Ethics, end-of-life decisions and grief

"I couldn't": A phenomenological exploration of ethical tensions experienced by bereaved family members during the pandemic

INTRODUCTION

The COVID-19 pandemic entailed significant changes in accompaniment, end-of-life, and bereavement experiences. In some countries, public health measures prevented or restricted family caregivers from visiting their dying loved ones in residences, long-term care institutions, and hospitals. As a result, family members were faced with critical decisions that could easily lead to ethical dilemmas and moral distress.

AIM

This study aimed to understand better the experience of ethical dilemmas among family caregivers who lost a loved one.

METHDS

We interviewed twenty bereaved family caregivers and analysed their narratives using Interpretative phenomenological analysis.

RESULTS

Our analysis suggests that family caregivers struggled with their multiple responsibilities (collective, relational, and personal) and had to deal with the emotional cost of their choices. Results display three emerging themes describing the experience of ethical struggles: (1) Flight or fight: Struggling with collective responsibility; (2) Being torn apart: Assuming relational responsibility and (3) "Choosing" oneself: The cost of personal responsibility.

DISCUSSION/CONCLUSION

Results are discussed and interpreted using an ethical, humanistic, and existential conceptual framework.

Acceptability and feasibility of a pilot randomized controlled trial of Narrative e-Writing Intervention (NeW-I) for parent-caregivers of children with chronic life-threatening illnesses in Singapore

Background

Narrative e-Writing Intervention (NeW-I) is a novel psycho-socio-spiritual intervention which aims to bridge gaps in paediatric palliative care by providing anticipatory grief support to parent-caregivers who are looking after their child with a chronic life-threatening illness in Singapore. This is done via a therapist-facilitated smartphone app that focuses on strengths and meaning derived from parents’ caregiving journey. NeW-I is empirically informed by an international systematic review and a Singapore-based qualitative inquiry on the lived experience of parental bereavement and supported by anticipatory grief interventions literature for improving the holistic well-being for parent-caregivers of seriously ill children. NeW-I is implemented in Singapore as an open-label two-armed randomized controlled trial comprising an intervention and control group.

Methods

This study examined the acceptability (via analysis of participants’ post-intervention qualitative feedback and responses to a post-intervention evaluation survey) and feasibility (via records and memos of therapists’ experience of delivering the intervention) of NeW-I among 26 intervention participants drawn from the larger trial.

Results

Framework analysis of participants’ post-intervention feedback revealed four themes, namely: (i) Meaningful opportunity for reflection, (ii) Congruity with parent-caregivers’ needs, (iii) Compatibility of online narrative writing and (iv) Sustainability and enhancement recommendations. The post-intervention evaluation survey showed that participants were overall satisfied with their NeW-I experience with a large number of participants acknowledging that NeW-I had improved their spiritual well-being, hopefulness about the future and perception of social support that was available to them, as well as lessened their feelings of sadness and depression, caregiver burden and fear and anxiety about their child’s illness. The research team found it feasible to deliver the intervention in the current setting.

Conclusion

NeW-I is an innovative e-health tool that could immeasurably value-add to paediatric palliative care services for Asian families in Singapore and around the world.

Trial registration

ClinicalTrials.gov, ID: NCT03684382, Verified: September 2018.

Witnesses and Victims Both: Healthcare Workers and Grief in the Time of COVID-19

Heathcare Workers (HCWs) recognize their responsibility to support the bereaved loved ones of our patients, but we also must attend to our own professional and personal grief in the COVID-19 pandemic. COVID-19 grief is occurring in the setting of incomplete grief, disenfranchised grief, fractured US governmental leadership, and evidence of great mistrust, systemic racism, and social injustice. In the intensity and pervasiveness of COVID-19, HCW fears for themselves, their colleagues, and their own loved ones are often in conflict with professional commitments. Even at the dawn of promising national and global vaccination programs, significant HCW morbidity and mortality in COVID-19 has already become clear, will continue to grow, and these effects likely will last far into the future. Given the risks of complicated grief for HCWs in the setting of COVID-19 deaths, individual HCWs must put every effort into their own preparation for these deaths as well as into their own healthy grieving. Equally importantly, our healthcare systems have a primary responsibility both to prepare HCWs and to support them in their anticipatory and realized grief. Special attention must be paid to our HCW trainees, who may have not yet developed personal or professional grief management strategies and are coming into healthcare practice during a time of great disruption to both teaching and clinical care.

Rapid review of decision-making for place of care and death in older people: lessons for COVID-19

Introduction

The coronavirus pandemic (COVID-19) has affected the functioning and capacity of healthcare systems worldwide. COVID-19 has also disproportionately affected older adults. In the context of COVID-19, decision-making surrounding place of care (PoC) and place of death (PoD) in older adults involves significant new challenges.

Aims

To explore key factors that influence PoC and PoD decisions in older adults. A secondary aim was to investigate key factors that influence the process and outcome of these decisions in older adults. To apply findings from current evidence to the context of COVID-19.

Methods

Rapid review of reviews, undertaken using WHO guidance for rapid reviews for the production of actionable evidence. Data extracted was synthesised using narrative synthesis, with thematic analysis and tabulation.

Results

10 papers were included for full data extraction. These papers were published between 2005 and 2020. Papers included discussed actual PoD, as well as preferred. Results were divided into papers that explored the process of decision-making, and those that explored decision-making outcomes.

Conclusions

The process and outcomes of decision-making for older people are affected by many factors—all of which have the potential to influence both patients and caregivers experience of illness and dying. Within the context of COVID-19, such decisions may have to be made rapidly and be reflexive to changing needs of systems and of families and patients.

A Novel Narrative E-Writing Intervention for Parents of Children With Chronic Life-Threatening Illnesses: Protocol for a Pilot, Open-Label Randomized Controlled Trial

Background

A novel evidence-based Narrative e-Writing Intervention (NeW-I) has been developed and tested in Singapore to advance psychosociospiritual support for parents of children with chronic life-threatening illnesses. NeW-I is informed by an international systematic review and a Singapore-based qualitative inquiry on the lived experience of parental bereavement and supported by literature on anticipatory grief interventions for improving the holistic well-being of parent caregivers of seriously ill children.

Objective

This study's aim was to provide an accessible platform, NeW-I—which is a strengths- and meaning-focused and therapist-facilitated mobile app and web-based counseling platform—that aims to enhance quality of life, spiritual well-being, hope, and perceived social support and reduce depressive symptoms, caregiver burden, and risk of complicated grief among parents of children with chronic life-threatening illnesses.

Methods

The NeW-I therapist-facilitated web-based platform comprises a mobile app and a website (both of which have the same content and functionality). NeW-I has been implemented in Singapore as a pilot open-label randomized controlled trial comprising intervention and control groups. Both primary and secondary outcomes will be self-reported by participants through questionnaires. In collaboration with leading pediatric palliative care providers in Singapore, the trial aims to enroll 36 participants in each group (N=72), so that when allowing for 30% attrition at follow-up, the sample size will be adequate to detect a small effect size of 0.2 in the primary outcome measure, with 90% power and two-sided significance level of at least .05. The potential effectiveness of NeW-I and the accessibility and feasibility of implementing and delivering the intervention will be assessed.

Results

Funding support and institutional review board approval for this study have been secured. Data collection started in January 2019 and is ongoing.

Conclusions

NeW-I aspires to enhance holistic pediatric palliative care services through a structured web-based counseling platform that is sensitive to the unique cultural needs of Asian family caregivers who are uncomfortable with expressing emotion even during times of loss and separation. The findings of this pilot study will inform the development of a full-scale NeW-I protocol and further research to evaluate the efficacy of NeW-I in Singapore and in other Asian communities around the world.

Trial Registration

ClinicalTrials.gov NCT03684382; https://clinicaltrials.gov/ct2/show/NCT03684382

International Registered Report Identifier (IRRID)

DERR1-10.2196/17561

Grief During the COVID-19 Pandemic: Considerations for Palliative Care Providers

The COVID-19 pandemic is anticipated to continue spreading widely across the globe throughout 2020. To mitigate the devastating impact of COVID-19, social distancing and visitor restrictions in health care facilities have been widely implemented. Such policies and practices, along with the direct impact of the spread of COVID-19, complicate issues of grief that are relevant to medical providers. We describe the relationship of the COVID-19 pandemic to anticipatory grief, disenfranchised grief, and complicated grief for individuals, families, and their providers. Furthermore, we provide discussion regarding countering this grief through communication, advance care planning, and self-care practices. We provide resources for health care providers, in addition to calling on palliative care providers to consider their own role as a resource to other specialties during this public health emergency.

Trauma to Transformation: the lived experience of bereaved parents of children with chronic life-threatening illnesses in Singapore

BACKGROUND

In 2016, over 6.6 million children died globally, and 245 children died in Singapore. Chronic illnesses are prevalent causes of child mortality around the world. Despite growing research that examines the lived experience of parents bereaved by their child's chronic life-threatening illness, there is no such study within the Asian context.

METHODS

To bridge this knowledge gap, meaning-oriented, strength-focused interviews were conducted with 25 parental units (i.e. 6 couples, 13 lone mothers, 4 lone fathers, and 2 primary parental figures) who lost their child to chronic life-threatening illness in Singapore (N = 31), including those of Chinese (n = 17), Malay (n = 10) and Indian ethnicities (n = 4), between August 2017 and April 2018.

RESULTS

Data analysis adhering to the grounded theory approach revealed 7 themes and 25 sub-themes that were organized into a Trauma-to-Transformation Model of Parental Bereavement. This model shows the major milestones in participants' lived experience of their child's chronic life-threatening illness and death, starting from the diagnosis of their child's chronic life-threatening illness and the subsequent emotional turmoil (Theme 1), the mourning of their child's death and the losses which accompanied the death (Theme 3) and participants' experience of posttraumatic growth through reflection of their journey of caregiving and child loss (Theme 5). The model further describes the deliberate behaviors or 'rituals' that helped participants to regain power over their lives (Theme 2), sustain an intimate bond with their child beyond death (Theme 4), and transcend their loss by deriving positive outcomes from their experience (Theme 6). Finally, the model denotes that the lived experiences and well-being of participants were embedded within the health-and-social-care ecosystem, and in turn impacted by it (Theme 7).

CONCLUSION

These themes and their corresponding sub-themes are discussed, with recommendations for enhancing culturally sensitive support services for grieving Asian parents around the globe.

Lived experience of a child's chronic illness and death: A qualitative systematic review of the parental bereavement trajectory

To understand the lived experience of parents who have lost their child to a chronic life-limiting condition, six major databases were searched by adhering to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Articles were screened for appropriateness using the Sample, Phenomenon of Interest, Design, Evaluation, Research type tool, and relevant qualitative studies were selected for full-text data analysis using Thematic Synthesis. Findings were categorized into 13 themes that were further organized into a four-phase trajectory of parental bereavement experience of child loss, namely: Liminal Margin, Holding Space, Navigating Losses, and Reconstructing Lives. The findings are discussed in the light of existing literature with practical recommendations for enhancing parental bereavement support services.

A snapshot of Australian social workers in palliative care and their work with estranged clients

This paper describes a mixed method survey that was administered to a group of Australian palliative care social workers (n = 27). Specifically, it aimed to investigate the ways that social workers understood and worked with clients who were estranged from family at the end of life. Respondents suggested that estrangement potentially impacted clients emotionally, practically, and existentially. They were challenged to make clear assessments, provide emotional support, encourage news ways of thinking about estrangement, to manage practical issues, work with the client's family, and monitor their own professional role. Theories and models of intervention and levels of training are also discussed.

The Changing Presentation of Death in the Obituary, 1899–1999

Obituaries from the New York Times are examined at three points to illuminate changing conceptions of death. The findings are twofold. Changes in the obituary demonstrate how the locus of social control over death has shifted from nature and God, to medicine and most recently to the individual. Additionally, it is shown that descriptions of biophysical aspects of the dying process are marginalized over time and that there is more frequent use of language that emphasizes death-resistant themes in the most recent obituaries. This finding exemplifies the observation of increasing claims to authority over mortality by individuals in recent decades.

Exhaust All Measures: Ethical Issues in Pediatric End-of-Life Care

The death of a child may have a profound impact on parents, family members, and health care providers who provided care for the child. Unique challenges are faced by parents of seriously ill children as they must serve as the legal authority for health care decisions of children under age 18, although the child's wishes must also be considered. Social workers must balance core social work values, bioethical values, and psychosocial issues presented by such situations. While studies have been conducted with physicians and nurses regarding ethical issues in pediatric end-of-life care settings, little is known about how social workers experience these conflicts. This article utilizes two vignettes to illustrate potential ethical issues in this setting and applies the National Association of Social Workers Standards for Palliative and End of Life Care (NASW, 2004 ) to explore options for their resolution. These vignettes provide descriptions of possible reactions in this setting and can be used as a basis for further exploration of ethics in pediatric end-of-life care from a social work perspective.

Grief and loss for patients before and after heart transplant

OBJECTIVES

The purpose of the study was to examine the loss and grief experiences of patients waiting for and living with new hearts.

BACKGROUND

There is much scholarship on loss and grief. Less attention has been paid to these issues in clinical transplantation, and even less on the patient experience.

METHODS

Part of a qualitative inquiry oriented to the work of Merleau-Ponty, a secondary analysis was carried out on audiovisual data from interviews with thirty participants.

RESULTS

Patients experience loss and three forms of grief. Pre-transplant patients waiting for transplant experience loss and anticipatory grief related to their own death and the future death of their donor. Transplanted patients experience long-lasting complicated grief with respect to the donor and disenfranchised grief which may not be sanctioned.

CONCLUSIONS

Loss as well as anticipatory, complicated and disenfranchised grief may have been inadvertently disregarded or downplayed. More research and attention is needed.

An Exploratory Study of Grief and Health-Related Quality of Life for Caregivers of People With Dementia

The aim of this qualitative study was to explore key positive and negative factors that impact on grief resolution and health outcomes of caregivers who were caring, or had cared, for a family member with dementia who had died. The study was a scoping study and involved face-to-face interviews with these family caregivers (N = 13). Results indicated a complex interaction of issues (many unique to dementia caregiving) which in different combinations acted as protective or risk factors for caregiver outcomes. Interaction of individual characteristics, role appraisal, value of intrinsic and extrinsic resources, and experiences with health professionals during the caregiving period and around the death of their relative were shown to have the most influence on caregiver outcomes. Psychological resilience and satisfaction with caregiving were protective against negative outcomes while unresolved grief was a risk factor. These findings highlight the potential benefits of multicomponent, holistic dementia caregiver interventions.

End-of-life planning activities: an integrated process

This study examined end-of-life planning and whether common characteristics predicted completion of these decisions. Participants in the Nebraska End-of-Life Survey were asked whether they had heard about or completed five plans: a health care power of attorney agreement, a living will, a last will and testament, funeral or burial preplanning, and organ and tissue donation. Logistic regression was used to identify predictors of these outcomes. Predictors of completing end-of-life plans, including funeral and burial preplanning, included older age, higher household income, and higher religiosity. This suggests that all of these decisions may be part of an integrated planning process at the end of life. Further, results from this study indicate that the role of religiosity, found in this study to predict both financial and health care planning, warrants further exploration.

Investigating factors associated with nurses' attitudes towards perinatal bereavement care: a study in Shandong and Hong Kong

AIMS

To explore nurses' attitudes towards perinatal bereavement care and to identify factors associated with these attitudes.

BACKGROUND

It is likely that the attitude of nursing staff can influence recovery from a pregnancy loss and that nurses with positive attitudes to bereavement care can help bereaved parents to cope during their grieving period.

DESIGN

Survey.

METHOD

Data were collected through a structured questionnaire; 657 nurses were recruited from Obstetrics and Gynaecology units in Hong Kong and Shandong during 2006. Outcome measures included attitudes towards perinatal bereavement care, importance of hospital policy and training support for bereavement care.

RESULTS

The majority of nurses in this study had a positive attitude to bereavement care. Results show that only 21.6% (n = 141) of the nurses surveyed had bereavement-related training. In contrast, about 89.8% (n = 300) believed they needed to be equipped with relevant knowledge, skills and understanding in the care and support of bereaved parents and more than 88.5% (n = 592) would share their experiences with their colleagues and seek support when feeling under stress. A regression model showed that age, past experience in handling grieving parents, recent ranking and nurses' perceived attitudes to hospital policy and training provided for bereavement care were the factors associated with nurses' attitudes to perinatal bereavement care.

CONCLUSIONS

Nurses in both cities emphasised their need for increased knowledge and experience, improved communication skills and greater support from team members and the hospital for perinatal bereavement care.

RELEVANCE TO CLINICAL PRACTICE

These findings may be used by nursing educators to educate their students on issues related to delivery of sensitive bereavement care in perinatal settings and to enhance nursing school curricula.

Grief: the Constant Companion of Illness

This article describes the grieving process. It begins by delineating the nature of grief, noting the ways that grief may be experienced in both sudden loss and in more protracted illness and then explores the nature and process of grief, reviewing current models and research on the experience of mourning. Finally, the discussion examines the research on caregiver grief, noting that grief in health care professionals is often disenfranchised, yet the holistic treatment of individuals with disease begins with an acknowledgment that loss is a constant companion to illness, for patients, families, and health care professionals alike.