Want Him Suffering Either": Comparing Bereaved Parents' Narratives With Nursing End-of-Life Assessments in the Pediatric Intensive Care Unit

Little is known about how nursing care at the end of a child's life impacts long-term parental bereavement. We aimed to explain, contextualize, and examine comparisons between quantitative trends in children's end-of-life care and parents' qualitative perceptions. We used a mixed methods design, combining quantitative data from the RESTORE clinical trial with qualitative interviews with bereaved parents. Patients who died during RESTORE were included in quantitative analyses. A subset of their parents was interviewed 7 to 11 years later. The quantitative analyses included 104 children. Eight parents were interviewed; 4 had a child die after cancer, and 4 had a child die after a complex chronic illness. Quantitatively, patients' pain and sedation scores were generally comfortable. Children died with multiple invasive devices in place. Parents' descriptions of their child's comfort and critical care requirements differed by illness trajectory (cancer, complex chronic illness). Parents' memories of their child's suffering aligned with peaks in clinical scores, rather than averages. Invasive devices and equipment altered parents' ability to make meaningful final memories with the dying child. Pediatric intensive care clinicians may need to broaden how they attend to dying children's pain and corresponding parental distress, as parents' memories of their dying child's suffering persist for years.

Furthering Palliative Care Training in Latin America: Development and Assessment of an Advanced Diploma Course in Palliative Care in Chile

CONTEXT

The vast majority of people with serious health-related suffering in low- and middle-income countries lack access to palliative care (PC). In Latin America, this shortage is critical, and PC education is greatly needed.

OBJECTIVES

This study aims to assess the effects of an advanced PC diploma course in Chile through assessment of participants' satisfaction, knowledge, behavior, and self-efficacy.

METHODS

We developed and implemented a 12-day, hybrid-setting, advanced PC diploma course for Latin American clinicians and collected and analyzed pre course, immediate post course, and 6-month post course quantitative and qualitative data on satisfaction, knowledge, behaviors, and self-efficacy.

RESULTS

Thirteen Latin American doctors participated in this advanced PC diploma course. Overall knowledge and self-efficacy increased post course. One hundred percent of participants described the course as "very high quality" or "high quality," described the course's teaching methods as "very easy to understand" or "easy to understand," and ranked role-play as a "very useful" tool.

CONCLUSION

There is a critical shortage of PC in Latin America where PC education is greatly needed. The lessons learned from this pilot advanced PC diploma course will inform further PC educational development in Latin America. The results of our course assessments show that an advanced diploma course can increase participants' PC knowledge, behaviors, and self-efficacy with a goal of leveraging the Train the Trainer model to increase PC educational leadership and enable training at participants' home institutions.

Leveraging Grief: Involving Bereaved Parents in Pediatric Palliative Oncology Program Planning and Development

As pediatric palliative care (PPC) became a recognized medical specialty, our developing clinical PPC team longitudinally partnered with bereaved parents to understand the care that their children received as they transitioned towards end of life. Families developed Eight Priorities, shared within, to improve care for children with a poor chance of survival based on their experience of losing a child to cancer. In this paper, we delineate the top eight PPC needs from a parent perspective to offer multi-layered, individually tailored resources for patients and families. One of these Eight Priorities noted that bereavement care for the remaining family members is vital for healing after the death of a child to promote meaning making and resilience in bereaved families. Here, we outline the creation of a bereaved parent-designed bereavement support program as one example of how we have partnered with parents to fulfill their Eight Priorities for quality care.

Family-centered communication: A pilot educational intervention using deliberate practice and patient feedback

OBJECTIVE

There are few opportunities in medical education dedicated to learning skills for effective communication in life altering patient scenarios. We therefore aimed to develop and assess a longitudinal advanced communication curriculum for pediatric residents using patient feedback and deliberate practice.

METHODS

Pediatric residents at a large academic center were randomized into 2 groups. The intervention group received 6 educational sessions from 2019 to 2020, parent feedback of performance via the Communication Assessment Tool (CAT), and monthly communication tips. Communication skills of both groups were assessed at the end of the intervention.

RESULTS

We collected 937 CAT assessments on 36 first-year residents. The intervention group demonstrated statistically significant improvement in communication skills from pre to post assessment (p = 0.0063, (odds ratio (OR) 1.76, 95 % confidence interval (CI) [1.17, 2.63]) compared to the control group (p = 0.080, OR 1.41, 95 % CI [0.96, 2.05]).

CONCLUSIONS

There are patient and self-identified performance gaps in communication skills for pediatric residents, underscoring the need for formalized curricula dedicated to these skills.

PRACTICE IMPLICATIONS

Our study highlights the value of deliberate practice and the integration of family feedback as an educational tool in communication skills development.

The state of the science for communication training in pediatric oncology: A systematic review

Within the field of pediatric oncology, communication skills training (CST) has been recognized as a high priority by professional and accrediting organizations. However, the effectiveness of formalized CST interventions for pediatric oncology providers remains poorly understood. We systematically searched PubMed, Web of Science, Scopus, and PsycInfo for original research articles assessing the effectiveness and quality of CST interventions targeting pediatric oncology clinicians. From 971 deduplicated references, eight articles representing six communication interventions were eligible for inclusion. This review summarizes the existing literature with respect to CST content, intervention methodology, targeted outcome metrics, measurement tools, short-term and sustained benefits, design biases, and availability of materials to allow for reproduction of interventions. Ultimately, studies on CST in pediatric oncology are few, heterogeneous, and lacking in standardized outcome metrics; however, synthesis of the available literature suggests feasibility and effectiveness. Increased scientific rigor is needed, and specific recommendations to advance the field are described.

Parents as Teachers: Teaching Pediatrics Residents the Art of Engaging in Difficult Conversations

BACKGROUND

Physicians often lack the skills and confidence needed to have difficult conversations with patients and their families. Patients and families who have experienced these conversations can provide valuable insight for resident physicians.

OBJECTIVE

We developed a communication skills workshop for pediatrics residents using parents and a team of social workers, nurses, chaplains, and physician facilitators in role-playing exercises.

METHODS

From 2007 to 2016, half-day "difficult conversation" workshops were held annually for postgraduate year 1 (PGY-1) and PGY-2 residents that included an interprofessional team and parents of children with life-threatening diagnoses. Questionnaires assessed residents' prior training, effectiveness of the sessions, and narrative feedback on the impact of this approach. Parents and team members were surveyed on the effectiveness of the training and the value of parent involvement.

RESULTS

Median self-reported confidence levels for incoming PGY-1 residents following the workshop rose from 2 to 4 on a 5-point Likert scale (99% response rate [128 of 129 surveyed], P < .001). The majority of PGY-2 residents (91%, 115 of 126) reported the workshop increased their confidence in engaging in difficult conversations (91% response rate [126 of 139]). Parents and clinical care team members agreed that parents would likely be preferable to standardized actors for these types of role-playing exercises (84% response rate [37 of 44]).

CONCLUSIONS

Involving patients' parents and an interprofessional team in role-playing scenarios was a well-received method for teaching residents how to engage in difficult conversations with patients and families, and improved their self-reported confidence when having these conversations.

Communication Skills Training for Professionals Working with Adolescent Patients with Cancer Based on Participants' Needs: A Pilot

Purpose: We aimed to pilot and evaluate communication skills training (CST) for health care professionals (HCPs) interacting with adolescent patients with cancer and their parents based on participants' needs. Methods: We developed and piloted a 2-day CST with physicians and nurses in adolescent oncology. The CST's agenda was determined by the critical incidents reported by the participants. Training consisted of experiential learning based on role-play between HCPs and simulated patients and parents. Whenever suited, short lectures were given on specific communication techniques. Skills were self-assessed by questionnaires before, immediately after, and 6 months after training. We compared the proportion of participants who felt confident in 19 predefined areas of difficult communication before and 6 months after training. Responses to open-ended questions were analyzed qualitatively by thematic analysis. Results: Twenty-six physicians and 24 nurses participated in 6 CSTs. The proportion of participants who felt confident increased significantly in 6 of 19 communication items (p < 0.05). Positive feedback outweighed negative in quantity and quality. Predominant themes immediately after training were the training's practical orientation and intensity, and 6 months later, increased self-confidence and applied communication techniques. Participants noted that the effect diminishes with time, and expressed their need for booster trainings. Conclusion: The results of CST tailored to the specific needs of HCPs in adolescent oncology were promising. We suggest that similar training opportunities are implemented elsewhere.

From Fear to Confidence: Changing Providers' Attitudes About Pediatric Palliative and Hospice Care

CONTEXT

Children have limited access to hospice care: few existing hospice programs have dedicated pediatric teams, and adult hospice providers feel inadequately trained to care for children.

OBJECTIVES

The aim of this study was to increase access to pediatric hospice care by empowering adult hospice providers to care for children through a comprehensive education program. Education empowers providers by changing their attitudes from inadequacy to confidence.

METHODS

The authors developed a two-day education program to train interdisciplinary teams of adult hospice providers in pediatric care. The curriculum consists of 13 modules to improve participants' knowledge, skills, and attitudes. Ninety-three providers across the U.S. learned via multiple teaching methods including lectures, role plays by professional actors, interviews of bereaved parents, and self-reflections. Learning was evaluated with assessments before, immediately after, and six months after the program. Responses were compared using a one-sided analysis of variation with a significance level of alpha <0.05.

RESULTS

Participants improved their knowledge in 12 of 13 modules. Self-reported confidence levels with pediatric care improved significantly in all 13 modules (P < 0.05). After this program, 79% of providers reported feeling better prepared to care for pediatric hospice patients. Qualitative data reinforced that learners felt more prepared to care for pediatric patients.

CONCLUSION

A two-day, high-intensity low-cost community-based education program can improve adult providers' knowledge of and skill level with pediatric care, leading to a change in attitude from fear to confidence. This model has the potential to increase access to pediatric hospice care as it uses existing adult hospice infrastructure.

Incorporating Bereaved Parents as Faculty Facilitators and Educators in Teaching Principles of Palliative and End-of-Life Care

BACKGROUND:

Education and training for interdisciplinary pediatric providers requires training in principles of palliative and end-of-life (EOL) care. The experiences of bereaved parents can inform and enhance palliative care educational curricula in uniquely powerful and valuable ways. The objective of this study is to present an innovative palliative care educational program facilitated by trained bereaved parents who serve as volunteer educators in local and national palliative care educational forums and to describe how incorporation of bereaved parents in these educational forums affects participant comfort with communication and management of children at the EOL.

METHODS:

Parent educators underwent both general and session-specific training and participated in debriefings following each session. Survey tools were developed or adapted to determine how bereaved parent educators affected participant experiences in 3 different educational forums. Pre- and postsession surveys with incorporation of retrospective preprogram assessment items to control for response shift were used in the evaluation of institutional seminars on pediatric palliative and EOL care and role-play-based communication training sessions. Results from feedback surveys sent to attendees were used to appraise the participants' experience at the international oncology symposium.

RESULTS:

Involvement of trained parent educators across diverse, interdisciplinary educational forums improved attendee comfort in communicating with, and caring for, patients and families with serious illness. Importantly, parent educators also derive benefit from involvement in educational sessions with interdisciplinary clinicians.

CONCLUSIONS:

Integration of bereaved parents into palliative and EOL care education is an innovative and effective model that benefits both interdisciplinary clinicians and bereaved parents.

Development and Implementation of an End-of-Life Curriculum for Pediatric Residents

Background:

Caring for a child near the end of life (EOL) can be a stressful experience. Resident physicians are often the frontline providers responsible for managing symptoms, communicating difficult information, and pronouncing death, yet they often receive minimal education on EOL care.

Objective:

To develop and implement an EOL curriculum and to study its impact on resident comfort and attitudes surrounding EOL care.

Design:

Kern’s 6-step approach to curriculum development was used as a framework for curriculum design and implementation.

Setting/Participants:

Categorical and combined pediatric residents at a large quaternary care children’s hospital were exposed to the curriculum.

Measurements:

A cross-sectional survey was distributed pre- and postimplementation of the curriculum to evaluate its impact on resident comfort and attitudes surrounding EOL care.

Results:

One-hundred twenty-six (49%) of 258 residents completed the preimplementation survey, and 65 (32%) of 201 residents completed the postimplementation survey. Over 80% of residents reported caring for a dying patient, yet less than half the residents reported receiving prior education on EOL care. Following curriculum implementation, the percentage of residents dissatisfied with their EOL education fell from 36% to 14%, while the percentage of residents satisfied with their education increased from 14% to 29%. The postimplementation survey identified that resident comfort with communication-based topics improved, and they sought additional training in symptom management.

Conclusions:

The implementation of a longitudinal targeted multimodal EOL curriculum improved resident satisfaction with EOL education and highlighted the need for additional EOL education.

Consult, Negotiate, and Involve: Evaluation of an Advanced Communication Skills Program for Health Care Professionals

Effective communication is central to children, young people, and their families’ experiences of health care. Most patient complaints in developed health care systems result from ineffective communication, including inadequate information provision, not feeling listened to, failure to value patients concerns, and patients not feeling involved in care decisions. Advanced communication skills training is now embedded within cancer care policy in the United Kingdom and now features prominently within cancer education in many countries. Here, we share findings from a research evaluation of an advanced communication skills training program dedicated to health professionals caring for children and young people with cancer. We evaluated participants’ (n = 59) perceptions of the program, impact on their skills, knowledge, competence, and confidence. An appreciative inquiry design was adopted; data included interviews, precourse-postcourse evaluations, e-mail blog survey, and 360-degree reflective work records. The framework approach underpinned data analysis and triangulation of data sets. Key findings highlighted good and poor practice in health professionals’ engagement with children, young people, and their families; the purpose of communicating effectively was not always consistent with collaborative working. Attending a program helped participants expand their knowledge of communication theories and strategies. Participants valued using simulated scenarios to develop their skills and were keen to use their new skills to enhance care delivery. Our emphasis within this evaluation, however, remained on what was communicated, when and how, rather than to what effect. The impact of programs such as these must now be evaluated in terms of patient benefit.

Pediatric palliative oncology: the state of the science and art of caring for children with cancer

PURPOSE OF REVIEW

Pediatric palliative oncology (PPO) is an emerging field that integrates the principles of palliative care early into the illness trajectory of children with cancer. PPO providers work with interdisciplinary clinicians to provide optimal medical and psychosocial care to children with cancer and their families. Ongoing advances in the field of pediatric oncology, including new treatment options for progressive cancers, necessitate the early integration of palliative care tenets including holistic care, high-quality communication, and assessment and management of refractory symptoms.

RECENT FINDINGS

Research in this emerging field has expanded dramatically over the past several years. This review will focus on advancements within several key areas of the field, specifically regarding investigation of the communication needs and preferences of patients and families, exploration of educational initiatives and interventions to teach PPO principles to clinicians, study of patient-reported and parent-reported tools to better assess and manage refractory symptoms, and development of novel models to integrate palliative care within pediatric oncology.

SUMMARY

Research findings in the field of PPO, concurrent with advances in the treatment of pediatric cancer, may help improve survival and quality of life for children with cancer.

Personalized and yet standardized: An informed approach to the integration of bereavement care in pediatric oncology settings

OBJECTIVE

The death of a child has been associated with adverse parental outcomes, including a heightened risk for psychological distress, poor physical health, loss of employment income, and diminished psychosocial well-being. Psychosocial standards of care for centers serving pediatric cancer patients recommend maintaining at least one meaningful contact between the healthcare team and bereaved parents to identify families at risk for negative psychosocial sequelae and to provide resources for bereavement support. This study assessed how this standard is being implemented in current healthcare and palliative care practices, as well as barriers to its implementation.

METHOD

Experts in the field of pediatric palliative care and oncology created a survey that was posted with review and permission on four listservs. The survey inquired about pediatric palliative and bereavement program characteristics, as well as challenges and barriers to implementation of the published standards of care.ResultThe majority of participants (N = 100) self-reported as palliative care physicians (51%), followed by oncologists (19%). Although 59% of staff reported that their center often or always deliver bereavement care after a child's death, approximately two-thirds reported having no policy for the oncology team to routinely assess bereavement needs. Inconsistent types of bereavement services and varying duration of care was common. Twenty-eight percent of participants indicated that their center has no systematic contact with bereaved families after the child's death. Among centers where contacts are made, the person who calls the bereaved parent is unknown to the family in 30% of cases. Few centers (5%) use a bereavement screening or assessment tool.Significance of resultsLack of routine assessment of bereavement needs, inconsistent duration of bereavement care, and tremendous variability in bereavement services suggest more work is needed to promote standardized, policy-driven bereavement care. The data shed light on multiple areas and opportunities for improvement.

Empowering Bereaved Parents Through the Development of a Comprehensive Bereavement Program

Parents who experience the loss of a child have unique and valuable insights into the grief journey and can help health care providers identify key components intrinsic to the development, implementation, and maintenance of a comprehensive bereavement program. The bereavement program at St. Jude Children's Research Hospital was developed by pediatric palliative care experts in collaboration with bereaved parents to standardize and improve the institutional support provided to families around and after the death of a child. This article describes the components of a parent-derived bereavement program and presents early results on the effects of specific program components. The program, under the leadership of the bereavement coordinator, includes clinical and supportive interventions offered throughout the grief journey, parent-created bereavement support materials, and opportunities for parents and families to participate in research, quality improvement initiatives and educational interventions. Parents report that services and interventions provided through the bereavement program are beneficial to families after the death of their child. In addition, both health care providers and bereaved parents report that participation in educational interventions positively impacts their experiences as clinicians and parents, respectively. The innovative nature of this parent-driven, comprehensive bereavement program may serve as a paradigm for the development of bereavement programs in the fields of pediatrics, palliative oncology and hospice and palliative medicine.