Parental experience following perinatal death: exploring the issues to make progress

Bereavement care guidelines used in health care facilities immediately following perinatal loss: a scoping review

OBJECTIVE

The objective of the scoping review was to explore the evidence and describe what is known about perinatal bereavement care guidelines provided within health care facilities prior to discharge. Additionally, the review sought to identify what is known about parents' mental health outcomes, and map these outcomes to the characteristics of the bereavement care guidelines.

INTRODUCTION

Perinatal loss poses a serious risk of emotional trauma and mental health sequelae. Conflicting evidence for international bereavement care guidelines and inconsistent implementation, a lack of experimental studies, and older syntheses with a limited focus or population made synthesis complex. Therefore, a scoping review was undertaken to determine the breadth and depth of the existing literature on this topic.

INCLUSION CRITERIA

Sources pertaining to bereavement care guidelines used in health care facilities immediately after perinatal loss (miscarriage, stillbirth, or neonatal death) and parents' mental health outcomes were included. Sources pertaining to family members other than parents, perinatal loss occurring outside of a health care facility, and physical care guidelines were excluded.

METHODS

The review was conducted using JBI methodology for scoping reviews. The team considered quantitative and qualitative studies, practice guidelines, case reports, expert opinions, systematic reviews, professional organization websites, and gray literature. CINAHL (EBSCOhost), PsycINFO (EBSCOhost), SocINDEX (EBSCOhost), Cochrane Library, JBI Evidence-based Practice Database (Ovid), Embase, PubMed (NLM), ProQuest Dissertations and Theses A&I (ProQuest), Web of Science Core Collection, and Epistemonikos were the major databases searched. OpenGrey, Google Scholar, and organizational websites were also searched. The earliest empirical study publication found (1976) served as the starting date limit. After pilot-testing the screening process, data were extracted, collated, and presented in narrative form as well as in tables and figures. The search was first conducted in September and October 2021, and an updated search was performed on February 9, 2023.

RESULTS

The results provide a broad view of bereavement care guidelines to support grieving parents' mental health. The included sources (n = 195) were comprised of 28 syntheses, 96 primary studies, and 71 literature review/text and opinion. From the studies that specified the number of participants, 33,834 participants were included. Key characteristics of bereavement care guidelines were categorized as i) making meaning/memories, ii) good communication, iii) shared decision-making, iv) effective emotional and social support, and v) organizational response. Parents' reported mental health outcomes included both negative outcomes, such as depression, anxiety, anger, and helplessness, and positive outcomes, including coping, healing, recovery, and well-being.

CONCLUSIONS

Conceptually the characteristics of published guidelines are fairly consistent across settings, with cultural variations in specific components of the guidelines. Despite the exponential increase in research pertaining to bereavement care after perinatal loss, there is a gap in research pertaining to certain characteristics of bereavement care guidelines accepted as best practice to support parents' mental health outcomes. This review provides support for future research given the trauma and mental health risks following perinatal loss. Policies ensuring consistent and appropriate implementation of bereavement care guidelines are essential to improve parents' mental health outcomes.

Desired Care for Perinatal Bereavement: Meeting the Needs of Mothers After Discharge From the Hospital-a Qualitative Study

This study aimed to investigate the understanding and experiences of mothers who have suffered perinatal loss regarding their needs after being discharged from the hospital. Data were collected through semi-structured face-to-face and telephone interviews using purposive sampling with maximum diversity. The sample included 15 mothers and 6 midwives who had experienced fetal loss and perinatal bereavement. The interviews were audio-recorded and transcribed verbatim. Conventional content analysis was used to analyze the data. Sampling was conducted from July 2022 to March 2023, continuing until data saturation was reached. The study identified 2 main categories of needs for mothers who have experienced perinatal loss: continuous healthcare (including the Comprehensive Mother Tracking System, provision of psychological welfare, and educational needs) and provision of a support network, including "spouse and family support" and "peer and colleague support." The primary theme of this study was "Deliberating Care for Grieving Mothers." The study results indicate that mothers who experience perinatal loss require continuity of care after being discharged. Psychological screening and counseling support are essential for both parents. Considering the significant impact of spousal, familial, and community support on an individual's life, it is crucial to prepare the community to comprehend and embrace grieving parents.

Measuring experience of and satisfaction with newborn care: a scoping review of tools and measures

BACKGROUND

Standardised measures on experience of care are essential to understanding the care women and newborns receive and to designing appropriate interventions and responses. This review builds on ongoing work in the realm of maternity care and complements it by reviewing existing tools and measures to assess experience of and satisfaction with the care of the newborn.

METHODS

We conducted a scoping review of published literature to identify measures and tools of experience (physiological or indirect) and satisfaction with newborn care. We systematically searched five bibliographic databases from 1 January 2010 through 1 December 2022 and contacted professional networks. Using a predefined evidence template, we extracted data on the studies and the tools' characteristics. We mapped the tools and measures against the WHO quality of care frameworks to identify the most frequent measured domains of care and to highlight existing gaps.

RESULT

We identified 18 292 records of which 72 were eligible. An innovative finding of this review is the inclusion of newborn perspectives through behavioural responses, physiological signals, pain profiles as well as other non-verbal cues as markers of newborn experience. Domains related to parental participation and decision-making, ensuring continuity of care and receiving coordinated care, were the most measured across the included tools.

CONCLUSION

Comprehensive and validated instruments measuring all aspects of care are needed. Developing a robust theoretical ground will be fundamental to the design and utilisation of standardised tools and measures.

PROTOCOL REGISTRATION DETAILS

This review was registered and published on protocol.io (dx.doi.org/10.17504/protocols.io.bvk7n4zn).

Provider Perceptions on Bereavement Following Newborn Death: A Qualitative Study from Ethiopia and Ghana

OBJECTIVE

The objective of this study was to explore how clinicians in low- and middle-income countries engage and support parents following newborn death.

STUDY DESIGN

Qualitative interviews of 40 neonatal clinicians with diverse training were conducted in Addis Ababa, Ethiopia, and Kumasi, Ghana. Transcribed interviews were analyzed and coded through the constant comparative method.

RESULTS

Three discrete themes around bereavement communication emerged. (1) Concern for the degree of grief experienced by mothers and apprehension to further contribute to it. This led to modified communication to shield her from emotional trauma. (2) Acknowledgment of cultural factors impacting neonatal loss. Clinicians reported that loss of a newborn is viewed differently than loss of an older child and is associated with a diminished degree of public grief; however, despite cultural expectations dictating private grief, interview subjects noted that mothers do suffer emotional pain when a newborn dies. (3) Barriers impeding communication and psychosocial support for families, often relating to language differences and resource limitations.

CONCLUSIONS

Neonatal mortality remains the leading global cause of mortality under age 5, with the majority of these deaths occurring in low- and middle-income countries, yet scant literature exists on approaches to communication around end-of-life and bereavement care for neonates in these settings. We found that medical providers in Ghana and Ethiopia described structural and cultural challenges that they navigate following the death of a newborn when communicating and supporting bereaved parents.

Parent moral distress in serious pediatric illness: A dimensional analysis

BACKGROUND

Moral distress is an important and well-studied phenomenon among nurses and other healthcare providers, yet the conceptualization of parental moral distress remains unclear.

OBJECTIVE

The objective of this dimensional analysis was to describe the nature of family moral distress in serious pediatric illness.

DESIGN AND METHODS

A dimensional analysis of articles retrieved from a librarian-assisted systematic review of Scopus, CINAHL, and PsychInfo was conducted, focusing on how children, parents, other family members, and healthcare providers describe parental moral distress, both explicitly through writings on parental moral experience and implicitly through writings on parental involvement in distressing aspects of the child's serious illness.

ETHICAL CONSIDERATIONS

To promote child and family best interest and minimize harm, a nuanced understanding of the moral, existential, emotional, and spiritual impact of serious pediatric illness is needed. The cases used in this dimensional analysis come from the first author's IRB approved study at the Children's Hospital of Philadelphia and subsequent published studies; or have been adapted from the literature and the authors' clinical experiences.

FINDINGS

Three dimensions emerged from the literature surrounding parent moral distress: an intrapersonal dimension, an interpersonal dimension, and a spiritual/existential dimension. The overarching theme is that parents experience relational solace and distress because of the impact of their child's illness on relationships with themselves, their children, family, healthcare providers, their surrounding communities, and society.

DISCUSSION

Elucidating this concept can help nurses and other professionals understand, mitigate, or eliminate antecedents to parental moral distress. We discuss how this model can facilitate future empirical and conceptual bioethics research, as well as inform the manner in which healthcare providers engage, collaborate with, and care for families during serious pediatric illness.

CONCLUSION

Parent moral distress is an important and complex phenomenon that requires further theoretical and empirical investigation. We provide an integrated definition and dimensional schematic model that may serve as a starting point for future research and dialogue.

Experience of parents who have suffered a perinatal death in two Spanish hospitals: a qualitative study

Background

Perinatal grief is a process that affects families in biological, psychological, social and spiritual terms. It is estimated that every year there are 2.7 million perinatal deaths worldwide and 4.43 deaths for every 1000 births in Spain. The aim of this study is to describe and understand the experiences and perceptions of parents who have suffered a perinatal death.

Methods

A qualitative study based on Gadamer’s hermeneutic phenomenology. The study was conducted in two hospitals in the South of Spain. Thirteen mothers and eight fathers who had suffered a perinatal death in the 5 years prior to the study participated in this study. In-depth interviews were carried out for data collection. Inductive analysis was used to find themes based on the data.

Results

Eight sub-themes emerged, and they were grouped into three main themes: ‘Perceiving the threat and anticipating the baby’s death: “Something is going wrong in my pregnancy”’; ‘Emotional outpouring: the shock of losing a baby and the pain of giving birth to a stillborn baby’; “We have had a baby”: The need to give an identity to the baby and legitimise grief’.

Conclusion

The grief suffered after a perinatal death begins with the anticipation of the death, which relates to the mother’s medical history, symptoms and premonitions. The confirmation of the death leads to emotional shock, characterised by pain and suffering. The chance to take part in mourning rituals and give the baby the identity of a deceased baby may help in the grieving and bereavement process.

Having empathy for the parents and notifying them of the death straightaway can help ease the pain. Midwives can help in the grieving process by facilitating the farewell rituals, accompanying the family, helping in honouring the memory of the baby, and supporting parents in giving the deceased infant an identity that makes them a family member.

Perinatal Palliative Care: A qualitative study evaluating the perspectives of pregnancy counselors

BACKGROUND

A prenatal diagnosis of a life-limiting disease raises complex ethical, emotional, and medical issues. Studies suggest that 40%-85% of parents decide to continue the pregnancy if given the option of Perinatal Palliative Care. However, structured Perinatal Palliative Care programs are missing in many European countries. In Germany, parents have the right to free psychosocial support from pregnancy counseling services after the prenatal diagnosis of a life-limiting disease.

AIM

We aimed to investigate whether German professional pregnancy counselors perceive the need for structured Perinatal Palliative Care and if so, how it should be conceived.

DESIGN

This is a qualitative interview study with purposeful sampling. The interviews were analyzed with the coding method of Saldaña.

SETTING/PARTICIPANTS

A total of 10 professionals from three different pregnancy counseling services participated in the study.

RESULTS

The main topics raised by the professionals were as follows: (1) counseling and parental support during the decision-making process; (2) fragmented or missing support infrastructure for parents; and (3) challenges, hesitations, and barriers, particularly from the different stakeholders, regarding a Perinatal Palliative Care framework. They highlighted the importance of the integration of Perinatal Palliative Care in existing structures, a multi-professional approach, continuous coordination of care and education for all healthcare providers involved.

CONCLUSION

A structured Perinatal Palliative Care program is considered as necessary by the pregnancy counselors. Future research should focus on (1) needs reported by concerned parents; (2) attitude and role of all healthcare providers involved; (3) strategies to include stakeholders in the development of Perinatal Palliative Care networks; and (4) outcome parameters for evaluation of Perinatal Palliative Care frameworks.

[An exploration of factors influencing nursing practice with families experiencing perinatal loss ]

INTRODUCTION

Perinatal loss is a complex phenomenon with multiple dimensions and represents a professional challenge for nurses. There are as many different ways of coping with bereavement as there are parents, and nurses must adapt their intervention in order to adequately support grieving parents.

PURPOSE

This qualitative study explored the factors that influence nursing practice with bereaved families in a secondary obstetric care center in Quebec.

METHODS

Guba and Lincoln's fourth generation evaluation approach was used. Ten nurses participated in this qualitative study. Data collection was performed using semi-structured interviews. Validation interviews were conducted with three nurses and two gynecologists. The analysis was performed within the perspective of Watson's theory of caring.

RESULTS

A thematic analysis was performed and five themes were identified: the relational quality between the nurse and the family, personal characteristics of the nurse, the feelings expressed by nurses, the working environment, and the context in which the nursing care is provided to the family.

CONCLUSION

In light of the results, some aspects of nursing practice should be encouraged in order to assure adequate support is provided to grieving families.

Compassion and Community in Perinatal Palliative Care: Understanding the Necessity of the Patient Perspective Through Narrative Illustration

Advancing technology in reproductive medicine has led to more frequent perinatal diagnoses of fatal or life-limiting anomaly. For those parents who choose to continue pregnancies while facing such a diagnosis, compassionate and communal perinatal palliative care provides beneficial physical and psycho-socio-emotional support for these families, so that they may preserve and acknowledge the relationship with their child, no matter how brief his/her life.

Suporte aos pais que vivenciam a perda do filho neonato: revisão de literatura

Objetivos: investigar y discutir publicaciones acerca del soporte relacionado al duelo de padres que vivencian la pérdida del hijo neonato. Material y método: revisión crítica de literatura con búsqueda en las bases de datos CINAHL, Embase, PubMed, PsycINFO y Scopus, de artículos publicados entre enero del 2010 y julio del 2017, utilizando análisis temática para el tratamiento de los datos recolectados. Resultados: se diseñaron tres categorías temáticas: 1) apoyo y soporte a los padres que vivencian la experiencia de la pérdida del hijo neonato; 2) sentimientos de los padres ante situaciones de muerte y duelo, y 3) participación de los padres en el proceso de tratamiento y pronóstico del hijo. Se destacaron algunas necesidades: mejor preparo de los profesionales, comunicación adecuada; formación de memoria del neonato, vínculo de los padres en el proceso de muerte. Conclusiones: se evidencia la diversidad cultural en la experiencia de duelo, la que se debe considerar en el cuidado al enlutado; la continuidad del vínculo con familiares luego del proceso de muerte/morir del neonato puede ser fuente de prevención de trastornos durante el duelo. Reflexionar sobre directrices, políticas y formación curricular ampliada puede traer diferencial al equipo de salud en la asistencia al duelo y, por ende, a la salud mental.

Decision-making at the borderline of viability: Who should decide and on what basis?

Parents and medical staff usually agree on the management of preterm labour at borderline viability, when there is a relatively high risk of long-term neurodevelopmental problems in survivors. If delivery is imminent and parents and staff cannot agree on the best management, however, who should decide what will happen when the baby is delivered? Should the baby be resuscitated? Should intensive care be initiated? Three ethicists, one of whom is also a neonatologist, discuss this complex issue.

Quality Indicators and Parental Satisfaction With Perinatal Palliative Care in the Intrapartum Setting After Diagnosis of a Life-Limiting Fetal Condition

Measurement of quality indicators (QIs) in perinatal palliative care has not been addressed. Parents who chose to continue pregnancy after a diagnosis of a life-limiting fetal condition described perceptions of quality care and their satisfaction with care. This research identified which QIs explained parental satisfaction. High QI scores are associated with parental satisfaction. Parents who were satisfied reported 2.9 times the odds that their baby was treated with dignity and respect and 3.4 times the odds their medical care was addressed. This research is a first step in developing a robust measure of QIs in perinatal palliative care.

Health professionals' perspectives on bereavement following loss from a twin pregnancy: a qualitative study

OBJECTIVE

To provide an in-depth understanding of the perspectives of health professionals caring for parents who have lost a baby from a twin pregnancy, either during pregnancy or in the neonatal period.

STUDY DESIGN

A qualitative study involving semi-structured interviews. Twenty-six health professionals were interviewed from maternity and neonatal departments in one hospital. Data were analyzed using a generative thematic approach.

RESULTS

Three main themes were identified from the data: health professionals' lack of confidence in their interactions with bereaved parents; their desire to learn more about bereavement; and a consideration of sensitive health-care practices for bereaved parents.

CONCLUSIONS

Health professionals acknowledged that parents who experience the loss of a twin have specific needs, some of which can be addressed by relatively small changes to clinical practices and behaviors. They felt, however, that they needed education about bereavement in order to react more effectively to bereaved parents' needs.

Neonatal end of life care in a tertiary care centre in Canada: a brief report

OBJECTIVE

To describe the processes followed by a neonatal team engaging parents with respect to end of life care of babies in whom long term survival was negligible or impossible; and to describe feedback from these parents after death of their child.

METHODS

A retrospective review was conducted of health records of neonates who had died receiving palliative care over a period of 5 years at a tertiary neonatal centre. Specific inclusion criteria were determined in advance that identified care given by a dedicated group of caregivers.

RESULTS

Thirty infants met eligibility criteria. After excluding one outlier an average of 4 discussions occurred with families before an end of life decision was arrived at. Switching from aggressive care to comfort care was a more common decision-making route than having palliative care from the outset. Ninety per cent of families indicated satisfaction with the decision making process at follow-up and more than half of them returned later to meet with the NICU team. Some concerns were expressed about the availability of neonatologists at weekends.

CONCLUSIONS

A compassionate and humane approach to the family with honesty and empathy creates a positive environment for decision-making. An available, experienced team willing to engage families repeatedly is beneficial. Initiating intensive care with subsequent palliative care is acceptable to families and caregivers.

Caring Decisions: The Development of a Written Resource for Parents Facing End-of-Life Decisions

Background: Written resources in adult intensive care have been shown to benefit families facing end of life (EoL) decisions. There are few resources for parents making EoL decisions for their child and no existing resources addressing ethical issues. The Caring Decisions handbook and website were developed to fill these gaps.

Aim: We discuss the development of the resources, modification after reviewer feedback and findings from initial pilot implementation.

Design: A targeted literature review-to identify resources and factors that impact on parental EoL decision-making; development phase-guided by the literature and the researchers' expertise; consultation process-comprised a multi-disciplinary panel of experts and parents; pilot evaluation study-hard-copy handbook was distributed as part of routine care at an Australian Children's Hospital.

Setting/Participants: Twelve experts and parents formed the consultation panel. Eight parents of children with life-limiting conditions and clinicians were interviewed in the pilot study.

Results: Numerous factors supporting/impeding EoL decisions were identified. Caring Decisions addressed issues identified in the literature and by the multidisciplinary research team. The consultation panel provided overwhelmingly positive feedback. Pilot study parents found the resources helpful and comforting. Most clinicians viewed the resources as very beneficial to parents and identified them as ideal for training purposes.

Conclusions: The development of the resources addressed many of the gaps in existing resources. The consultation process and the pilot study suggest these resources could be of significant benefit to parents and clinicians.

Mothers' perspectives on the perinatal loss of a co-twin: a qualitative study

BACKGROUND

There is a growing body of literature exploring the emotional impact of perinatal loss upon parents but only limited research focussing specifically on the views and experiences of parents who have experienced a loss from a twin or higher order pregnancy. We undertook a qualitative study to provide an in-depth understanding of the experiences of mothers who have had a loss from a twin pregnancy and subsequently continued visiting hospital whilst their surviving twin was cared for.

METHODS

A qualitative study involving semi-structured interviews. Mothers were recruited from a Neonatal Intensive Care Unit and Fetal Medicine department. Fourteen interviews were carried out with mothers who had experienced a loss in pregnancy or the neonatal period and had a surviving twin on the neonatal unit. Data were analysed using a generative thematic approach.

RESULTS

The analysis identified three key themes in the accounts mothers gave of their experiences: the status of 'special'; the importance of trust; and control and empowerment. Where the surviving co-twin remained in hospital for many weeks, mothers described the emotional support of health professionals as crucial to their wellbeing. Few mothers sought formal bereavement support, instead they kept their grief 'on hold' in order to support their surviving baby. Due to the trauma of their loss, mothers reflected that they had been unable to make informed decisions, in particular in relation to the funeral of their deceased baby.

CONCLUSIONS

Our study highlighted that there are a specific set of issues for mothers who have lost a baby from a twin pregnancy. Relatively small changes to practice however, made a significant difference to wellbeing during their time in hospital with a surviving twin. Findings from this research will provide insight into the needs of bereaved mothers, will inform healthcare planning and the development of care packages.

What information do parents need when facing end-of-life decisions for their child? A meta-synthesis of parental feedback

Background

The information needs of parents facing end-of-life decisions for their child are complex due to the wide-ranging dimensions within which such significant events unfold. While parents acknowledge that healthcare professionals are their main source of information, they also turn to a variety of additional sources of written information in an attempt to source facts, discover solutions, and find hope.

Much has been written about the needs of parents faced with end-of-life decisions for their child but little is known about the written information needs such parents have. Research in the adult intensive care context has shown that written resources impact positively on the understanding of medical facts, including diagnoses and prognoses, communication between families and healthcare professionals, and the emotional wellbeing of families after their relative’s death.

Methods

A meta-synthesis of predominantly empirical research pertaining to features which assist or impede parental end-of-life decisions was undertaken to provide insight and guidance in our development of written resources (short print and online comprehensive version) for parents.

Results

The most prominently cited needs in the literature related to numerous aspects of information provision; the quantity, quality, delivery, and timing of information and its provision impacted not only on parents’ ability to make end-of-life decisions but also on their emotional wellbeing. The meta-synthesis supports the value of written materials, as these provide guidance for both parents and healthcare professionals in pertinent content areas.

Conclusions

Further research is required to determine the impact that written resources have on parental end-of-life decision-making and on parents’ wellbeing during and after their experience and time in the hospital environment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-015-0024-0) contains supplementary material, which is available to authorized users.

Outcomes following childhood arterial ischaemic stroke: a Delphi Consensus on what parents want from future research

AIM

Currently there are few population-based data on the outcomes of stroke in childhood, and no data on what parents want from such research. We conducted a Delphi Consensus Process among parents of children (n = 26) who had suffered an arterial ischaemic stroke to investigate which research outcomes they think are most important to follow up, and what methods of assessment they would find most acceptable.

METHODS

A postal Delphi Consensus Process was conducted.

RESULTS

The Delphi panel reached consensus that motor, cognitive and communication outcomes are the most important outcome domains to assess. They strongly preferred home visits over hospital visits or telephone interview. The majority were happy with assessment visits lasting up to 1.5 h. Ongoing concerns for panel members related to the cause of the original stroke, the risk of recurrence and the long term outcome for their child.

INTERPRETATION

Future outcome studies should preferably assess outcomes at home and focus on children's motor, cognitive and communication abilities. There is an ongoing need to clarify issues with regards to the likely cause of children's strokes and their risk of recurrence.

A descriptive study evaluating perinatal healthcare providers' perspectives of palliative programming in 3 Canadian institutions

A paucity of research has evaluated the perspectives of the broader healthcare team regarding perinatal palliative care. This study examines the views of healthcare providers involved in perinatal palliative care in 3 tertiary care hospitals in Canada. Developing an understanding of their perspectives of care provision, as well as the interactions that took place with families and other teams while providing perinatal palliative care, was of interest. Twenty-nine healthcare providers were involved in 4 focus groups and 5 individual interviews. Data were transcribed and content analysis was undertaken. The overarching theme of communication materialized from the data. Within this theme were 3 subthemes, each highlighting an aspect of communication that impacted care provision: connecting through proximity, protected time and dedicated space, and flexibility and formality. The study also describes a model of integrated perinatal palliative care program development and explains where each of the 3 sites falls along this continuum. The development of formal programs in these facilities is varied and recommendations are included to enhance communication and assist in providing improved and integrated programming.

Best practice in bereavement photography after perinatal death: qualitative analysis with 104 parents

Background

Postmortem memento photography has emerged in Western hospitals as part of compassionate bereavement care for parents facing perinatal death. Many parents endorse this psychosocial intervention, yet implementation varies greatly and little research on parents’ specific needs guides health care professionals. Parents are in crisis and vulnerable after the death of their child, thus best practice is crucial. This study contributes 104 parents’ experiences and opinions toward the understanding of best practice in perinatal bereavement photography.

Methods

Parents who experienced the perinatal death of their child were recruited from U.S.-based bereavement organizations and social media sites. Volunteers completed an anonymous internet survey with open- and closed-ended questions. Direct recommendations and pertinent statements regarding the process of postmortem photography were analyzed for thematic content in keeping with conventional content analysis. Recurrent themes and sub-themes were counted to identify response patterns.

Results

Of 93 parents with pictures, 92 endorsed them. Of 11 without pictures, nine wanted them. Parents made a variety of recommendations regarding appropriate psychosocial support, the consent process, obstacles to photography, logistics of photography, and material aspects of photographs themselves. Overall, parents wanted many pictures and much variety. Some wanted professional photography while others wanted support for taking their own pictures. Parents wanted guidance from staff who respected their particular needs. Many said decisions were difficult during their crisis. Parents who were initially resistant expressed current appreciation for pictures or expressed regret that they had not participated. Parents recommended that professionals strongly encourage parents to create memento photos despite parents’ initial reservations. Persistent cultural reasons against photography emerged in one case. Quotes by parents illuminate themes and enable respondents to speak directly to health care professionals.

Conclusions

Parents overwhelmingly support postmortem bereavement photography when conducted sensitively, even if imperfectly executed. Providers significantly influence parents during their crises; mindful, patient-centered care with appropriate respect for difference is necessary. Providers must understand the importance of postmortem photographs to parents who have limited opportunity to capture memories of their child. Hospitals should provide education and support for this important psychosocial intervention.

Electronic supplementary material

The online version of this article (doi:10.1186/2050-7283-2-15) contains supplementary material, which is available to authorized users.

Parental grief and memento mori photography: narrative, meaning, culture, and context

Postmortem photography is a widespread practice in perinatal bereavement care, yet few studies have explored how it affects bereaved parents, or how it might be received by parents of older children. This study is an examination of the meaning, utility, and social context of postmortem photography in a sample of 181 bereaved parents. Data were subjected to both quantitative and qualitative analysis. Photographs were positively regarded by most parents after perinatal death and several parents of older children. Other parents rejected postmortem photography for aesthetic, personal, or cultural reasons. Brief recommendations are offered for healthcare providers.

State of the science on perinatal palliative care

OBJECTIVE

To report the state of the science since 1995 on the concept of palliative care for parents who opt to continue a pregnancy after receiving a life-limiting fetal diagnosis.

DATA SOURCES

PubMed, Ovid, PsycInfo, CINAHL, and Medline were searched from 1995 to July 2012 using the terms perinatal palliative care and perinatal hospice.

STUDY SELECTION

Inclusion criteria included empirical studies written in English that focused on experiences of parents who opted to continue a pregnancy in which the fetus had a life-limiting condition or on perinatal palliative care. Twenty studies met inclusion criteria.

DATA EXTRACTION

Results from empirical studies contributing to the knowledge base of perinatal palliative care are presented.

DATA SYNTHESIS

Women are confronted with powerful emotions, challenging decisions, and considerable uncertainty following the news of a life-limiting fetal anomaly. Women choose to continue their pregnancies for a variety of reasons and when doing so embark on a search for meaning. The science suggests that perinatal palliative care is welcomed by parents and is a medically safe and viable option. Women voiced positive feedback about their decisions to continue their pregnancies, and parents cited personal growth in the aftermath. Perinatal palliative care programs provide services that incorporate early and integrative care beginning in the antenatal period. A multidisciplinary coordinated approach provides parents with comprehensive, holistic support.

CONCLUSION

More research is needed to elucidate the factors that will benefit parents who continue their pregnancies. Investigating the needs and perceptions of clinicians and their willingness to participate in this new model of care is necessary as is examining barriers that may undermine care. Nurses can lead research on these topics and implement evidence-based practice grounded on study findings.

[Palliative care birth plan: a field of perinatal medicine to build]

Some couples may choose to continue the pregnancy unable to decide for termination of pregnancy. Such situations recently occurred in neonatology units and may lead to neonatal palliative care. Faced with all uncertainties inherent to medicine and the future of the baby, medical teams must inform parents of different possible outcome step by step. Consistency in the reflection and intentionality of the care is essential among all different stakeholders within the same health team to facilitate support of parents up to a possible fatal outcome. This issue in perinatal medicine seems to be to explore how caregivers can contribute in the construction of parenthood in a context of a palliative care birth plan.

Pediatric palliative care - The role of the patient’s family

Whenever a child suffers, what does she or he cry Mother! What does that mean Palliative care is not a type of medicine based on objective evidence or statistics. The only relevant standard is the very individual quality of life. Nobody knows better what this actually means but the patient himself. Thus, if the mother’s presence has the biggest impact on a child’s wellbeing or comfort, she herself is the most valuable treatment modality. In nearly every publication dealing with pediatric palliative care, it is stated that palliative care does not only imply care for the sick child but also for the parents and the whole family. Usually, it is pointed out that they are suffering a lot as well. But helping them does also mean: helping the child! Of course, it means higher efforts, obligations and costs for the healthcare system. Thus the justification of this effort may be put in question; in particular, it may be argued that disorders of family members should, if necessary, be treated as such. But this is only one side of the coin! In the following, we will, based on published literature, look at the role of mothers, fathers, and siblings for the wellbeing of an ill or even dying child. As a conclusion, we will learn that if it is our task to give a dying child the best available care, helping mothers, fathers and sibling is an inevitable part of it.

Rights of the newborn and end-of-life decisions

Advances in perinatal medicine have dramatically improved neonatal survival. End-of-life decision making for newborns with adverse prognosis is an ethical challenge and the ethical issues are controversial. The newborn is a person with specific rights which he cannot claim, due to his physical and mental immaturity. These rights impose to the society obligations and responsibilities, which health professionals and institutions of all countries must enforce. Every newborn has the right to life with dignity. Providing compassionate family-centered end-of-life care to infants and their families in the NICU should be a mandatory component of an optimally neonatal palliative care.

Ethics in neonatology: a look over Europe

Advances in perinatal medicine have dramatically improved neonatal survival. End-of-life decision making for newborns with adverse prognosis is an ethical challenge, the ethical issues are controversial and little evidence exists on attitudes and values in Europe.

OBJECTIVE

to assess the attitudes of the neonatal departments in perinatal clinical practice in the hospitals of European countries.

METHODS

a questionnaire was send to 55 NICUs from 19 European countries.

RESULTS

Forty five (81.8%) NICUs were Level III. Religion was Christian in 90.7% and we observed that in north countries the religion is more influent on clinical decisions (p = 0.032). Gestational age was considered with no significant difference for clinical investment. North countries consider birth weight (p = 0.011) and birth weight plus gestational age (p = 0.024) important for clinical investment. In north countries ethical questions should not prevail when the decision is made (p = 0.049) and from an ethical point of view, there is no difference between withdraw a treatment and do not initiate the treatment (p = 0.029). More hospitals in south countries administer any analgesia (p = 0.007). When the resuscitation is not successful 96.2% provide comfort care.

CONCLUSION

Our study reveals that cultural and religious differences influenced ethical attitudes in NICUs of the European countries.