The dying child

The Unspeakable Nature of Death & Dying During Childhood: A Silenced Phenomenon in Pediatric Care

In pediatric settings, the concept of hope is frequently positioned as a fundamental aspect of care and at odds with the possibility and proximity of death. This arguably fosters silence about death and dying in childhood despite evidence indicating the benefits of open communication at the end of life. In this paper, we describe the unspeakable nature of death and dying in childhood, including its conceptual and clinical causes and dimensions, its persistence, and the associated challenges for children and youth facing critical illnesses, their families, and society. We explore how the tension between hope and death can be reframed and apply our analysis to the context of medical assistance in dying for mature minors in Canada. Considering the lack of related literature, this paper offers initial reflections to form a framework for the unspeakable nature of death and dying in childhood and to advance the crucial need for research.

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.

Wished for and avoided conversations with terminally ill individuals during final conversations

The current investigation examines retrospectively wished for and avoided conversations during the end of life with a deceased relational partner. Participants reported on conversations they wished they had engaged in and conversations that they intentionally avoided, as well as reasons why they did not engage in the conversations. Analyses revealed the following wished for and avoided conversations: negative relationship characteristics; death and dying; postdeath arrangements; and personal information. Furthermore, participants indicated the following reasons for not discussing the aforementioned topics during final conversations: emotional protection, relational differences, and condition of the dying. Theoretical and practical implications for end-of-life communication are discussed.

How Lay Are Lay Beliefs?

The article explores and problematizes the concept of lay beliefs. The article undertakes this using an example of ‘good practice’ in lay beliefs research – an article by Ilka Kangas recently published in health: (2001 vol. 5(1)) – to illustrate how fundamental problems with the concept still arise. The article argues that lay beliefs are extremely difficult, if not impossible, to study because they are tied up with the certainty of diagnosis and the legitimacy that is afforded by taking on medical rationality. Moreover, ‘commonsense’ views are themselves based upon understandings within expert paradigms. Implications for research are considered and the author calls for a shift of focus from lay beliefs to illness accounts where individual understandings can be appreciated.

Advance Care Planning in palliative care: a qualitative investigation into the perspective of Paediatric Intensive Care Unit staff

BACKGROUND

The majority of children and young people who die in the United Kingdom have pre-existing life-limiting illness. Currently, most such deaths occur in hospital, most frequently within the intensive care environment.

AIM

To explore the experiences of senior medical and nursing staff regarding the challenges associated with Advance Care Planning in relation to children and young people with life-limiting illnesses in the Paediatric Intensive Care Unit environment and opportunities for improvement.

DESIGN

Qualitative one-to-one, semi-structured interviews were conducted with Paediatric Intensive Care Unit consultants and senior nurses, to gain rich, contextual data. Thematic content analysis was carried out.

SETTING/PARTICIPANTS

UK tertiary referral centre Paediatric Intensive Care Unit. Eight Paediatric Intensive Care Unit consultants and six senior nurses participated.

FINDINGS

Four main themes emerged: recognition of an illness as 'life-limiting'; Advance Care Planning as a multi-disciplinary, structured process; the value of Advance Care Planning and adverse consequences of inadequate Advance Care Planning. Potential benefits of Advance Care Planning include providing the opportunity to make decisions regarding end-of-life care in a timely fashion and in partnership with patients, where possible, and their families. Barriers to the process include the recognition of the life-limiting nature of an illness and gaining consensus of medical opinion. Organisational improvements towards earlier recognition of life-limiting illness and subsequent Advance Care Planning were recommended, including education and training, as well as the need for wider societal debate.

CONCLUSIONS

Advance Care Planning for children and young people with life-limiting conditions has the potential to improve care for patients and their families, providing the opportunity to make decisions based on clear information at an appropriate time, and avoid potentially harmful intensive clinical interventions at the end of life.

Parents' views of their child's end-of-life care: subanalysis of primary care involvement

BACKGROUND

The medical literature encourages primary care pediatricians (PCPs) to play a role in the care of patients who are dying. Actual involvement has not been investigated.

OBJECTIVE

Our objective was to explore current involvement of PCPs when their patients face the end of life and bereaved parents' attitudes toward it.

DESIGN

Individual, in-depth, semi-structured interviews were conducted using a focused ethnographic technique. Qualitative analysis was performed on the interviews.

SETTING/SUBJECTS

Most (14/16) interviews were conducted in the family's home, involving parents of Massachusetts children who died aged 1 month to 11 years during 2005.

MEASUREMENTS

Themes identified through thematic analysis of interview transcripts were utilized.

RESULTS

Interviews were thematically analyzed, revealing four categories of themes: 1) the role of individual PCP in decision making and care at end of life; 2) general attitudes about the care provided by the PCP; 3) the impact of practice infrastructure on the PCP's care; and 4) bereavement involvement. From the interviews we hypothesize that PCPs play a supportive and appreciated role while having limited involvement in decision making and care; an involved PCP acting with knowledge of a family may in some cases provide profound guidance, but that kind of involvement is not typical; and although there is an articulated role for the PCP with the parents' and siblings' bereavement, it is not routinely exercised.

CONCLUSIONS

The interviews suggest limited involvement by PCPs in care at the end of life and subsequent bereavement. Parents overall seem to accept this role. Further research is needed to examine these observations from the perspective of PCPs.

Caring for children dying from cancer at home: a qualitative study of the experience of primary care practitioners

BACKGROUND

The rarity of childhood cancers makes providing palliative care in the community an unusual event for primary care practitioners. Providing this care requires effective inter-professional collaboration with the team that forms to provide the care often working together for the first and only time.

OBJECTIVE

To explore the experiences of primary care practitioners following their involvement in the palliative care of a child with cancer at home.

METHODS

The study design was a community-based qualitative study. The study location was the West Midlands region. Purposeful sample of GPs and community nurses involved in providing palliative care to 12 children. One-to-one in-depth interviews with 47 primary care professionals (10 GPs and 37 community nurses) and 5 facilitated case discussions were undertaken. Field notes were documented and grounded theory data analysis undertaken: chronological comparative data analysis identifying generated themes.

RESULTS

GPs had minimal input into the preceding care of children undergoing treatment for cancer but sought to re-establish their role at the child's transition to palliative care. GPs felt they had a role to play and could add value to this phase of care, highlighted their continuing role with the child's family and acknowledged that they had gained from the experience of contributing. However, lack of specialist knowledge and uncertainty about their role within the team made this more challenging. In contrast, community nurses were routinely involved in both active treatment and palliation care phases. There was little evidence of collaboration between the specialist and primary care professionals involved. There was considerable variation in out of hours provision across cases.

CONCLUSIONS

Engaging primary care practitioners needs to be more actively anticipated and negotiated at the transition to palliation. Variation in out of hours care is another cause for concern. Enhancing inter-professional collaboration and planning during both active and palliative care phases may help.

Loving your child to death: Considerations of the care of chronically ill children and euthanasia in Emil Sher's Mourning Dove

How do parents cope when their child is ill or dying, and when he or she is experiencing constant pain or suffering? What do parents think of the contributions that medical professionals make to the care of their chronically or terminally ill child? Is it possible for a parent to love a child so much that they wish their child to be dead? The purpose of the present paper is to explore these questions and aspects of the care of chronically or terminally ill children using Mourning Dove's portrayal of one family's attempt to care for their ill daughter. Mourning Dove, a play written by Canadian playwright Emil Sher, was inspired by the case of Saskatchewan wheat farmer Robert Latimer who killed his 12-year-old daughter, Tracy, who suffered with cerebral palsy and had begun to experience tremendous pain. Rather than focusing on the medical or legal aspects of the care of a chronically ill child, the play offers a glimpse into how a family copes with the care of such a child and the effect the child's illness has on the family. The reading and examination of nonmedical literature, such as Mourning Dove, serves as a useful means for medical professionals to better understand how illness affects and is responded to by patients and their families. This understanding is a prerequisite for them to be able to provide complete care of children with chronic or terminal illnesses and their families.

Parental experiences of adult child death from cancer

BACKGROUND

Although parents experience the death of adult children diagnosed with cancer, most of the literature on adult child death has examined the issues of violent death or suicide. Where death from cancer has been studied, the focus has been mainly on psychological outcomes. Little is known about parents' experiences with this phenomenon.

OBJECTIVE

To understand parents' experience of having an adult child die from cancer.

DESIGN

Descriptive-exploratory study utilizing semistructured interviews with parents of 10 adult children who had died of cancer.

SETTING

Parents who had lost a child to cancer were interviewed in their own home or in the interviewer's office.

ANALYSIS

Interviews were recorded, transcribed, and analyzed. Latent content analysis and constant comparison techniques were used to develop coding labels, which were then classified into categories and subcategories.

RESULTS

Parents experienced a tension between their strong desire to "parent" their child, and their recognition that their child was an autonomous adult, sometimes with a spouse and family who took precedence over them. Parents of a dying child felt helpless, and sometimes were excluded/unacknowledged by health care professionals. To cope, they reconfigured their parent role using various strategies. After the death of their child further reconfiguring takes place, including preserving memories of the child, and talking about him/her. Continuing family and social relationships influence this stage.

CONCLUSION

The conflict of wishing to "parent" a dying adult child while recognizing the child's autonomy creates uncertainty for parents at an already stressful time. Facilitating parent-child communication during the illness is important. After the death of the adult child parents may continue to face difficulty with their perceived role in society (parent and/or bereaved person), and sometimes within their family. Health care professionals should make greater efforts to include the parents of the dying adult in the circle of care. The bereavement experience of these parents is intense and long-lasting. Further research is needed regarding the ways in which health care providers can best assist parents to successfully integrate this profound loss.

A study into the educational needs of children's hospice doctors: a descriptive quantitative and qualitative survey

OBJECTIVES

To identify and explore the educational needs of children's hospice doctors in England.

DESIGN

A descriptive quantitative and qualitative survey.

SETTING

Children's hospices in England.

PARTICIPANTS

All children's hospice doctors (n =55) in England were approached, and 35 (65%) consented.

INTERVENTIONS

A questionnaire designed to survey doctors' self-assessed educational competencies (confidence and perceived need for training) in subject areas derived from analysis of existing children's palliative care literature. Educational diaries used prospectively in practice to identify areas of unmet educational need.

MAIN OUTCOME MEASURES

Self-perceived confidence and usefulness scores for each subject area. An analysis of support, education and training needs deriving from educational diaries and one-to-one interviews.

RESULTS

Confidence and usefulness scores suggest that respondents would most value support, education and training in the management of emergencies, symptoms and physical disease. Educational diary analysis revealed that respondents would most value support, education and training in communication skills, team-working skills, and personal coping strategies.

CONCLUSIONS

There is a disparity between educational needs as derived from self-rated competencies and from educational diary keeping; suggesting that children's hospice doctors may not be fully aware of their own educational, support and training needs. Self-rated competencies emphasise the value of education in craft or clinical skills; whereas personal diary keeping emphasises the value of education in intrapersonal and interpersonal skills such as communication, team-working and personal coping skills. The current curricula and educational resources need to acknowledge that interpersonal and intrapersonal competencies are as important as clinical competencies. While the study looks particularly at the educational needs of children's hospice doctors, readers may feel that the findings are of relevance to all specialities and disciplines.

Palliative care in the community for children with cancer in South East England

In-depth interviews and discussions were held with 40 different professionals in South East England involved in managing palliative care for children with cancer in the community. Participants included paediatric oncologists and outreach nurse specialists in tertiary centres, paediatricians in shared care units, children's community nurses, general practitioners, social workers and child psychologists. The research examined palliative care services available in the region, exploring attitudes to both current provision and possible service improvements. Providing palliative care in the community involves multi-agency collaboration and the study highlighted a range of different approaches to case management with the diversity of resources available. Key improvements proposed by health-care professionals included: better communication and liaison between all the professionals involved; clearer allocation of roles and responsibilities; 24-hour availability of specialist advice on palliative care for children with cancer; faster access to social work and psychology services at the community level; continuity of nursing and respite care. The provision of specialist local palliative care services for children with cancer was generally rejected. The participants favoured improving community palliative care for all children with life-limiting or life-threatening conditions with community nursing teams providing continuity of care and outreach nurses providing specialist advice and support.

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.