Imparting the diagnosis of life threatening illness in children

Palliative Care in Duchenne Muscular Dystrophy: A Study on Parents' Understanding

Introduction

Duchene muscular dystrophy (DMD) is a neuromuscular disease of childhood, which has clear progression. The international standardized care guidelines for DMD suggest that palliative care is essential for the affected children.

Objective

To explore the parent's understanding of palliative care services available for children with DMD and the challenges faced by them in utilizing the same.

Methods

A cross-sectional qualitative exploratory study was conducted among six families of boys diagnosed with DMD. A semi-structured interview guide with prompts was used to conduct in-depth interviews which lasted for an average of 1 h. Thematic analysis was done to identify the pattern or themes.

Results

The major themes identified were "palliative care, living with DMD, Awareness about palliative care services and challenges." Awareness about palliative care services is the dominant theme identified as influencing rest of the experiences narrated by the parents of children with DMD.

Discussion

Integration of palliative care services from an early stage of the illness can help the child to make transition from one stage to another stage of the illness. To ensure the utilization of the available palliative care services, there is a need to create awareness about it among the general public.

Conclusion

Introducing the concept of palliation of symptoms and ensuring quality of life of the child with DMD by accessing the available services can aid the parents to reach out for help for their child.

Issues in Pediatric Palliative Care: Understanding Families

While family-centred care has always been Part of the rhetoric of hospice and palliative care, few models have been developed that successfully integrate care of the caregivers into the overall schema. Systematic analyses of interventions have failed to produce any demonstrable benefit to families arising from the modern practice of palliative care. This alarming finding constitutes the greatest challenge for the 21st century. Pediatric palliative care may have much to teach in its approach to family care. Family-focused grief therapy is one model, used with both adolescent and adult families, that has promise for the field. The time has surely arrived for palliative medicine to focus on family-based research.

Communication with children and adolescents about the diagnosis of their own life-threatening condition

When a child is diagnosed with a life-threatening condition, one of the most challenging tasks facing health-care professionals is how to communicate this to the child, and to their parents or caregivers. Evidence-based guidelines are urgently needed for all health-care settings, from tertiary referral centres in high-income countries to resource limited environments in low-income and middle-income countries, where rates of child mortality are high. We place this Review in the context of children's developing understanding of illness and death. We review the effect of communication on children's emotional, behavioural, and social functioning, as well as treatment adherence, disease progression, and wider family relationships. We consider the factors that influence the process of communication and the preferences of children, families, and health-care professionals about how to convey the diagnosis. Critically, the barriers and challenges to effective communication are explored. Finally, we outline principles for communicating with children, parents, and caregivers, generated from a workshop of international experts.

Autism Diagnosis in the United Kingdom: Perspectives of Autistic Adults, Parents and Professionals

Accessing an autism diagnosis is a key milestone, both for an individual and their family. Using a qualitative methodology, the current study examined the views and experiences of ten autistic adults, ten parents of children on the autism spectrum, and ten professionals involved in autism diagnosis, all based in the United Kingdom (UK). Interviewing these 30 respondents about the diagnostic process and subsequent support options, the goal was to identify aspects of the diagnostic process that are working well, and areas in which improvements are needed. Using thematic analysis, three key themes were identified: the process of understanding and accepting autism; multiple barriers to satisfaction with the diagnostic process; and inadequate post-diagnostic support provision.

Effect of Breaking Bad News on Patients’ Perceptions of Doctors

The breaking of bad news is a routine but difficult task for many health professionals. There are numerous anecdotes of insensitive practice but the subject has attracted little systematic research. We therefore interviewed 106 patients with advanced cancer (from an original sample of 195) to assess their perceptions of the doctors involved in their care. Aspects of the ‘breaking bad news’ event were recorded during discussion of the illness history and were subsequently rated. Participants were also asked to nominate doctors under the headings ‘most helpful’ and ‘less helpful’, and completed standardized psychological screening questionnaires.

In 94 of the 106 cases the bad news had been given by a doctor, usually a surgeon. Of the 13 doctors categorized as ‘most helpful’ when breaking bad news, 8 were general practitioners; of the 7 categorized as ‘less helpful’ all were surgeons. 69% of patients were neutral or positive about the bad-news consultation, but 20% were negative and 6% very negative. Doctors in surgical specialties were significantly more likely to be rated poorly than non-surgical specialists or general practitioners.

Surgeons were the group of doctors most likely to break bad news, but non-surgical doctors were rated more positively in performance of the task. This finding has implications for training.

Diagnosis in Autism

The results of a survey of almost I300 parent members of autistic societies in the UK are described. The ages of their children ranged from 2 to 49 years. The survey focused on parents' views of the diagnostic process and data were collected on the age at which diagnosis was made, the time taken to obtain a diagnosis and the professionals involved. Differences in geographical area were also assessed. Overall, the results indicate that children are now being diagnosed earlier than in previous decades, but the average age of diagnosis is still around 6 years. There are also wide regional variations in diagnosis. The survey indicates that many parents continue to experience lengthy and often frustrating delays before they finally receive a diagnosis. Moreover, even when this process is completed, the amount of practical help subsequently provided is generally very limited. Factors related to parental satisfaction with the diagnostic process are discussed in detail.

Experiences of autism diagnosis: A survey of over 1000 parents in the United Kingdom

A sample of 1047 parents completed an online survey about their experiences and opinions regarding the process of attaining a diagnosis of autism spectrum disorder for their children. The results revealed that parents usually waited a year from when they first had concerns about their child’s development before they sought professional help. On average, there was a delay of around 3.5 years from the point at which parents first approached a health professional with their concerns to the confirmation of an autism spectrum disorder diagnosis. Just over half of the parents surveyed were dissatisfied with the diagnostic process as a whole. Several factors predicted parents’ overall levels of satisfaction with the diagnostic process, including the time taken to receive a diagnosis, satisfaction with the information provided at diagnosis, the manner of the diagnosing professional, the stress associated with the diagnostic process and satisfaction with post-diagnostic support. Post-diagnosis, the support (if any) that was provided to parents was deemed unsatisfactory, and this was highlighted as an area of particular concern among parents.

Difficult conversations: from diagnosis to death

BACKGROUND

Communication is the cornerstone of good multidisciplinary medical care, and the impact of conversations about diagnosis, treatment, and prognosis is indisputable. Healthcare providers must be able to have difficult conversations that accurately describe diagnostic procedures, treatment goals, and the benefits and/or risks involved.

METHODS

This paper reviews the literature about the importance of communication in delivering bad news, the status of communication training, communication strategies, and psychosocial interventions.

RESULTS

Although many published guidelines address difficult communication, communication training is lacking. Consequently, many clinicians may have difficulties with, or in the worst-case scenario, avoid delivering bad news and discussing end-of-life treatment. Clinicians also struggle with how to have the last conversation with a patient and how to support patient autonomy when they disagree with a patient's choices.

CONCLUSION

There is a clinical imperative to educate physicians and other healthcare workers on how to effectively deliver information about a patient's health status, diagnostic avenues to be explored, and decisions to be made at critical health junctions. Knowing how to implement the most rudimentary techniques of motivational interviewing, solution-focused brief therapy, and cognitive behavioral therapy can help physicians facilitate conversations of the most difficult type to generate positive change in patients and families and to help them make decisions that minimize end-of-life distress.

The autism diagnostic experiences of French parents

This survey focused on French parents' views of the diagnostic process relating to their child with autism. Data were collected on the age at diagnosis, the time taken to obtain a diagnosis and the difficulties encountered. Questionnaires filled in by the parents (n = 248) and in-depth interviews (n = 43) were analyzed in order to obtain quantitative and qualitative results. The ages of the children ranged from 4 to 45. This approach enabled us to compare the practices of professionals now and in the past. The mean age of diagnosis was 10 ± 8 years from 1960 to 1990, 5 ± 3 years from 1990 to 2005 (3 ± 1 from 2003 to 2005). The results showed that the mean delays between first consultation and diagnosis were reduced. Regarding the way the diagnosis was announced, 63% of the parents of children with autism and 93% of the parents of adults with autism were dissatisfied. We discuss the parents' reactions and the changes in the diagnostic process.

Parental perceptions of being told their child has cancer

BACKGROUND

Finding out that your child has cancer is a devastating experience. How this information is communicated can have a lasting impression on parents receiving the news. The purpose of this study was to assess how well parents recall discussing the diagnosis of cancer and to summarize suggestions for improvement.

METHODS

A questionnaire was developed with input from several parents of children previously diagnosed with cancer. All parents of children <18 years of age with a diagnosis of cancer who were >1 month post-diagnosis at our children's hospital were asked to participate. The patient sample was identified through the in- and outpatient clinics from June to August 2006.

RESULTS

One-hundred sixteen parents (mothers and fathers) completed the questionnaire, with only two parents refusing (1.7%). The moment of disclosure of the diagnosis was remembered vividly in 77%, well in 20%, and somewhat, vaguely or not at all in 1% each. Parental reaction to the disclosure was viewed as a positive experience 79% of the time and a negative experience 21% of the time. Parents also provided a number of suggestions for future disclosure.

CONCLUSIONS

The majority of parents recall receiving the diagnosis and the discussions that ensued about their child's diagnosis of cancer. Most parents were satisfied with their experience with receiving the diagnosis. Suggestions for improvement can be incorporated into future educational indicatives for front line healthcare providers to improve communication of sensitive diagnoses with parents.

Communicating with children and families: from everyday interactions to skill in conveying distressing information

Health care communication is a skill that is critical to safe and effective medical practice; it can and must be taught. Communication skill influences patient disclosure, treatment adherence and outcome, adaptation to illness, and bereavement. This article provides a review of the evidence regarding clinical communication in the pediatric setting, covering the spectrum from outpatient primary care consultation to death notification, and provides practical suggestions to improve communication with patients and families, enabling more effective, efficient, and empathic pediatric health care.

Assessing the diagnostic experiences of a small sample of parents of children with autism spectrum disorders

Although no Canadian studies have been conducted, studies suggest parents of children with autism experience difficulties obtaining a diagnosis for their child. Fifty-six parents of children with autism completed three questionnaires providing information on the families' demographics, parents' experiences throughout the diagnostic process, and their child's autistic symptomatology. These parents experienced significant difficulties obtaining a diagnosis for their child. Parents saw an average of 4.5 professionals, and waited almost 3 years to receive a diagnosis following their first visit to a professional regarding their child's development. The impact of autistic symptomatology on the diagnostic process is discussed.

Palliative care and paediatric respiratory medicine

Progressive respiratory failure is a common modality of death in children with a terminal illness. The management of respiratory failure, and in particular symptoms of dyspnoea and musculoskeletal chest pain in children receiving palliative care, remains challenging. The emergence of palliative care paediatricians and the application of non-invasive ventilation to children with progressive respiratory failure are the two major advances in the care of children with respiratory complaints in the palliative care setting. This article outlines current approaches to palliative care in children with progressive respiratory symptoms.

Parents' informational needs at the birth of a baby with a surgically correctable anomaly

Previous studies have assessed informational needs of parents of sick fetuses, neonates and children to identify favourable patterns of physician-parent interaction. The aim of this paper was to assess parents' informational needs before and after the operation when the one affected by a surgically correctable anomaly is a newborn. In the period ranging from 1997 to 2000 all couples with newborns undergoing major surgical procedures at birth, at the Newborn Surgery Unit of the Hospital Bambino Gesù, were surveyed by means of a questionnaire. Thirty couples form the object of the study. The two genders did not show significant difference in any of the considered items. All 30/30 mothers (M; 100%) and 29/30 fathers (F; 97%) had never heard about the anomaly before the diagnosis was established in their baby. All parents (100%) stated that it would be better if the surgeon informed them with written educational material. Principal informational needs before operation regard: the description of the anomaly (M = 10; F = 11) and the prognosis in terms of survival chances of the baby (M = 17; F = 15); after surgery the cause of the anomaly (M = 5; F = 3); the steps of the recovery process (M = 10; F = 12) as well as the quality of their baby's life (M = 9; F = 9). In the immediate perioperative period the surgeon should well address parents' informational needs, which may significantly differ from his communication plan.

Improving the quality of end-of-life care in the pediatric intensive care unit: parents' priorities and recommendations

OBJECTIVE

Despite recognition that dying children and their families have unique palliative care needs, there has been little empirical inquiry of parent perspectives to improve the quality of end-of-life care and communication. The purpose of this study was to identify and describe the priorities and recommendations for end-of-life care and communication from the parents' perspective.

METHODS

This was a qualitative study based on parental responses to open-ended questions on anonymous, self-administered questionnaires, conducted at 3 pediatric ICUs in Boston, Massachusetts. Fifty-six parents whose children had died in PICUs after withdrawal of life support participated in this study. We measured parent-identified priorities for end-of-life care and communication.

RESULTS

Parents identified 6 priorities for pediatric end-of-life care including honest and complete information, ready access to staff, communication and care coordination, emotional expression and support by staff, preservation of the integrity of the parent-child relationship, and faith.

CONCLUSIONS

Parental priorities and recommendations offer simple yet compelling guidance to improve pediatric end-of-life clinical practice and research.

Collaborative Clinical Research on End-of-Life Care in Pediatric Oncology

OBJECTIVES

To present an overview of research into end-of-life (EoL) care for pediatric patients with cancer and to describe research completed by a newly formed collaboration of researchers.

DATA SOURCES

Professional group position papers and guidelines; research studies.

CONCLUSION

Studies to date in pediatric EoL care used retrospective, descriptive, or pilot intervention designs, have been conducted in single-institution settings, and have included small numbers of patients. Most studies have explored perspectives of parents and health care professionals but have omitted the perspective of the dying child.

IMPLICATIONS FOR NURSING PRACTICE

Advancing the science of EoL care will depend on intervention-based clinical trials that include the perspective of the dying child in addi tion to parents and health care professionals.

Antenatal diagnosis of diaphragmatic hernia: parents' emotional and cognitive reactions

PURPOSE

The aim of this study was to assess parent's emotional and cognitive reactions to the prenatal diagnosis of diaphragmatic hernia in their prospective children.

METHODS

A survey was conducted by means of a questionnaire. In the period ranging from 1997 to 2002, 40 couples in whom an established diagnosis of diaphragmatic hernia was made in their fetus were seen for prenatal consultation at a tertiary referral center.

RESULTS

Overall response rate was 93% (37 couples). Mean period since diagnosis for compilation of the questionnaire was 2 weeks. Mean gestational age at diagnosis was 25 weeks (range, 16 to 35 weeks). All parents lacked prediagnostic knowledge of diaphragmatic hernia and consider a single consultation with the paediatric surgeon inadequate to have a clear understanding of the anomaly. Only 1 mother and 1 father reported they understood all the information given by the surgeon. The most frequent (75%) feeling during and after the consultation was fear. Most parents (70%) referred to the intense emotions as the factor that made it difficult to follow the surgeon's explanations as well as to ask questions.

CONCLUSIONS

Because of the incompatibility of emotional distress and optimum learning, impairment of early comprehension of information about diaphragmatic hernia is unavoidable. Therefore, we believe that follow-up antenatal consultations and provision of written and visual illustration are extremely important to facilitate informed choices.

Establishing nursing research priorities on a paediatric haematology, oncology, immunology and infectious diseases unit: involving doctors and parents

Following a Delphi survey undertaken with nurses on a specialist children's unit to identify priorities for nursing research, this paper outlines the results of a survey to ascertain the views of doctors and parents regarding the results of the Delphi. This approach was in keeping with national guidance on multi-professional working in paediatric oncology and the importance of service-user involvement in planning and evaluating care. Convenience samples of doctors (n=16) and parents (n=10) were asked to rank the priorities previously identified by nurses. Results highlighted that in the main, nurses, doctors and parents agreed on the key areas that should take priority for research. Nurse's knowledge of day-to-day symptom management, children's quality of life, negotiation and communication in relation to care provision were identified by all three groups as high priorities. There were some areas where the views varied: this was generally in relation to the different primary focus of the individual groups-parents being very concerned with the effect of daily ward routines and procedures and their child's overall hospital experience, nurses with issues such as staff retention and morale, whereas doctors were more concerned with issues around information giving and consent to treatment. Limitations of the study, including sample selection and the transient nature of the population involved are discussed within the paper. The paper concludes that all three groups shared similar views, being focused on issues directly related to patient care. Consensus between the groups should result in future research initiatives reflecting a shared focus and responding to an identified need.

Parents' stories of sensitive and insensitive care by paediatricians in the time leading up to and including diagnostic disclosure of a life-limiting condition in their child

This study explored parents' experiences of care by paediatricians in the time leading up to and including diagnostic disclosure of a life-limiting condition in their child.

RESEARCH METHODS

Qualitative exploration using in depth interviews with a purposive sample of 30 families whose child was diagnosed with a life-limiting condition.

RESULTS

Parents' stories centred upon their need to have their concerns and needs as parents validated by paediatricians. Demonstrable qualitative differences were shown to exist between the sensitive and insensitive clinical practices of paediatricians. Parents' stories identify the need for clinical practice to be based upon a humanistic approach to care. These also identify how sensitive paediatricians achieved this ideal through meeting the 'double obligation' of combining technical skills with an understanding of their needs as parents.

Effect of breaking bad news on patients' perceptions of doctors

The breaking of bad news is a routine but difficult task for many health professionals. There are numerous anecdotes of insensitive practice but the subject has attracted little systematic research. We therefore interviewed 106 patients with advanced cancer (from an original sample of 195) to assess their perceptions of the doctors involved in their care. Aspects of the 'breaking bad news' event were recorded during discussion of the illness history and were subsequently rated. Participants were also asked to nominate doctors under the headings 'most helpful' and 'less helpful', and completed standardized psychological screening questionnaires. In 94 of the 106 cases the bad news had been given by a doctor, usually a surgeon. Of the 13 doctors categorized as 'most helpful' when breaking bad news, 8 were general practitioners; of the 7 categorized as 'less helpful' all were surgeons. 69% of patients were neutral or positive about the bad-news consultation, but 20% were negative and 6% very negative. Doctors in surgical specialties were significantly more likely to be rated poorly than non-surgical specialists or general practitioners. Surgeons were the group of doctors most likely to break bad news, but non-surgical doctors were rated more positively in performance of the task. This finding has implications for training.

Palliative care and the child with cancer

There is a growing awareness and a WHO directive that the palliative care paradigm should be incorporated into the care of all children with cancer, irrespective of geographic location. The barriers to pediatric palliative care identified by pediatric oncologists [3] are lack of formal courses in pediatric palliative care, a high reliance on trial-and-error learning, lack of strong role models, and lack of access to a pain and palliative care service. These barriers must be overcome.

Factors predicting communication about the diagnosis of maternal breast cancer to children

OBJECTIVE

To identify factors influencing mothers' communication with their children about their diagnosis and initial treatment.

DESIGN

Cross-sectional cohort.

SETTING

Two breast cancer treatment centres.

SUBJECTS

Thirty-two women with Stage I or Stage II breast cancer with 56 school-aged children.

MAIN OUTCOME MEASURES

Semistructured interview regarding timing and extent of communication with children from the time that a problem was first identified to initial treatment, and children's reactions.

RESULTS

Children were most likely to be told about their mother's illness after the diagnosis had been confirmed by biopsy but a minority were told nothing until after surgery and some nothing at all. The information children received did not necessarily include mention of cancer. Predictors of communication were child age, with older children being told earlier and more information, and maternal education, with children of more highly educated mothers being told less. Child gender was not related to communication.

CONCLUSION

Mothers who are being investigated for breast cancer are likely to benefit from the opportunity to consult a supportive professional about communication with their children during all stages of their diagnosis and treatment, but particularly early on in the investigation when they are more reluctant to initiate discussions with their children. At later points, those with children of varying ages may need specific advice on ways to discuss their illness in relation to children's understanding.

The use of standardized patients in pediatric residency training in palliative care: anatomy of a standardized patient case scenario

The use of standardized patients (SPs) is an emerging strategy in palliative care education. We have used this strategy to provide pediatric residents with a structured educational experience focused on effectively communicating bad news and concurrently understanding the emotions that they and the parents may experience. This article describes the importance of and process for realistic SP case development explicitly designed to address predetermined educational goals and objectives. Topics addressed include the types of potential SPs that can be utilized, their potential strengths and weaknesses, training issues which include giving constructive feedback, implementation strategies for the case scenarios and evaluation strategies.

'Breaking bad news' within a paediatric setting: an evaluation report of a collaborative education workshop to support health professionals

AIMS OF PROJECT: To evaluate a workshop to prepare health professionals for breaking bad news in the paediatric setting.

BACKGROUND

Breaking bad news can be difficult for health professionals, and it seems that few receive specific training for undertaking this challenging task. Latterly, however, there have been reports of training programmes being developed to prepare health professionals for breaking bad news, although most focus upon meeting needs of medical staff only. While doctors have a uniquely important role in breaking bad news it is evident that other health professionals, most frequently nurses, can be equally involved in this encounter. Accordingly, nurses and other professionals need training to recognize the contribution that they can make in ensuring sensitive and effective bad news disclosure.

DESIGN

A one-day, multi-professional, experiential training workshop.

METHOD

Forty-five participants, mainly nurses (34, 76%) and doctors (10, 22%), attended one of five breaking bad news workshops set up for staff working in a range of paediatric settings including Accident and Emergency and Intensive Care. Each of the workshops was facilitated by three facilitators from varied backgrounds. Using an experiential design, participants were supported to explore and reflect upon breaking bad news issues, which also included engagement with actors to act out realistic bad news scenarios. Debriefing, using a positive learner-centred model of feedback, provided the main platform for promoting learning. Following the workshop, participants completed an evaluation questionnaire, seeking their perceptions of the effectiveness of the workshop in enhancing knowledge and communication skills.

DATA ANALYSIS

Atlas.ti, a qualitative computer data analysis software program was used to explore the evaluation comments made by participants, resulting in the generation of common themes.

FINDINGS

Seven themes, including development of practice, the value of sharing, benefit of feedback, and team work, emerged from responses. All responses indicated that the workshop had been beneficial and an effective training method, with most participants (40 of 89%) indicating that they would strongly recommend their colleagues to attend a similar workshop.

CONCLUSION

The educational approach reported is considered by participants to be beneficial in preparing health professionals for breaking bad news in a collaborative way.

Down's syndrome: experiences of mothers from different cultures

The purpose of this study is to explore the lived experiences of mothers from different cultural backgrounds who have a child with Down's syndrome. Today, in multicultural Britain, cultural awareness and understanding are necessary if relevant care is to be offered. People from different cultures have different health beliefs, understanding and expectations. In order to try to understand these differences, a small selected sample of mothers from three different cultures who had given birth to a child diagnosed with Down's syndrome were interviewed in their own homes. When their responses were analysed they demonstrated their comparative isolation and the influence of cultural beliefs, and also that despite much research and study there is still a lack of respect and value in the way they had been treated. The author of this article addresses the requirement of more sensitivity and empathy to parents' needs.

Pediatric palliative care

This article presents a model of integrated palliative care for children with life-limiting illnesses, with emphasis on collaboration of care over time among family, primary care providers, and several other groups of providers. Some of the unique aspects of caring for children related to normal developmental changes and the family unit are considered. Issues related to pain and to specific diseases are also reviewed.

Hearing the bad news of a cancer diagnosis: the Australian melanoma patient's perspective

BACKGROUND

In the past, recommendations on how to break the bad news of a cancer diagnosis have been based on expert opinion. Recently, consensus-based guidelines for medical practitioners have been developed. The objective of this work is to investigate patient preferences for communication practices and to identify any disparities between these guidelines, patient preferences and patient recollections of hearing their diagnosis.

PATIENTS AND METHODS

A consecutive sample of 131 newly diagnosed melanoma patients were surveyed approximately 4 months after initial diagnosis to document their preferences and recollections of their communication experiences.

RESULTS

Of the 'breaking bad news' recommendations investigated, patients did not strongly endorse the doctor helping tell others of the diagnosis or telling the patient about cancer support services. Very few patients expressed a preference for having another health professional present. One communication feature, the patient feeling confident about getting the best treatment, was endorsed as 'very important' but does not feature in published guidelines. The most notable disparities between guidelines and the reported experiences of patients related to perceived delays in receiving the diagnosis, and having adequate opportunity to ask their clinician questions.

CONCLUSION

Current Australian recommendations on how to communicate a diagnosis of cancer were generally supported by the patients' expressed preferences, but several modifications are proposed.

IMPLICATIONS

Suggestions are offered to help overcome the disparities identified between recommendations and patients' preferences when a diagnosis of cancer is being communicated.

Qualitative interview study of communication between parents and children about maternal breast cancer

OBJECTIVE

To examine parents' communication with their children about the diagnosis and initial treatment of breast cancer in the mother.

DESIGN

Qualitative interview study within a cross-sectional cohort.

SETTING

Two breast cancer treatment centers.

PARTICIPANTS

32 women with stage I or stage II breast cancer with 56 school-aged children. Main outcome measures Semistructured interview regarding timing and extent of communication with children about the diagnosis and initial treatment of the mother's illness, reasons for talking to children or withholding information, and help available and requested from health professionals.

RESULTS

Women were most likely to begin talking to their children after their diagnosis had been confirmed by biopsy, but a few waited until after surgery or said nothing at all. Family discussion did not necessarily include mention of cancer. There was considerable consistency in the reasons given for either discussing or not discussing the diagnosis. The most common reason for not communicating was to avoid children's questions, particularly those about death. Although most women had helpful discussion with a physician concerning their illness, few were offered help with talking to their children; many would have liked help, particularly the opportunity for both parents to talk to a health professional with experience in understanding and talking to children.

CONCLUSION

Parents diagnosed with cancer or other serious illnesses should be offered help to think about whether, what, and how to tell their children and about what children can understand, especially as they may well be struggling themselves to come to terms with their illness.

Qualitative interview study of communication between parents and children about maternal breast cancer

OBJECTIVE

To examine parents' communication with their children about the diagnosis and initial treatment of breast cancer in the mother.

DESIGN

Qualitative interview study within cross sectional cohort.

SETTING

Two breast cancer treatment centres.

PARTICIPANTS

32 women with stage I or stage II breast cancer with a total of 56 school aged children.

MAIN OUTCOME MEASURES

Semistructured interview regarding timing and extent of communication with children about the diagnosis and initial treatment of the mother's illness, reasons for talking to children or withholding information, and help available and requested from health professionals.

RESULTS

Women were most likely to begin talking to their children after their diagnosis had been confirmed by biopsy, but a minority waited until after surgery or said nothing at all. Family discussion did not necessarily include mention of cancer. There was considerable consistency in the reasons given for either discussing or not discussing the diagnosis. The most common reason for not communicating was avoidance of children's questions and particularly those about death. While most mothers experienced helpful discussion with a doctor concerning their illness, few were offered help with talking to children; many would have liked help, particularly the opportunity for both parents to talk to a health professional with experience in understanding and talking to children.

CONCLUSIONS

Parents diagnosed with cancer or other serious illnesses should be offered help to think about whether, what, and how to tell their children and about what children can understand, especially as they may well be struggling themselves to come to terms with their illness.

The challenge of breaking bad news

Critical care nurses will be involved in supporting patients and their families who are receiving, or who have received 'bad news'. This paper will identify the specific challenges faced by critical care staff involved in imparting bad news within an intensive care setting. A framework for practice is shared which might assist them to meet successfully the challenges posed.

Communication about parental illness with children who have learning disabilities and behavioural problems: three case studies

Parental illness can have a profound impact on family relationships and children's behaviour. The amount and nature of communication between parents and children about the illness can play an important role, both positively and negatively, in mediating the outcomes. When children have a disability, families can be reluctant to communicate with them about family difficulties. They are often concerned about the impact that parental unavailability may have on their child's life. This paper reports on three families in which the mother was diagnosed with breast cancer and one child in the family had a disability. The extent and specific characteristics of their communication about the maternal illness with their children, behavioural changes in the children, explanations of communication strategies and attributions of behavioural changes are described. Family coping strategies are examined with reference to Lazarus's process model of stress and coping and the use of either problem-focused or emotion-focused strategies. Implications for possible clinical interventions are proposed. In particular it is suggested that families be offered consultation about: what children might understand; ways in which to communicate effectively; and strategies for coping with the long-term implications of serious parental illness.

The partnership myth? Examining current opinions

There is a need for further clarification of the concept of partnership. A philosophy of 'family-centred care' will require negotiation with, and commitment from, all concerned with care delivery in the ward and beyond. Paediatric nursing needs to adopt a flexible and non-judgmental approach in order to facilitate the needs of all families. The concept of 'partnership in care' is of benefit to families caring for sick children in the context of today's economic and political climate.

The paediatric oncology community nurse specialist: the influence of employment location and funders on models of practice

A specialist nursing service has evolved in recent years, to care for children with cancer or leukaemia and their families, and co-ordinate care in the community. These paediatric oncology community nurse specialists (POCNS) are mostly based at regional children's cancer treatment centres, although some are based within paediatric units of district general hospitals. In addition to the National Health Service (NHS), a major source of funding has been provided from a range of charities. This paper examines the impact that the employment location (regional or district) and funding sources have on the process, practice and structure of nursing within the speciality. All 43 POCNSs were interviewed from 28 different hospitals across the United Kingdom and Eire. Thirty-one were based at regional treatment centres, whilst 12 were from district general hospitals. Funding was provided by: the NHS (9); Cancer and Leukaemia in Childhood (CLIC) (10); Cancer Relief Macmillan Fund (5); and other charities (19). Major differences were found according to the location of POCNSs, i.e. the regional model and the district model, and according to funders, i.e. the Macmillan model, the CLIC model and the 'other funders' model. This research suggests that both funding source and location of POCNSs have implications for nursing practice.

Breaking bad news to parents with disabled children--a cross-cultural study

This cross-cultural retrospective study investigates the problems parents experience when told that their child is physically and/or mentally disabled. The authors try to compare, where relevant, some of the responses of the parents from different ethnic groups. The parents of 40 randomly selected coloured, 26 white and 24 black pre-school children who were first seen at the Developmental Assessment Clinic at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa between January 1989 and December 1990 were asked to participate in this study. The final sample comprised 65 children. Except for the Xhosa speaking parents, the majority of parents received the diagnosis in their own language (English or Afrikaans). Most Xhosa speaking parents denied having received an explanation of the diagnosis, or having had an opportunity to ask questions. Only a few black parents reported being asked as to their understanding of the diagnosis. White parents tended to deny the diagnosis of mental handicap more often than the other groups despite reporting that explanations were given. The majority of parents would have liked a written report after the first consultation. Despite these findings, most parents felt satisfied with the way the news were given to them, reported good progress in their children and some of them expected their children to go to a normal school. Use of a language other than the parent's tongue tends to have a negative influence on the communication between doctors and parents. A diagnosis of mild mental handicap, a 'perception' of good progress and an absence of visible signs of the disability contribute to parental denial of the reality of the child's developmental delay and its scholastic consequences. The process of 'breaking the news' can be facilitated by the introduction of a few simple measures as described in the recommendations.

How should a positive HIV result be given? The patients' view

The study aimed at obtaining information about the experience of how the diagnosis of HIV infection was given. Thirty asymptomatic HIV seropositive subjects completed a self-report questionnaire enquiring about their views of the process of communication of a positive test result. Subjects' current mood was assessed with the Hospital Anxiety and Depression Scale (HAD). Only about one-third of subjects were definitely satisfied with the way they were told the diagnosis. Satisfaction was associated with perceived reassurance and sympathy, and with the quality of the information given. The views of patients, as reported in this study, should be taken into account when training staff in the notification of HIV test results.

Communication with parents of children with cancer

The purpose of this study was to assess the receptiveness of parents to information given about their child's life threatening illness. Three months after the child's diagnosis, an independent interviewer, using a structured questionnaire, interviewed the parents about what and how they had been told, and assessed the stage of parental coping reached at that time. All patients were treated at a regional paediatric oncology centre (RHSCE) and the interviews were conducted preferably in the family home (61%), or in a 'quiet' hospital room (39%). Twenty-five, unselected, consecutive patients with cancer and leukaemia diagnosed and treated at the RHSCE and their families were recruited into the study (1988-1989). One child died during the first three months and one single parent family refused co-operation. Eighteen of the 23 interviews conducted were with both parents, and five were with single parents (all maternal). All 23 sets of parents admitted deep shock and devastation on hearing the initial diagnosis, with 12 sets feeling that they had taken in little or none of the information given. A long interview was conducted a few days after the initial talk with the consultant. The parents of four children (17%) denied that the long interview had occurred whilst 10/19 who remembered it expressed specific lack of understanding of some or all details. All families remembered a large number (10-20) of subsequent talks with a wide range of staff, but 14/23 felt that some of the information was still confusing or conflicting, and 9/14 did not want to ask for further clarification, principally because they did not want to hear more bad news. The majority felt the child understood little of what was going on. At the study interview, most parents were assessed as still being very anxious about their child's illness, whilst two couples, one single mother and one father, were content with what and how they had been told about their child's illness and were in a state of emotional homeostasis. It is concluded that communication of bad news is a two-way process requiring skilled medical staff, but also a receptive audience. The emotional state of the parent determines his or her ability to hear and comprehend the information given. The results imply that repetition and clarification at consultation interviews is required until parents are emotionally able to hear, accept and comprehend complex news. Written material, taped interviews and simple videos can assist in this process.

How should an AIDS diagnosis be given? The views of patients

The report aimed at obtaining information about patients' experience of how the diagnosis of AIDS was given to them by their doctors, and about patients' satisfaction with the consultation. Thirty people with AIDS completed a self-report questionnaire enquiring about their views and satisfaction with the process of communication of the diagnosis. Results showed that about two-thirds of patients were satisfied, while almost a quarter were definitely not satisfied with the consultation. Satisfaction was associated with the general attitude of the person giving the diagnosis and with the quality of the information given. The relevance of the findings for the training of doctors is discussed.

Preterm labour and delivery: psychological sequelae

The psychological care of preterm babies and their families is challenging and at least as demanding for staff as the technical aspects of care. There is growing evidence for the effectiveness of therapeutic interventions in this area, thus ensuring the optimum outcome for the baby, the family and the staff.

The use of taped parental interviews to improve communication with childhood cancer families

Communication with the parents of children with cancer is essential. Denial of information given, confusion over details, and emotional distress all prevent comprehension by parents. Information-giving sessions were taped and the effect this had on parental contentment and understanding was assessed. The use of simpler language by doctors and repetition of complex information was requested by parents. Those parents who have not reached emotional homeostasis will not absorb what is said to them, but replaying the tapes may assist in overcoming this.

Giving sad and bad news

When bad news is broken insensitively the impact can be distressing for both giver and recipient. For the recipient especially, the effect can be longlasting. Poor training in communication skills leaves most doctors unable to give bad news appropriately. Doctors must realise what impact the news can have on the patient; must overcome fear of being blamed for the message and of a sense of failure for not being able to improve the situation; and must learn how to cope with the recipient's reaction. Doctors should prepare adequately for the meeting, ensure that the patient has understood the message, and see to the patient's immediate needs after the interview. If diagnostic investigations or therapeutic options are being discussed at the same time, giving the patient an audiotape recording of the interview is helpful.

An enquiry into death and dying at the Adelaide Children's Hospital: a useful model?

As a result of a desire amongst the hospital staff to improve the management of dying children and their families, a four person subcommittee was appointed to investigate this area of care. Nineteen persons were interviewed (15 hospital staff members and four parents) and 12 written submissions were received (10 from staff and two from parents) over a 10 week period. An analysis of one year's deaths of Adelaide Children's Hospital patients showed that most took place in the hospital and about one in five were at home. Nearly 60% occurred in children aged 0-5 years, 15% in those aged 6-10 years, 15% in those aged 11-15 years, and 13% in children aged more than 15 years. The four commonest causes of death were: cancer (27%), congenital abnormalities (19%), sudden infant death syndrome (SIDS) (16%), and trauma (11%). Sudden unexpected deaths are most common, particularly for infants. Recommendations included improved privacy for families and friends; more sensitive body viewing, mortuary, autopsy and funeral arrangements; and better in-service education for staff and information giving for families. Areas of insufficient staff support were identified and the appointment of a specialist palliative care clinical nurse consultant was proposed. Stronger links with palliative and hospice care teams, general practitioners and community nurses were suggested. Addressing the issues of living and dying, and working through the stages of grief are integral parts of long term clinical care. The need for good continuity of psychosocial support was a recurring theme. More awareness of the availability of the specialised pain relief service was required. Ethical issues should be addressed as part of the general development of education and information services. The advantages and limitations of the enquiry are discussed and the model is proposed as a potentially useful one for both paediatric and adult palliative care and hospice care service development.