Experiences of mothers in five countries whose child died of cancer

Psychometric properties of the PG-13-R scale to assess prolonged grief disorder among bereaved Iranian adults

OBJECTIVES

The PG-13-Revised (PG-13-R) is a self-report measure to assess prolonged grief disorder (PGD) in terms of Diagnostic and Statistical Manual of Mental Disorders, fifth revision, Text Revision. This measure has been shown to yield good psychometric properties in Western samples. This study aimed to evaluate the psychometric properties of the Persian PG-13-R.

METHODS

Three hundred forty-seven individuals (209 women and 138 men) fully completed the scales. The participants were recruited using convenience sampling. The confirmatory factor analysis (CFA), convergent and divergent validity, and reliability of the Persian version of the PG-13-R were evaluated.

RESULTS

CFA results of a unidimensional model support the construct validity of this version of the PG-13-R. The results of this study demonstrated that this version of the PG-13-R has internal consistency reliability (omega coefficient of 0.93), and the test-retest reliability with an interval of 6 weeks was 0.89. The convergent and divergent validity was shown with significant correlations between the PG-13-R and measures of depression, PTSD, functional impairment, and hope.

SIGNIFICANCE OF RESULTS

Overall, the Persian version of the PG-13-R showed good psychometric properties in the Iranian population.

Mourning Experiences of Families of Dead Infected with COVID-19: A Qualitative Study

Background: With the outbreak of the Coronavirus, many restrictions are imposed on the processes of a funeral procession, funeral ablution, burial, mass mourning, and the memorial gathering of the family, relatives, friends, and neighbors. Objectives: Given the lack of research on the mourning experiences of families of the dead infected with coronavirus, the present study was to fill this gap in the literature. Methods: In this qualitative study, some semi-structured individual interviews were carried out in the Bu Ali Sina Medical Educational Center, Sari, Iran, with 16 individuals of the families of the dead with coronavirus, who were selected using the purposive sampling method. The interviews were recorded, transcribed, encoded, and categorized, and the data analysis was performed using Graneheim and Lundman’s qualitative approach. Guba and Lincoln’s criteria were also adopted to ensure the data reliability and validity. Results: Four main themes (namely psychological, behavioral, and physical reactions, virtual mourning, regretful mourning, and feelings of rejection and fear) and twelve subthemes were extracted from the collected data. Conclusions: According to the research results, COVID-19 changed the personal and social lives of the families with dead infected with Coronavirus from different perspectives. In this regard, providing support to families during the mourning period would help them better adjust with such changes causing the loss of a family member.

Addressing Spirituality in Pediatric Hospice and Palliative Care

Hospice and palliative care principles mandate clinicians to provide “total” care to patients and their families. Such care incorporates not only physical, emotional, and psychosocial care, but spiritual care as well. Even though considerable attention has been directed to spiritual issues for adult patients in hospice and palliative care, spirituality in pediatric palliative care has been virtually neglected. The need for guidelines to assess spirituality in this population was identified as a priority issue by members of a subcommittee of the Children's International Project on Children's Palliative/Hospice Services, created under the auspices of the National Hospice Organization. Committee members, based on their clinical, research, and personal experiences, identified several aspects relevant to spirituality in general, and to spirituality in pediatric palliative care in particular, and developed guidelines for clinicians in pediatric palliative care. The purpose of this paper is to share the results of this committee's work and, in particular, to present their guidelines for addressing spiritual issues in children and families in pediatric hospice and palliative care.

Perceptions of a Good Death in Children with Life-Shortening Conditions: An Integrative Review

Background: For children with life-shortening illness, achieving a "good death" can be a tacit goal. There is little understanding of how different stakeholders perceive what a "good death" might be. Objective: To review empirical literature to construct an understanding of a "good death" for children with life-shortening conditions. Design: An integrative review approach was followed. This involved searching across Embase, Web of Science, Medline, CINAHL, and PsycINFO (no date limits set), as well as identifying eligible studies tracking reference lists. Appraisal of shortlisted articles in full text was performed, followed by data extraction, synthesis, and interpretation. Results: Analysis of articles (n = 24) yielded a dynamic and layered narrative about a good death that revolved around three themes. (1) Level of needs: includes both practical support and aspirational goals such as "do everything." (2) The composite experience: whether positive or negative adds to produce a sense of suffering. (3) Control (preservation and letting go): moving from maintaining status quo to acceptance of the child's death, the experience of which also contributes to suffering. Framed using a health care system perspective, a concept map that interprets a good death in children with life-shortening conditions is represented. Conclusions: A single yet holistic understanding of a good death experienced in the "real world" is suggested. Pediatric health and social care providers, and even policy makers, can use this new understanding to conceive alternative approaches to enhance support to dying children and their families.

Integrating Palliative Care in Pediatric Oncology: Evidence for an Evolving Paradigm for Comprehensive Cancer Care

BACKGROUND

The demonstrated benefit of integrating palliative care (PC) into cancer treatment has triggered an increased need for PC services. The trajectory of integrating PC in comprehensive cancer centers, particularly pediatric centers, is unknown. We describe our 8-year experience of initiating and establishing PC with the Quality of Life Service (QoLS) at St. Jude Children's Research Hospital.

METHODS

We retrospectively reviewed records of patients seen by the QoLS (n=615) from March 2007 to December 2014. Variables analyzed for each year, using descriptive statistics, included diagnostic groups, QoLS encounters, goals of care, duration of survival, and location of death.

RESULTS

Total QoLS patient encounters increased from 58 (2007) to 1,297 (2014), new consults increased from 17 (2007) to 115 (2014), and mean encounters per patient increased from 5.06 (2007) to 16.11 (2014). Goal of care at initial consultation shifted from primarily comfort to an increasing goal of cure. The median number of days from initial consult to death increased from 52 days (2008) to 223 days (2014). A trend toward increased outpatient location of death was noted with 42% outpatient deaths in 2007, increasing to a majority in each subsequent year (range, 51%-74%). Hospital-wide, patients receiving PC services before death increased from approximately 50% to nearly 100%.

CONCLUSIONS

Since its inception, the QoLS experienced a dramatic increase in referrals and encounters per patient, increased use by all clinical services, a trend toward earlier consultation and longer term follow-up, increasing outpatient location of death, and near-universal PC involvement at the end-of-life. The successful integration of PC in a comprehensive cancer center, and the resulting potential for improved care provision over time, can serve as a model for other programs on a broad scale.

Bereavement Follow-Up After the Death of a Child as a Standard of Care in Pediatric Oncology

After a child's death to cancer, families commonly want continued connection with the healthcare team that cared for their child, yet bereavement follow-up is often sporadic. A comprehensive literature search found that many bereaved parents experience poor psychological outcomes during bereavement and that parents want follow-up and benefit from continued connection with their child's healthcare providers. Evidence suggests that the standard of care should consist of at least one meaningful contact between the healthcare team and bereaved parents to identify those at risk for negative psychosocial sequelae and to provide resources for bereavement support.

End-of-life care for hospitalized children

High-quality palliative care is the standard for children with life-threatening illness, especially when a cure is not possible. This review outlines a model for clinical practice that integrates clinical, psychosocial, and ethical concerns at the end of life (EOL) into a standard operating procedure specifically focused on inpatient deaths. Palliative care for children at EOL in the hospital setting should encompass the personal, cultural, and spiritual needs of the child and family members and aim to minimize suffering and increase support for all who are involved, including hospital staff.

Cultural Influences in Pediatric Cancer

Objective: To review the literature on cultural factors influencing clinical care and family management of pediatric cancer. Methods: A literature review including 72 articles related to cultural issues in pediatric cancer was conducted. Information was organized around several clinically driven themes. Results: Cultural factors influenced many aspects of the cancer experience including illness representations, reaction to diagnosis, illness disclosure patterns, complementary and alternative medicine use, management of medical procedures, coping strategies, and end of life issues. Conclusion: Increased awareness of cultural factors is needed to improve clinical care and reduce health disparities. Specific strategies to approach cultural differences are provided to enhance patient and family care from diagnosis to cure/end of life.

Parent and clinician preferences for location of end-of-life care: home, hospital or freestanding hospice?

BACKGROUND

Current options for location of end-of-life (EOL) care for children with cancer include home, hospital, and freestanding pediatric hospice (FSPH). However, access to these options varies greatly depending on geographical location. We aimed to determine bereaved parent and clinician preferences for location to EOL care and death.

PROCEDURE

We administered questionnaires to 75 bereaved parents (response rate 54%) and 48 pediatric oncology clinicians (response rate 91%) at a large teaching hospital. Main outcome measure was parent and clinician ranking for preferred location of EOL care and death if given the options of home, hospital or FSPH.

RESULTS

Majority of parents and clinicians ranked home as their first choice for EOL care (70.2% and 87%, respectively) and death (70.8% and 89.1%, respectively). Compared to clinicians, parents gave a higher ranking to hospital (P < 0.01) and lower ranking to FSPH (P < 0.01) as the preferred location for EOL care and death. Congruence between actual and preferred location of EOL care was more likely when a palliative care team was involved (P < 0.01) and less likely for children with haematologic malignancies (P = 0.03).

CONCLUSIONS

Parents and clinicians prefer home as the location for EOL care and death for children with cancer. Hospital based palliative care is a preferred alternative if home is not desired. FSPH is a relatively recent phenomena and further research needs to be directed towards understanding its cost benefit in comparison to home and hospital-based EOL care.

Comparison of continuing bonds reported by parents and siblings after a child's death from cancer

Few studies have distinguished similarities and differences between continuing bonds as they appear in various bereaved populations, particularly parent versus sibling cohorts following a child's death. This mixed-method study compared how parents and siblings experienced continuing bonds in 40 families who lost a child to cancer. Thirty-six mothers, 24 fathers, and 39 siblings were recruited 3-12 months post-loss (M = 10.7, SD = 3.5). Nearly all participants (97%) reported engaging in purposeful bonds with deceased children, while only 14% reported nonpurposeful connections. Over half of participants (58%) experienced comforting effects from reminders of the deceased child, whereas only 10% of family members experienced discomforting effects. Mothers communicated with the deceased, thought about the deceased, and did things that the deceased child would have liked more often than siblings. Mothers also reported significantly more comforting effects than siblings. Additional research is needed to further delineate continuing bonds for different types of loss and examine associations with positive and negative outcomes for bereaved individuals.

Conceptual framework for the study of parental end-of-life decision making in pediatric blood and marrow transplantation

PURPOSE/OBJECTIVES

To describe a conceptual framework that will facilitate research and practice concerning parental end-of-life decision making in pediatric blood and marrow transplantation (BMT).

DATA SOURCES

A review of relevant literature from Ovid, CINAHL, EBSCO, MEDLINE, PsycINFO, and various sociology and theology databases was combined with experiential knowledge.

DATA SYNTHESIS

The method of concept and theory synthesis and derivation as described by Walker and Avant was used in the development of this framework.

CONCLUSIONS

Use of the proposed conceptual framework is expected to provide the organization necessary for thinking, observation, and interpretation of parental end-of-life decision making in pediatric BMT.

IMPLICATIONS FOR NURSING

The ability to describe the process of parental end-of-life decision making in pediatric BMT will help nurses to provide appropriate counseling, education, and support for these children and their families at the end of life. In addition, the process will help nurses to promote the well-being of the children's families after end of life.

Looking beyond where children die: determinants and effects of planning a child's location of death

While dying at home may be the choice of many, where people die may be less important than argued. We examined factors associated with parental planning of a child's location of death (LOD) and its effects on patterns of care and parent's experience. In a cross-sectional study of 140 parents who lost a child to cancer at one of two tertiary-level U.S. pediatric hospitals, 88 (63%) planned the child's LOD and 97% accomplished their plan. After adjusting for disease and family characteristics, families whose primary oncologist clearly explained treatment options during the child's end of life and who had home care involved were more likely to plan LOD. Planning LOD was associated with more home deaths (72% vs. 8% among those who did not plan, P<0.001) and fewer hospital admissions (54% vs. 98%, P<0.001). Parents who planned were more likely to feel very prepared for the child's end of life (33% vs. 12%, P=0.007) and very comfortable with LOD (84% vs. 40%, P<0.001), and less likely to have preferred a different LOD (2% vs. 46%, P<0.001). Among the 73 nonhome deaths, planning was associated with more deaths occurring in the ward than in the intensive care unit or other hospital (92% vs. 33%, P<0.001), and fewer children being intubated (21% vs. 48%, P=0.029). Comprehensive physician communication and home care involvement increase the likelihood of planning a child's LOD. Opportunity to plan LOD is associated with outcomes consistent with high-quality palliative care, even among nonhome deaths, and thus may represent a more relevant outcome than actual LOD.

Living with hope and fear--the uncertainty of childhood cancer after relapse

This study explored the experiences of families when a child with cancer relapses. The aim was to develop an understanding of the human actions and emotions that shape the experience of relapse, to question what influences the care provided at relapse, and to challenge current practices. Twelve families were involved in a critical ethnography exploring their child's relapse. Each family participated in an average of 4 in-depth interviews (46 in total) over a period of 6(1/2) to 13 months. The most significant finding from this study was the profound impact of uncertainty. The families fluctuated between 2 states of reality-hoping for a cure and contemplating death-as they faced the uncertainty that surrounded their child's prognosis. A conceptual model of uncertainty at relapse is presented, demonstrating how uncertainty is significant to the child and family's experience, impacting the pursuit for cure, treatment-related decision making, and prognostic communications. Acknowledging the uncertainty of relapse and developing an awareness of the child and family's hopes and fears may lead to a greater understanding of the challenges faced and promote more open and honest communications at this critical period.

Cancer-related symptoms most concerning to parents during the last week and last day of their child's life

OBJECTIVE

Studies of symptoms in children dying a cancer-related death typically rely on medical chart reviews or parental responses to symptom checklists. However, the mere presence of a symptom does not necessarily correspond with the distress it can cause the child's parents. The purpose of this study was to identify the cancer-related symptoms that most concerned parents during the last days of their child's life and the strategies parents identified as helpful with their child's care.

METHODS

Sixty-five parents of 52 children who had died a cancer-related death within the previous 6 to 10 months participated in telephone interviews. Eligibility criteria included being the parent or guardian of a child aged 0 to 21 years who had died within the previous 6 to 10 months after being treated at a pediatric cancer center, having been with their child during the last week of the child's life, speaking English, being willing to participate, and having access to a telephone.

RESULTS

Eighteen symptoms of concern were identified as occurring during their child's final week and final day of life. The most frequently reported symptoms at both times included changes in behavior, changes in appearance, pain, weakness and fatigue, and breathing changes. The proportion of reported symptoms did not differ according to patient gender, disease, or location of death (intensive care, elsewhere in the hospital, or home). The most helpful strategies used by health care professionals to assist the child or parents included giving pain and anxiety medications, spending time with the child or family, providing competent care, and giving advice.

CONCLUSIONS

This knowledge can guide professionals in preparing parents for the symptoms that a child imminently dying of cancer is likely to experience and in providing care that will be helpful to parents.

Integration of palliative care practices into the ongoing care of children with cancer: individualized care planning and coordination

Most parents of children with cancer have dual primary goals: a primary cancer-directed goal of cure and a primary comfort-related goal of lessening suffering. Early introduction of palliative care principles and practices into their child's treatment is respectful and supportive of these goals. The Individualized Care Planning and Coordination Model is designed to integrate palliative care principles and practices into the ongoing care of children with cancer. Application of the model helps clinicians to generate a comprehensive individualized care plan that is implemented through Individualized Care Coordination processes as detailed here. Clinicians' strong desire to provide compassionate, competent, and sensitive care to the seriously ill child and the child's family can be effectively translated into clinical practice through these processes.

Being asked not to tell: nurses' experiences of caring for cancer patients not told their diagnosis

AIMS AND OBJECTIVES

The aim of the primary research was to investigate the impact of the nurse-patient relationship on clinical learning and subsequently clinical practice. Coincidently, 32 participants, all Registered Nurses in Hong Kong, provided details of nurse-patient encounters involving withholding of a cancer diagnosis.

BACKGROUND

The changing face of clinical practice and cancer care has fuelled discussion and debate around disclosure or non-disclosure of the diagnosis of cancer, global consensus on this issue still does not exist. In different countries there is marked variation in how and what a patient may be told about their diagnosis and prognosis. There is considerable variability in the reported rate of cancer diagnosis disclosure across studies and countries. Being asked not to tell a patient their diagnosis of cancer presents many problems for nurses caring for those patients. The issue of non-disclosure directly affects nurses and their clinical practice.

METHODS

This paper reports one of the findings of a large international qualitative study informed by phenomenology into the perceptions of nurses about caring for a patient with a diagnosis of cancer.

RESULTS

Responses from participants revealed considerable difficulties for nurses when caring for patients who were not informed of their diagnosis. They recounted having learned from the encounters but remarked on the negativity of the experience. They discussed their inability to act decisively in the past situations but expressed hope that they had found a resolve to act in future.

RELEVANCE TO CLINICAL PRACTICE

Although, overwhelmingly, participants doubted they would actually be able to change the reality of practice. The identified care episode and the nurse-patient relationship, according to participants, did change their clinical practice but often not for the better.

Home care of a child dying of a malignancy and parental awareness of a child's impending death

In this population-based study, we found that parents who are aware that their child will die from a malignancy are more likely to care for their child at home during the child's last month of life compared to parents who are not aware. End-of-life home care was comparable to hospital care for satisfactory pain relief, access to pain relief and access to medications for other physical symptoms. Using an anonymous postal questionnaire, we obtained information from 449 parents in Sweden who had lost a child due to a malignancy between 1992 and 1997, 4 to 9 years before participating in our study. The prevalence of dying at home and being cared for at home during the last month of life was 23.7% when parents realized intellectually more than 1 month in advance that the child would die (versus 12% who did not), 28.7% for parents who sensed that the child was aware of his or her imminent death (versus 7.8% who did not sense this) and 21.9% for those who received information that the child's illness was incurable (versus 9.4% who did not receive the information). Prevalence of children's unrelieved pain was 11.6% for those receiving home care and 15.3% for those receiving care outside the home.

Crianças com câncer e suas famílias

O objetivo deste estudo é revisar a literatura relativa à criança com câncer e sua família, a fim de identificar temas que têm sido pesquisados e levantar indicadores de necessidades, subsidiando a sistematização da assistência de enfermagem. A coleta de dados sistemática foi realizada em bancos de dados informatizados, entre 1997 e 2002, utilizando-se as palavras-chave child, cancer, chronic illness/disease, family e nursing. Realizou-se, também, busca não-sistemática de publicações científicas. Os resultados foram apresentados em três temas: impacto do câncer infantil no sistema familiar; processo de adaptação e estratégias de enfrentamento utilizadas pelos pais diante da doença e o processo de perda e luto diante da morte da criança. A revisão demonstrou que a enfermagem está construindo um conhecimento específico sobre as necessidades individuais, culturais e regionais das famílias de crianças com câncer, para uma assistência de enfermagem que considere o cuidado de acordo com a singularidade de cada caso.

A framework for integrated pediatric palliative care: being with dying

Recent studies highlight the need for an integrated model for palliative and end-of-life pediatric care. About 55,000 children die each year in the United States and, on any given day, about 8,600 children could benefit from care that acknowledges their limited life expectancy and severity of illness. Two case studies of children illustrate different approaches-one that aggressively applies all possible technologies to maximize chances of survival and another that focuses on the patient's overall quality of life and on healing rather than curing. The cases highlight characteristics of an integrated model of palliative care to address clinical, moral, and ethical uncertainties. This model integrates being with doing, provides for developing attunement and presence as capacities for being with children and their parents, and addresses challenges in the healthcare environment. Strategies for integrating palliative care into pediatric practice include listening, fostering respect for the child and parents across the organization, nurturing collaborative connections, managing uncertainty, tolerating ambiguity, making peace with conflict, and committing to self-care. Every pediatric nurse can play a role in making the vision of palliative care a reality integrated into the fabric of pediatric practice.

Advanced cancer in children: how parents decide on final place of care for their dying child

AIM

to explore retrospectively the decisions made by parents regarding their choice of place of care at time of death for their child with advanced cancer.

DESIGN

cross-sectional descriptive study.

ANALYSIS

interpretive phenomenological analysis.

SAMPLE

parents of five children who had died of advanced cancer, whose care was overseen by the participating paediatric oncology centre in the southeast of England. Three children died at home and two in hospital.

RESULTS

seven themes were identified, four of which will be discussed: valuing time left; needing to feel safe and secure; we didn't know what to expect; and the difference between specialist and non-specialist staff. Families' decisions were instinctive or intuitive rather than a calculated weighing up of options. Families identified aspects of care that were both valuable and could be improved.

CONCLUSION

parents value the time that their children have to live when they know that their child's disease is incurable. Decisions around place of care are just that, decisions around place of care not place of death. Families valued the same types of support from staff regardless of the setting in which care was provided and found the same deficiencies difficult.

Rigor in cross-cultural nursing research

With the increasing number of cross-cultural nursing studies, many scholars have suggested methods for conducting cross-cultural research. However, rigor in cross-cultural research has rarely been addressed. In this paper, five evaluation criteria for rigor in cross-cultural nursing research are proposed based on a review of the literature related to cross-cultural research published from 1965 to 2003. The proposed evaluation criteria include: (a) cultural relevance; (b) contextuality; (c) appropriateness; (d) mutual respect; and (e) flexibility. We advocate that these evaluation criteria be used to ensure rigor of cross-cultural nursing research, whether quantitative or qualitative work.

"Living in the dragon's shadow" fathers' experiences of a child's life-limiting illness

Grounded theory methods were used to study the experiences of 8 bereaved fathers whose children received care in a home-based hospice program. In-depth, unstructured interviews were audiotaped, transcribed, and coded for themes and categories. Every aspect of fathers' lives was affected by their experiences, which were described in metaphoric terms as living in a dragon's shadow. Fathers dealt with life in the dragon's shadow by battling the dragon (the illness)--the core social process. Battling was a conscious, active, continuous process that required strength, willpower, and work. Battling occurred within the context of fathers' experiences with fathering and fatherhood and was characterized by 3 aspects: battling with uncertainty, battling with responsibility, and battling with everyday disruption. Fathers were assisted by supportive work environments and by supportive relationships with health care providers. Unsatisfactory relationships with medical personnel compounded fathers' battling with life in the dragon's shadow.

A Therapeutic Model for Supporting Families of Children with a Chronic Illness or Disability

BACKGROUND

A therapeutic model for supporting families of children with a chronic illness or disability is described. The model presupposes that the chronic illness and/or disability of a child constitutes a trauma for the entire family.

METHOD

This paper describes a therapeutic model currently in practice and links it back to psychological dynamics addressed through the clinical interventions and the principles that underlie the model of service.

RESULTS

Service delivery comprises the interventions; counselling, psychological first aid, projects, peer groups, parent mentoring, social events and community education. The model is family centred, non-illness specific, preventative, non-linear and flexible.

CONCLUSIONS

The interventions offered in the model aim to address the psychological dynamics of hope, empowerment, reconnection, coping/resilience and reframing.

End of life in pediatric oncology: how clinical practice leads to research

In pediatric oncology nursing, and across practice disciplines in general, clinical research serves as the cornerstone for improving patient care. Historically, advances made in the care and cure of childhood cancer have stemmed directly from clinical research. The developments of new research questions are varied in their origin--some questions are based on previous work that leads logically to the next question, some are based on a clinical problem that requires more immediate attention, and then there are those that arise from an individual clinical experience. This last category provides clinicians with a poignant reason to search for answers on how to provide the most optimal care for all future patients. As the number of advanced practice nurses in pediatric oncology increases, there is the likelihood of an increased pursuit of clinical research. This article describes how one clinician's experience with dying children resulted in the pursuit of answers to clinical research questions. By reflecting on clinical practice and incorporating our practice in the development of research questions, we can improve the quality of care provided to all children with cancer.

Helpfulness of nursing actions to suddenly bereaved family members in an accident and emergency setting in Hong Kong

BACKGROUND

The sudden death of a family member is always traumatic to the family. Nursing actions such as providing comfort measures and providing an opportunity to view the deceased were consistently perceived as helpful by the suddenly bereaved. Little is known about the perception of bereaved family members in Hong Kong concerning the care they received in accident and emergency (A & E) departments. This study serves to identify actions, which were perceived as helpful in A & E setting in Hong Kong.

AIM

To gain knowledge about what nursing actions bereaved family members in Hong Kong perceived as helpful.

METHOD

This study was exploratory and descriptive in nature, and used a quantitative approach. Data were collected through structured telephone interviews using a modified Tye's questionnaire.

RESULTS

Seventy-six bereaved subjects were recruited in an A & E department in Hong Kong. The subjects perceived written information, opportunity to view the deceased, and respecting individual customs and religious procedures as most helpful and conversely, offering sedation, discouraging viewing of the body, and providing comfort measures as most unhelpful. No statistically significant differences among the overall mean of helpful nursing actions according to the subjects' age, gender, education level, family income and religions were found while using Mann-Whitney's U and Kruskal-Wallis' tests. Significant correlations between some actions and the respondents' age, family income and educational level were found.

CONCLUSION

Accident and emergency nurses have unique role in offering helpful actions to support suddenly bereaved family members.

Exploring documentation of end-of-life care of children with cancer

This article presents the findings of a study that explored documentation surrounding the end-of-life care of children with cancer. An in-depth history audit of 18 children with cancer, who died from disease progression at a single tertiary paediatric centre during 1999, was performed to explore the extent and the ways in which the shift from cure to palliation was reflected in the child's medical record. The study found that while physical aspects of care were documented there was little evidence of the human-to-human aspects of care or processes of decision-making when cure was no longer a possibility. Relapse and disease progression were identified as critical junctures for families and health professionals and an important area for future research. Further, the medical records documented ill-defined periods of palliation, with the child's approaching death appearing as a gradual awareness rather than a distinct shift in goals of care from cure to palliation.

Caring for dying children: a comparative study of nurses' experiences in Greece and Hong Kong

The purpose of this transcultural descriptive study was to explore the subjective experiences of 63 oncology and critical care nurses who provide care to dying children in Greece and Hong Kong. Semistructured interviews were conducted with 39 Greek and 24 Chinese nurses who described their experiences and responses to the dying process and death of children. The data were analyzed qualitatively and quantitatively, and nurses' responses were compared for their work setting (oncology versus critical care) and their ethnic background (Greek versus Chinese). Findings revealed that most nurses experience a sense of helplessness when caring for a dying patient and difficulties in their communication with the child and parents during the terminal phase of the disease. The large majority acknowledge that the impending or actual death of a patient elicits a grieving process, which is characterized by a fluctuation between experiencing and avoiding loss and grief. Greek and Chinese nurses differ in their expression of their grief and how they attribute meaning to childhood death. Despite the suffering caused by multiple deaths, nurses report significant rewards from caring for chronically and acutely ill children, and the majority are satisfied with their job, despite the difficulties they encounter, in both countries, mostly as a result of shortage in personnel and cooperation problems with physicians.

Cultural beliefs of Asian Americans associated with terminal illness and death

OBJECTIVES

Cultural competence often focuses on the skills of the professional; whereas, this article focuses on the needs of the patient.

DATA SOURCES

Research studies, review articles, book chapters, and clinical practice.

CONCLUSIONS

Patients benefit from health care professionals that are attuned and able to nurture patients in a process of identifying their needs regarding terminal illness and death. The health care professional's ability and sensitivity to be culturally aware, knowledgeable, and open directly influences the patient's quality of life and death.

IMPLICATIONS FOR NURSING PRACTICE

As the population becomes more diverse, health care professionals must develop cultural competence to add value to themselves, the profession of nursing, and health care in the future.