Ethical and logistical considerations of multicenter parental bereavement research

Home mechanical ventilation for children with severe neurological impairment: Parents' perspectives on clinician counselling

AIM

To retrospectively explore the perspectives of parents of children with severe neurological impairment (SNI), such as those with severe cerebral palsy, epilepsy syndromes, and structural brain differences, on clinician counseling regarding home mechanical ventilation (HMV).

METHOD

Inductive thematic analysis was performed on data from telephone interviews with parents who chose for and against HMV for their child with SNI at three academic children's hospitals across the USA.

RESULTS

Twenty-six parents/legal guardians of 24 children were interviewed. Fourteen children had static encephalopathy, 11 received HMV, and 20 were alive at the time of parent interviews. Themes included how HMV related to the child's prognosis, risk of death, and integration with goals of care. Although clinicians voiced uncertainty about how HMV would impact their child, parents felt this was coupled with prescriptive/intimidating examples about the child's end of life and judgments about the child's quality of life.

INTERPRETATION

While prognositc uncertainty exists, this study suggests that parents of children with SNI seek clinician counseling about HMV that considers their goals of care and views on their child's quality of life.

Family Experiences Deciding For and Against Pediatric Home Ventilation

OBJECTIVE

To understand what considerations drive family decisions for, and against, pediatric home ventilation.

STUDY DESIGN

Qualitative interviews with parents of children who faced a decision about home ventilation in the previous 5 years at 3 geographically dispersed institutions.

RESULTS

In total, 38 families (42 parents) were interviewed; 20 families opted for pediatric home ventilation, and 18 families opted against. Approximately one-quarter of children had isolated chronic lung disease; the remainder had medical complexity that was expected to remain static or decline. Parent perspectives about home ventilation generally reflected whether the child was early, or later, in their disease trajectory. Early on, parents often interpreted prognostic uncertainty as hope and saw home ventilation as a tool permitting time for improvement. For families of children later in their disease course, often already with home technology and home nursing, home ventilation held less possibility for meaningful improvement. Nearly all families experienced the decision as very emotionally distressing. Reflecting back, most families described feeling satisfied with whatever decision they made.

CONCLUSIONS

The 2 principal groups of families in our cohort-those with children whose respiratory insufficiency might improve, and those with children facing chronic decline-warrant targeted counseling approaches about initiating home ventilation. The distressing nature of this decision should be anticipated and family supports reinforced.

Designing a co-productive study to overcome known methodological challenges in organ donation research with bereaved family members

Background

Co‐production of research into public health services has yet to demonstrate tangible benefits. Few studies have reported the impact of co‐production on research outcomes. The previous studies of organ donation have identified challenges in engaging with public organizations responsible, gaining ethical approval for sensitive studies with the recently bereaved and difficulty in recruiting bereaved family members who were approached about organ donation.

Objective

To address these challenges, we designed the first large co‐productive observational study to evaluate implementation of a new system of organ donation in Wales. This paper outlines the co‐productive strategies that were designed to overcome known methodological challenges and reports what impact they had on resolving these challenges.

Design

Two‐year co‐produced study with multiple stakeholders with the specific intention of maximizing engagement with the National Health Service arm in Wales responsible for organ donation, and recruitment of bereaved family members whose perspectives are essential but commonly absent from studies.

Setting and participants

NHS Blood and Transplant, Welsh Government and multiple patient and public representatives who served as co‐productive partners with the research team.

Results

Co‐productive strategies enabled a smooth passage through four different ethics processes within the 10‐week time frame, family member recruitment targets to be surpassed, sharing of routinely collected data on 100% of potential organ donor cases and development of further research capacity and capability in a critically under researched area.

Discussion and conclusion

Although expensive and time consuming, co‐production was effective and added value to research processes and study outcomes.

Communicating prognosis with parents of critically ill infants: direct observation of clinician behaviors

OBJECTIVE

Delivering prognostic information to families requires clinicians to forecast an infant's illness course and future. We lack robust empirical data about how prognosis is shared and how that affects clinician-family concordance regarding infant outcomes.

STUDY DESIGN

Prospective audiorecording of neonatal intensive care unit family conferences, immediately followed by parent/clinician surveys. Existing qualitative analysis frameworks were applied.

RESULTS

We analyzed 19 conferences. Most prognostic discussion targeted predicted infant functional needs, for example, medications or feeding. There was little discussion of how infant prognosis would affect infant/family quality of life. Prognostic framing was typically optimistic. Most parents left the conference believing their infant's prognosis to be more optimistic than did clinicians.

CONCLUSIONS

Clinician approach to prognostic disclosure in these audiotaped family conferences tended to be broad and optimistic, without detail regarding implications of infant health for infant/family quality of life. Families and clinicians left these conversations with little consensus about infant prognosis.

Ethical and Practical Realities of Using Letters for Recruitment in Bereavement Research

Recruitment of participants into bereavement research may present many challenges for the research team. At present, there is little consensus for researchers and ethics committees on the most appropriate method of recruitment. There is some evidence that participants prefer to be contacted about research studies via letters. However, recruitment involving the use of a letter can occur in a number of ways, each with ethical and practical benefits and limitations. In a study of the experiences of bereaved parents, we used letters in three ways: direct mailing from the research team with an opt-out option; permission to mail letters obtained by social workers from a hospital-based follow-up program during routine contact; and letters mailed from the hospital's PICU research nurse at the hospital with instruction on how to opt in. In this paper, the practical and ethical realities of each method are highlighted, using examples from our own experiences. Nineteen parents also provided reflections in follow-up phone calls. While direct researcher contact is perhaps the most feasible for researchers, ethical concerns may render it unacceptable. While contact via a known member of a follow-up program is more ethically appropriate for participants, it also presents significant practical issues. We suggest that contact via a representative of the healthcare institution provides the best balance of ethical and practical acceptability for both participants and the research team, but responsiveness to the ethical and practical requirements of the study is crucial in ensuring it can be successfully undertaken. © 2017 Wiley Periodicals, Inc.

Family Conferences in the Neonatal ICU: Observation of Communication Dynamics and Contributions

OBJECTIVES

Clinicians in the neonatal ICU must engage in clear and compassionate communication with families. Empirical, observational studies of neonatal ICU family conferences are needed to develop counseling best practices and to train clinicians in key communication skills. We devised a pilot study to record and analyze how interdisciplinary neonatal ICU clinicians and parents navigate difficult conversations during neonatal ICU family conferences.

DESIGN

We prospectively identified and audiotaped a convenience sample of neonatal ICU family conferences about "difficult news." Conversations were analyzed using the Roter interaction analysis system, a quantitative tool for assessing content and quality of patient-provider communication.

SETTING

An urban academic children's medical center with a 45-bed level IV neonatal ICU.

SUBJECTS

Neonatal ICU parents and clinicians.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed 19 family conferences that included 31 family members and 23 clinicians. The child's mother was included in all conferences, and a second parent, usually the father, was present in 13 conferences. All but one conference included multiple medical team members. On average, physicians contributed 65% of all dialogue, regardless of who else was present. Over half (56%) of this dialogue involved giving medical information; under 5% of clinician dialogue involved asking questions of the family, and families rarely (5% of dialogue) asked questions. Conversations were longer with the presence of nonphysician clinicians, but this did not increase the amount of dialogue about psychosocial information or increase parent dialogue.

CONCLUSIONS

We collected a novel repository of audio-recorded neonatal ICU family meetings that offers insights into discussion content and process. These meetings were heavily focused on biomedical information even when interdisciplinary clinicians were present. Clinicians always talked more than parents, and no one asked many questions. Maximizing the participation of interdisciplinary clinicians in neonatal ICU family meetings may require explicit strategies. Methods to increase family engagement should be targeted.

Conducting End-of-Life Research

Conducting studies at the end of life is often challenging for researchers due to the sensitive nature of the research, the vulnerability of the participants and the inherent methodological complexities. Methodological challenges include identifying and gaining access to eligible research participants, estimating the duration of patient survival time in the study, minimizing the potential burden of data collection, and attending to issues of consent and confidentiality. In this paper, the authors identify challenges when conducting end-of-life research and draw from collective research experiences to describe strategies to achieve success.

Factors affecting recruitment and participation of bereaved parents and siblings in grief research

This study examined participation factors in a study of families (N = 84) within 1 year of a child's cancer-related death. Specific aims were to examine associations between: (a) recruitment variables (number of phone calls made to eligible families, number of calls answered by eligible families) and participation rates (study agreement and refusal) and (b) characteristics of deceased children (gender, age, length of illness, time since death) and participation rates. Characteristics of deceased children did not differ between participating and non-participating families. Researchers made significantly fewer calls to participating versus refusing families. Participating families most often agreed during the first successful call connection, and more calls did not mean more recruitment success. Thus, it is reasonable to limit the number of calls made to bereaved families. Despite recruitment challenges, many bereaved parents and siblings are willing and interested to participate in grief research.

How experience makes a difference: practitioners' views on the use of deferred consent in paediatric and neonatal emergency care trials

BACKGROUND

In 2008 UK legislation was amended to enable the use of deferred consent for paediatric emergency care (EC) trials in recognition of the practical and ethical difficulties of obtaining prospective consent in an emergency situation. However, ambiguity about how to make deferred consent acceptable to parents, children and practitioners remains. In particular, little is known about practitioners' views and experiences of seeking deferred consent in this setting.

METHODS

As part of a wider study investigating consent methods in paediatric emergency care trials (called CONNECT), a 20 item online questionnaire was sent by email inviting practitioners (doctors and nurses) who were involved in talking with families about children's and young people's (aged 0-16 years) participation in UK EC trials. To ensure those with and without experience of deferred consent were included, practitioners were sampled using a combination of purposive and snowball sampling methods. Simple descriptive statistics were used to analyse the quantitative data, whilst the constant comparative method was used to analyse qualitative data. Elements of a symbiotic empirical ethics approach was used to integrate empirical evidence and bioethical literature to explore the data and draw practice orientated conclusions.

RESULTS

Views on deferred consent differed depending upon whether or not practitioners were experienced in this consent method. Practitioners who had no experience of deferred consent reported negative perceptions of this consent method; these practitioners were concerned about the impact that deferred consent would have upon the parent-practitioner relationship. In contrast, practitioners experienced in deferred consent described how families had been receptive to the consent method, if conducted sensitively and in a time appropriate manner. Experienced practitioners also described how deferred consent had improved recruitment, parental decision-making capacity and parent-practitioner relationships in the emergency care setting.

CONCLUSIONS

The views of practitioners with first-hand experience of deferred consent should be considered in the design and ethical review of future paediatric EC trials; the design and ethical review of such trials should not solely be informed by the beliefs of those without experience of using deferred consent. Further research involving parents and children is required to inform practitioner training and normative guidance on the use and appropriateness of deferred consent in emergency settings.

Collaborative pediatric critical care research network: looking back and moving forward

OBJECTIVE

To update the pediatric critical care community on the progress of the Collaborative Pediatric Critical Care Research Network and plans for the future.

SETTING

The six sites, seven hospitals of the Collaborative Pediatric Critical Care Research Network.

RESULTS

From the time of its inception in August 2005, the Network has engaged in a number of observational and interventional trials, several of which are ongoing. Additional studies are in the planning stages. To date, these studies have resulted in the publication of six manuscripts and five abstracts, with five additional manuscripts accepted and in press.

CONCLUSION

The Network remains committed to its stated goal "to initiate a multicentered program designed to investigate the safety and efficacy of treatment and management strategies to care for critically ill children, as well as the pathophysiologic basis of critical illness and injury in childhood."