Exploring fathers' experiences of caring for a child with complex care needs through ethnography and arts-based methodologies

BACKGROUND

Although the number of children living with complex care needs (CCN) is increasing worldwide, there is limited data on the experience of fathers caring for children with CCN. This paper reports on findings specific to fathers' experiences of caring for their child with CCN and highlights recommendations provided for parents of children with CCN, service providers, and policymakers. The findings emerged from a larger study designed to examine how Canadian families of children with CCN participate in society.

METHODS

We used the qualitative research approach of ethnography and arts-based methodologies (ecomaps and photovoice) as well as purposive and snowball sampling techniques. Four parents were engaged as advisors and twenty-nine fathers participated in interviews (all were married or in a relationship; age range of 28 to 55 years). In line with an ethnographic approach, data analysis involved several iterative steps including comparing data from the first, second, and third set of interviews and refining themes.

RESULTS

One overarching theme, striving to be there for the child with CCN, was identified. Five supporting themes further exemplified how fathers strived to be there for their child: 1) contributing to the parental team through various roles; 2) building accessibility through adaptation; 3) engaging in activities with the child; 4) expressing admiration and pride in their children; and 5) meaning making. Recommendations for parents included making and nurturing connections and asking for help while recommendations for healthcare and social service providers included communicating authentically with families and listening to parents. Fathers also indicated that leadership and funding for programs of families of children with CCN should be priorities for policymakers.

CONCLUSIONS

In addition to documenting fathers' active involvement in their child's care and development, our findings provide new insights into how fathers make participation in everyday life accessible and inclusive for their children. Study findings also point to 1) priority areas for policymakers (e.g., accessible physical environments); 2) factors that are critical for fostering collaborative care teams with fathers; and 3) the need for complex care teams in the adult health care system. Implications for those providing psychosocial support for these families are noted as well as knowledge gaps worthy of future exploration such as the role of diversity or intersectionality in fathering children with CCN.

Palliative care nurse: A quantitative study of caring for neonates at end-of-life stage

Objective

This study aimed to evaluate the quality of the care provided to newborns at End-of-Life (EOL) stages and compare the care which is already being given to the infants admitted to the NICUs of the selected hospital in (XXX) with the existing standards. Knowing how End-of-Life nursing care is provided, compared with the standard in the terminal stage of neonates’ life can provide accurate information for policies, research, and educational practices.

Methods

In this descriptive study, 100 nursing care services, provided to neonates at the EOL stages and their parents, were observed and compared to the standard checklist which had been developed based on the literature review and existing standards in 2015. The study setting included the NICUs of the four hospitals affiliated to (XXX) The Content and Face Validity of the checklist were determined based on specialists’ comments. The Content Validity Index was 94.85%, and its reliability was evaluated too through the inter-rater correlation coefficient (ICC = 0.715).

Results

Only 11.49% of EOL nursing care services were given properly and 77.92% were not given at all. Results showed that 10.59% of EOL nursing care services were performed improperly.

Conclusion

The overall rate of accordance with the EOL nursing care standards was poor (16.78%). Nursing care given to infants and their parents at EOL stages is far from the standards. This can be due to various reasons, such as inadequate training and the lack of comprehensive guidelines.

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Knowing how End-of-Life nursing care is provided, comparing with the standard in the terminal stage of neonates' life.

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The overall rate of accordance with the EOL nursing care standards was poor (16.78%).

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Nursing care given to infants and their parents at EOL stages is far from the standards.

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This can be due to various reasons, such as inadequate training and the lack of comprehensive guidelines.

Stuck Moments and Silver-Linings: The Spectrum of Adaptation Among Non-Bereaved and Bereaved Parents of Adolescents and Young Adults With Advanced Cancer

CONTEXT

With advances in treatments that have resulted in children living longer with serious illness, it is essential to understand how parents adapt to changes during the final stages of their child's life or after their child's death.

OBJECTIVE

To examine the process by which parents adapt to their child's serious illness and death among a group of non-bereaved and bereaved parents of adolescents and young adults (AYAs) with advanced cancer.

METHODS

Qualitative study exploring the experiences of parents of AYAs who were being treated for recurrent or refractory advanced cancer (nonbereaved parents) or had died from their disease (bereaved parents) at one large academic center. Participants completed demographic surveys and semi-structured interviews to better understand parent adaptation. Data were analyzed using content and thematic approaches.

RESULTS

Of the 37 participating parents; 22 (59%) were non-bereaved and 15 (41%) were bereaved. The AYAs predominantly had hematologic malignancies (n = 18/34, 53%). Across both cohorts, parents described the process of adapting to their child's worsening health or death as moments of feeling stuck and moments of gratitude and meaning.

CONCLUSION

Adaptation to a child's serious illness and death likely occurs on a dynamic spectrum and parents may oscillate both cognitively and emotionally. This has important implications for how clinicians and communities support parents. Greater comfort with and normalization of the adaptation process may enable parents to more openly share both the unimaginable hardships and unexpected silver-linings that are part of their parenting experiences during their child's illness and death.

The Parental Experience of Unexpectedly Losing a Child in the Pediatric Emergency Department

Child loss is the most traumatic loss a parent can experience, increasing their risk of negative outcomes such as complicated grief. Unexpected loss in the unfamiliar environment of the Emergency Department (ED) significantly increases this risk. Despite this knowledge, research on child loss in the context of the ED is scarce. An interpretive description qualitative research study was performed with eight parents (five mothers and three fathers) to examine their experience of unexpectedly losing a child in the pediatric ED. Data collection included interviews, demographic questionnaires, and field notes. Data were analyzed using a constant comparative method and revealed four main themes: "grief as waves," "being the good parent," "coping through the waves of grief," and "the new normal." Improving understanding around child loss and implementing stronger support for parents, through communication, advocacy, and physical presence while in the ED, could greatly reduce parents' risk of negative outcomes.

Bereaved Family Members' Views of the Value of Coronial Inquests Into Fatal Work Incidents

Fatal work incidents result in an array of government responses, and in countries such as the United Kingdom and Australia, this may include the holding of coronial inquests. A common theme from the scant literature is that family members have a strong need to know how and why their loved one died. The inquisitorial nature of inquests suggests potential in uncovering this information, although little is known about families' experiences with these proceedings. Interviews with 40 bereaved relatives explored their views and experiences of inquests. Findings suggest that families, often frustrated with other investigative processes, want inquests to provide a better understanding of how and why the death occurred, uncover any failings/responsibilities, and thereby move closer to a sense of justice being obtained for the deceased. Families identified problems perceived to impair the process and where improvements could be made to secure a more effective and meaningful institutional response to the fatality.

Physicians’ conceptualization of “Closure” as A benefit of Physician-Parent Follow-Up Meetings after A Child's Death in the Pediatric Intensive Care Unit

We examined physicians’ conceptualization of closure as a benefit of follow-up meetings with bereaved parents. The frequency of use and the meaning of the word “closure” were analyzed in transcripts of interviews with 67 critical care physicians affiliated with the Collaborative Pediatric Critical Care Research Network. In all, 38 physicians (57 percent) used the word “closure” at least once (median: 2; range: 1 to 7), for a total of 86 times. Physicians indicated that closure is a process or trajectory rather than an achievable goal. They also indicated that parents and physicians can move toward closure by gaining a better understanding of the causes and circumstances of the death and by reconnecting with, or resolving relationships between, parents and health professionals. Physicians suggested that a primary reason to conduct follow-up meetings is that such meetings offer parents and physicians an opportunity to move toward closure. Future research should attempt to determine whether follow-up meetings reduce the negative effects of bereavement for parents and physicians.

Bereaved parents' experiences of research participation

Background

As understandings of the impacts of end-of-life experiences on parents’ grief and bereavement increase, so too does the inclusion of bereaved parents into research studies exploring these experiences. However, designing and obtaining approval for these studies can be difficult, as guidance derived from bereaved parents’ experiences of the research process are limited within the current literature.

Methods

We aimed to explore bereaved parents’ experiences of research participation in a larger grounded theory study exploring experiences of the death of a child in the paediatric intensive care unit. Data were obtained during follow-up phone calls made to 19 bereaved parents, five of whom provided data from their spouse, 1 week after their participation in the study. Participants were asked to reflect on their experiences of research participation, with a focus on recruitment methods, timing of research contact, and the location of their interview. Parents’ responses were analysed using descriptive content analysis.

Results

Our findings demonstrate that despite being emotionally difficult, parents’ overall experiences of research participation were positive. Parents preferred to be contacted initially via a letter, with an opt in approach viewed most favourably. Most commonly, participants preferred that research contact occurred within 12–24 months after their child’s death, with some suggesting contact after 6 months was also appropriate. Parents also preferred research interviews conducted in their own homes, though flexibility and parental choice was crucial.

Conclusions

Findings from this study offer further insight to researchers and research review committees, to help ensure that future studies are conducted in a way that best meets the unique needs of bereaved parents participating in research.

"A Mixed Blessing": Social Support as a Coping Resource for Parents Who Lost a Child in Terrorist Attacks in Israel

This article deals with the issue of perceived social support among 40 bereaved parents who have lost a child in a terrorist attack in Israel. The aim is to gain a better understanding of the nature and quality of the formal and informal support that the parents received. The parents were interviewed using semistructured in-depth interviews. The content analysis revealed that alongside the positive aspects, the parents also emphasized the negative side of the encounter with the social environment. The positive aspects included feeling of appreciation for the assistance in the coping process. The negative aspects included a sense of abandonment and distress. The dialectic nature of the domain, together with a recognition of its importance, points to the need to reconcile between the desire on the part of the social environment to assist the bereaved parent on one hand and ways to implement it on the other hand.

Best Practice in Provider/Parent Interaction

In this 3-year prospective grounded theory study in three pediatric settings, we aimed to develop a conceptualization of best practice health care providers (BPHCPs) in interaction with parents of children with complex, chronic, life-threatening conditions. Analysis of semistructured interviews with 34 parents and 80 health care professionals (HCPs) and 88 observation periods of HCP/parent interactions indicated that BPHCPs shared a broad worldview; values of equity, family-centered care, and integrity; and a commitment to authentic engagement. BPHCPs engaged in direct care activities, in connecting behaviors, and in exquisitely attuning to particularities of the situation in the moment, resulting in positive outcomes for parents and HCPs. By focusing on what HCPs do well, findings showed that not only is it possible for HCPs to practice in this way, but those who do so are also recognized as being the best at what they do. We provide recommendations for practice and initial and ongoing professional education.

Holocaust memory reconstruction among bereaved parents

Many studies have examined the trauma bereaved parents experience. The current study focuses on the role that the Holocaust's memory plays in the bereavement experience of parents who have lost a child in a terrorist attack in Israel. Forty bereaved parents were interviewed, using semistructured in-depth interviews. Bereaved parents related to the Holocaust memory as a meaningful experience in their private bereavement. The parents expressed dialectic feelings concerning their loss, personal victimization on the one hand and personal strength, and growth on the other hand. It seems that memory reconstruction of the Holocaust can be used as a coping resource.

A New State of Being

In spite of growing bereavement literature, the meaning of the lived experience of parental bereavement is not well understood. This article presents selected findings from a Heideggerian hermeneutic phenomenological study which aimed to describe the lived experience of bereaved parents who experienced the death of a child due to cancer. Conversational interviews were conducted with six parents who experienced the death of a young child due to cancer at least one year prior to participation. The nature of parental bereavement was revealed to be a new state of being into which parents enter immediately after the death of a child and which has no end point. Findings will equip health professionals and others who work with bereaved parents with a deeper understanding of the meaning of parental bereavement.

Fathers’ Experience After the Death of Their Child (Aged 1–17 Years)

The death of a child is traumatic for parents. The grief of bereaved fathers is inadequately understood since most studies on this subject have focused primarily on mothers. The goal of this phenomenological study was to understand fathers’ experiences following the death of their child. Interviews were conducted with 13 fathers whose child (aged 1–17 years) had died at least 1 and up to 6 years earlier, either from a life-limiting illness or unexpectedly in an intensive care unit in a pediatric hospital in Eastern Canada. The analysis indicates that fathers’ experience deep suffering after the death of their child and feel torn between the past and the future. Three major themes were identified: needing to push forward in order to avoid breakdown, keeping the child present in everyday life, and finding meaning in their experience of grief. Clinical implications for professionals working with this population are discussed.

Why Do Parents Want to Know their Child's Carrier Status? A Qualitative Study

When a child is identified with a genetic condition, some parents want to know the carrier status of their other children. There has been little exploration of why parents want this information. To address this question, semi-structured interviews were conducted with parents of 32 children with cystic fibrosis, haemophilia, and Duchenne muscular dystrophy who wanted to know the carrier status of their other children. Data was analyzed using inductive content analysis. Parents expressed a range of reasons for desiring their child's carrier status, which fell into two broad categories: 1) benefit for the parents and 2) perceived benefit to the child. Parents discussed the desire for certainty and peace of mind derived from having knowledge of their child's status. The most commonly expressed reason for wanting to know their child's carrier status was in order to communicate the information to their child to provide them with the ability to make informed reproductive decisions. These reasons suggest parents are seeking their children's carrier information both as a coping strategy and to communicate carrier information as part of their role as a parent. This has important implications for genetic counseling practice, especially as international guidelines generally recommend against carrier testing in children.

Adverse outcomes in bereaved mothers: The importance of household income and education

Intense and enduring psychological distress has been well-documented in numerous studies on bereaved parents including anxious, depressive, and traumatic stress symptoms. A state of poverty is also known to increase the risk of psychological distress in the general population, yet this variable has not yet been sufficiently evaluated in outcomes specifically for bereaved parents. This study is the first to investigate poverty, education, and parental bereavement while examining the relative risk of other variables as informed by the literature. The findings reveal that poverty was the strongest predictor of psychological distress when compared to others factors which have traditionally been considered significant in parental bereavement. Bereaved parents living in poverty may be less likely to seek support and have fewer available resources. Practice and policy implications are discussed.

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What is known on the subject:•

Anxious, grief-related depressive and traumatic stress symptoms are common in bereaved parents following the death of their child 90.

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What this paper adds to existing knowledge:•

People who had lower incomes had higher levels of anxiety, depression and posttraumatic stress.

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The implications for policy and practice:•

Parents with low incomes and low levels of education may not be able to access support following their loss.

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Providers and policy makers should aim to identify if other stressors are contributing to distress rather than focus solely on diagnoses related to loss.

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No cost broader bereavement services may be important to consider for those living in poverty.

Protocol: Evaluating the impact of a nation-wide train-the-trainer educational initiative to enhance the quality of palliative care for children with cancer

BACKGROUND

There are identified gaps in the care provided to children with cancer based on the self-identified lack of education for health care professionals in pediatric palliative care and in the perceptions of bereaved parents who describe suboptimal care. In order to address these gaps, we will implement and evaluate a national roll-out of Education in Palliative and End-of-Life Care for Pediatrics (EPEC®-Pediatrics), using a 'Train-the-Trainer' model.

METHODS/DESIGN

In this study we are using a pre- post-test design and an integrated knowledge translation approach to assess the impact of the educational roll-out in four areas: 1) self-assessed knowledge of health professionals; 2) knowledge dissemination outcomes; 3) practice change outcomes; and 4) quality of palliative care. The quality of palliative care will be assessed using data from three sources: a) parent and child surveys about symptoms, quality of life and care provided; b) health record reviews of deceased patients; and c) bereaved parent surveys about end-of-life and bereavement care. After being trained in EPEC®-Pediatrics, 'Master Facilitators' will train 'Regional Teams' affiliated with 16 pediatric oncology programs in Canada. Each team will consist of three to five health professionals representing oncology, palliative care, and the community. Each team member will complete online modules and attend one of two face-to-face conferences, where they will receive training and materials to teach the EPEC®-Pediatrics curriculum to 'End-Users' in their region. Regional Teams will also choose a Tailored Implementation of Practice Standards (TIPS) Kit to guide implementation of a quality improvement project in their region; support will be provided via quarterly meetings with Co-Leads and via a listserv and webinars with other teams.

DISCUSSION

Through this study we aim to raise the level of pediatric palliative care education amongst health care professionals in Canada. Our study will be a significant step forward in evaluation of the impact of EPEC®-Pediatrics both on dissemination outcomes and on care quality at a national level. Based on the anticipated success of our project we hope to expand the EPEC®-Pediatrics roll-out to health professionals who care for children with non-oncological life-threatening conditions.

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.

The central role of meaning in adjustment to the loss of a child to cancer: implications for the development of meaning-centered grief therapy

PURPOSE OF REVIEW

This review describes research on meaning and meaning-making in parents who have lost a child to cancer, suggesting the need for a meaning-centered therapeutic approach to improve their sense of meaning, purpose, and identity and help with management of prolonged grief symptoms.

RECENT FINDINGS

Several studies have demonstrated that parents bereaved by cancer experience unique meaning-related challenges associated with the caregiving and illness experience, including struggles with making sense of their loss, benefit-finding, their sense of identity and purpose, disconnection from sources of meaning, and sustaining a sense of meaning in their child's life. Meaning-centered grief therapy, adapted from meaning-centered psychotherapy, directly addresses these issues, highlighting the choices parents have in how they face their pain, how they honor their child and his/her living legacy, the story they create, and how they live their lives.

SUMMARY

Given the important role that meaning plays in adjustment to the loss of a child to cancer, a meaning-focused approach such as meaning-centered grief therapy may help improve parents' sense of meaning and grief symptoms. It seems particularly appropriate for parents who lost a child to cancer because it does not pathologize their struggles and directly targets issues they frequently face.

Parents' experiences of healthcare provider actions when their child dies: an integrative review of the literature

PURPOSE

To review, critique and synthesise current research studies that examine parental perceptions of healthcare provider actions during and after the death of a child.

CONCLUSIONS

Five main themes were synthesised from the literature: staff attitudes and affect; follow-up care and ongoing contact; communication; attending to the parents; and continuity of care.

PRACTICE IMPLICATIONS

This review helps to identify important aspects of paediatric end-of-life care as recognised by parents, with the intention of placing the family at the centre of any future end-of-life care education or policy/protocol development.

Changes in parental self-identity following the death of a child to cancer

This study explored parental self-identity at 6, 12, and 18 months following the death of a child to cancer. Semi-structured interviews were analyzed using qualitative methodology. Two patterns of parental self-identity emerged: identity reintegration, characterized by 6 associated themes (e.g., positive reframing, focusing on surviving children); and identity disintegration, characterized by 7 associated themes (e.g., negative perceptions of social support, self-destructive thoughts and behaviors). Patterns were stable from 6 to 12 months, but a shift towards identity disintegration was observed at 18 months. These findings suggest a need to support bereaved parents' well-being beyond the first year post-death.

Impact of research participation on parents of seriously ill children

BACKGROUND

There is a paucity of research evidence to guide health care providers' practice in pediatric palliative care. At the same time, some clinicians and Institutional Review Boards are reluctant to approve such studies because of concerns about further burdening families. Yet, there is some evidence that research participation can have positive effects for families.

OBJECTIVE

To obtain parents' perceptions about their experience of participating in one of two research studies.

DESIGN

Descriptive, quantitative survey.

SETTING/SUBJECTS

Caregivers of children with life-threatening conditions (n=323) who were caring for the child at home.

MEASUREMENTS

Researcher-designed Impact of Participation questionnaire.

RESULTS

Few differences between the two groups were found on Impact responses. Not a single parent reported regretting participating in their study and almost all (96.3%) reported that conducting research about family's experiences in pediatric palliative care had value. Just over three-quarters (76.2%) did not find participation at all painful, and 73.7% reported that participation was about as painful as expected, with 23.2% reporting less painful. Approximately half (50.5%) said that participation had at least some positive effect and only three parents reported any negative effect. An overwhelming majority (93.4%) would recommend participation to other parents in a similar situation.

CONCLUSIONS

Participation in research for families with children who have a life-threatening condition is not only acceptable to parents, but may in fact have a positive effect. Although clinicians and Institutional Review Boards may be hesitant to fully support such research, it is clear that conducting research in the field of pediatric palliative care is important.

Effect of having a subsequent child on the mental health of women who lost a child in the 2008 Sichuan earthquake: a cross-sectional study

OBJECTIVE

To assess whether having a subsequent child had an effect on the mental health of Chinese mothers who lost a child during an earthquake.

METHODS

A cross-sectional survey of bereaved mothers was conducted 30 to 34 months after the 2008 Sichuan earthquake using individual structured interviews to assess sociodemographic characteristics, post-disaster experiences and mental health. The interviews incorporated standardized psychometric measures of anxiety, depression, post-traumatic stress disorder (PTSD) and complicated grief (CG). Social support was also assessed. An adjusted model taking potential confounders into account was used to explore any association between psychological symptoms and the birth of a subsequent child.

FINDINGS

The prevalence of psychological symptoms was higher in mothers who did not have a child after losing the first one. In an adjusted model, symptoms of anxiety (odds ratio, OR: 3.37; 95% confidence interval, CI: 1.51-7.50), depression (OR: 9.47; 95% CI: 2.58-34.80), PTSD (OR: 5.11; 95% CI: 2.31-11.34) and CG (OR: 10.73; 95% CI: 1.88-61.39) were significantly higher among the 116 women without a subsequent child than among the 110 mothers who had another child after bereavement. More than two thirds of the mothers with new infants had clinically important psychological symptoms.

CONCLUSION

Women who have lost an only child in a natural disaster are especially vulnerable to long-term psychological problems, especially if they have reached an age when conception is difficult. Research should focus on developing and evaluating interventions designed to provide women with psychosocial support and reproductive services.

When Grief Turns Into Love

A child’s death caused by cancer generates a deep impact on his/her parents, who can be affected by serious health problems due to an impairment of their lifestyle. Notwithstanding their suffering, some parents manage to overcome it and discover a new meaning for their lives. The goal of this phenomenological study is to understand the lived experiences that help parents to revive after the death of their child due to cancer. The participants were fathers and mothers who believe that they have elaborated their mourning. Their lived experiences were collected in interviews they had previously agreed to give. The question that steered the interview was: “What is the experience you went through that helped you to revive after your child died due to cancer?” Data were analyzed using Streubert’s method. Analyzing the interviews of the participants, 3 interweaved essences were detected: transition from surviving to reviving themselves; ascribing a sense and meaning to the life, agony, and death of a child; and helping other parents through one’s own experience.

Psychological and social consequences of losing a child in a natural or human-made disaster: a review of the evidence

Exposure to natural and human-made disasters is associated with long-term health consequences, including for mental health. Parents who have lost children, particularly their only children, in any circumstances are also at increased risk of developing mental health problems. The aim of this study was to review the available evidence about the psychological and social consequences for parents who had faced these circumstances simultaneously through losing children in a disaster. Systematic searching of the English and Chinese language literatures about the psychological and social functioning of bereaved parents after disasters revealed that a small number of studies met inclusion criteria. The results showed that bereaved parents had more mental health problems than bereaved spouses and non-bereaved parents, and mothers appeared to be more vulnerable to mental health problems than fathers. Potential protective factors for bereaved parents' mental health included having psychological interventions, having adequate social support, seeing their children's bodies and having a subsequent baby. Although the literature was modest and methodologically diverse, there was a consistent finding that parents who have lost children in disasters were at high risk of suffering mental health problems, especially bereaved mothers. As there was little evidence, further studies are needed to understand the best advice and interventions to offer bereaved parents and provide enhanced mental health care of such bereaved populations after disasters.

Parents' thoughts and perceptions on hearing that their child has incurable cancer

BACKGROUND

Parents of children with incurable cancer face difficulties in making end-of-life decisions, and thus far, little research has been conducted on the thoughts and perceptions of these parents.

PURPOSE

The study aims to describe parental thoughts and perceptions when they hear that their child has incurable cancer.

METHODS

Semi-structured, open-ended interviews were conducted with 23 parents who had lost children to cancer. A constant comparative content analysis was also conducted.

RESULTS

Regarding parental thoughts, five categories emerged: "not allowing my child to die," "being compelled to continue cancer-directed/life-sustaining treatment," "wanting to put an end to my child's suffering and wanting him/her to be comfortable," "valuing my child's wish and dignity," and "wanting to be there for my child." However, some parents did not mention all five categories. Regarding parental perceptions of their children's condition, six categories emerged: "understanding change/deterioration of my child's condition," "recognition of my child's sufferings," "awareness of the possible death of my child," "no recognition of my child's impending death as reality," "avoiding facing my child's death," and "realizing the truth and coming to terms with the reality of death."

CONCLUSION

When parents were told that their child had incurable cancer, their first thought was to protect their child. Because thoughts and perceptions in such a situation vary across parents, health care professionals should support parents in realizing their thoughts and perceptions and in making decision as parents.

Living with the loss of a child: Mothers in the criminal justice system

Objective:

Bereaved mothers have expressed the need to maintain a bond with their children who have died, to retain control over the funeral rituals, and to express their loss to others who are empathetic. This study describes grief over the loss of a child in women who have been or are currently incarcerated, and the influence of the women's family members.

Method:

This descriptive qualitative study consisted of open-ended interview questions to encourage the women to describe their experience in their own words. A purposive sample (N = 10) was recruited from a prison re-entry program and a county jail.

Results:

All of the participants described maladaptive responses such as the use of alcohol and drugs, restricted family support, and dysfunctional coping. None of the participants had received focused bereavement services.

Significance of Results:

The descriptive perspective from the participants can inform clinicians who work with women who have a history of involvement with the criminal justice system, and recommends that they should inquire about the women's children and experiences with loss. Community re-entry and jail/prison counselors should provide access to confidential and group-based therapeutic support, including Compassionate Friends.

"Almost the copy of my child that's dead": Shakespeare and the loss of Hamnet

This article emphasizes the importance of studies which look at changes and similarities in mourning over time. It argues that relevant evidence can come from creative fiction as well as from other sources, provided that this is analyzed rigorously in terms of structures and patterns. As an illustration of this approach, it examines the evidence in recurring features of Shakespeare's plays that his writing was deeply and lastingly affected by the death of his only son Hamnet, a twin, at the age of 11, and identifies five motifs which support this interpretation: the resurrected child or sibling; androgynous and twin-like figures; a growing emphasis on father-daughter relationships; paternal guilt; family division and reunion. The article suggests that this approach could be applied to other instances where a body of creative writing shows traces of overt or buried grief.

The complexity of couple communication in bereavement: an illustrative case study

Sharing grief experiences, or "storying"grief can be a key resource in adapting to loss, one that can contribute to stronger bonds and relational intimacy within the family. In this article, the authors conceptualize communication between grieving family members in terms of 3 "D" processes, emphasizing the extent to which such communication is dialectic, dialogic, and dynamic in nature. They illustrate the complexity of sharing about a mutual loss, focused on these 3 features, by referring to a case study of a couple coping with the death of a child in the context of a newly formed family. Rather than unilaterally advocating the promotion of open communication, the authors suggest that therapists working with bereaved families first discuss the complexities of communication with the family members, specifically those concerning talking and keeping silent, and explore the different meanings associated with sharing grief experiences with each other.

Parental perceptions of end-of-life care on paediatric intensive care units: a literature review

AIM AND OBJECTIVE

The aim of this study was to review the literature relating to parental perceptions on what constitutes quality end-of-life care (ELC) at the time of their child's death in paediatric intensive care units (PICUs).

BACKGROUND

There are few issues in medicine as complex as those involving ELC provision and within paediatric intensive care, these decisions are particularly emotive. Improving the quality of ELC has become a national priority and an understanding of the reality of parents during and after the loss of a child is a mandatory step in achieving this. Efforts to improve ELC in PICU must be based on an understanding of the issues and problems that are unique to parents within this environment and cannot simply be extrapolated from other settings. It is imperative that this has a high priority in training, clinical practice and research for all members of the intensive care team.

SEARCH STRATEGY

Databases were systematically searched to identify primary research that related specifically to parental needs during the death of their child on PICU and published between 2000 to the present.

CONCLUSIONS

Although the retrospective nature of the studies reviewed presents some limitations, it does provide a broad overview of the characteristics of parental needs, indicating the scope for further empirical research. The identification and acknowledgement of the fundamental needs of parents at this time can enable health professionals to provide competent and compassionate ELC which is as focussed and evidence based as other aspects of paediatric critical care medicine.

Informing parents about the actual or impending death of their infant in a newborn intensive care unit

Modern perinatal and neonatal care practices have increased survival of infants that in previous care eras would have perished. The majority of infants admitted to a newborn intensive care unit following delivery currently do well and are discharged home. Unfortunately for others, the ultimate outcome may be death. The death of a newborn infant is clearly a devastating loss to parents. How parents are informed of their infant's actual or impending death can either add to a grief reaction, or help support parents through their loss. The literature supports that most healthcare professionals frequently feel inept while discussing the death of a newborn with the baby's family. This article will present parents' descriptions of what helped or did not help when they were informed of their infant's inevitable death. It will also demonstrate how simulation may be effective in improving communication of bad or sad news to families in a manner that sustains them in the immediate present, as well as adds to their future well-being.

Parents' experiences in decision making with childhood cancer clinical trials

Childhood cancer requires families to deal with many stressors, including decision making in terms of their child's treatment. Adding to the stress of families is that most children participate in clinical research trials. Minimal research has been done to explore parents' decisions related to involving their child in childhood cancer clinical trials. Especially missing is a description of Canadian parents' perspectives. This article describes a qualitative study that sought to understand Canadian parents' participation in decisions about childhood cancer clinical trials. Person-centered, individual, open-ended interviews were conducted with 31 parents of children with cancer. The parents ranged in age between 27 and 51 years. Data analyzed by the constant comparative method revealed that parents found their participation in decisions about childhood cancer clinical trials as a difficult and extraordinary experience that included 6 themes: (1) living a surreal event, (2) wanting the best for my child, (3) helping future families of children with cancer, (4) coming to terms with my decision, (5) making one decision among many, and (6) experiencing a sense of trust. This study indicates that parents need more support not only during the initial decision-making period but also throughout the entire time their child is enrolled in a clinical trial.

Designing and implementing a longitudinal study of children with neurological, genetic or metabolic conditions: charting the territory

Background

Children with progressive metabolic, neurological, or chromosomal conditions and their families anticipate an unknown lifespan, endure unstable and often painful symptoms, and cope with erratic emotional and spiritual crises as the condition progresses along an uncertain trajectory towards death. Much is known about the genetics and pathophysiology of these diseases, but very little has been documented about the trajectory of symptoms for children with these conditions or the associated experience of their families. A longitudinal study design will help to close this gap in knowledge.

Methods/Design

Charting the Territory is a longitudinal descriptive, correlational study currently underway with children 0-19 years who are diagnosed with progressive neurological, metabolic, or chromosomal conditions and their families. The purpose of the study is to determine and document the clinical progression of the condition and the associated bio-psychosocial-spiritual experiences of the parents and siblings age 7-18 years. Approximately 300 families, both newly diagnosed children and those with established conditions, are being recruited in six Canadian cities. Children and their families are being followed for a minimum of 18 months, depending on when they enroll in the study. Family data collection will continue after the child's death if the child dies during the study period. Data collection includes monthly parental assessment of the child's symptoms; an annual functional assessment of the child; and completion of established instruments every 6 months by parents to assess family functioning, marital satisfaction, health status, anxiety, depression, stress, burden, grief, spirituality, and growth, and by siblings to assess coping and health. Impact of participation on parents is assessed after 1 year and at the end of the study. Chart reviews are conducted at enrollment and at the conclusion of the study or at the time of the child's death.

Discussion

Knowledge developed from this study will provide some of the first-ever detailed descriptions of the clinical symptom trajectory of these non-curable progressive conditions and the bio-psychosocial-spiritual aspects for families, from diagnosis through bereavement. Information about developing and implementing this study may be useful to other researchers who are interested in designing a longitudinal study.

Pediatric palliative care

Palliative care has always been a part of the care of children. It includes any intervention that focuses on relieving suffering, slowing the progression of disease, and improving quality of life at any stage of disease. In addition, for even the child with the most unpredictable disease, there are predictable times in this child's life when the child, family, and care team will be suffering in ways that can be mitigated by specific interventions. Rather than defining pediatric palliative care in terms of a patient base, severity of disease, or even a general philosophy of care, palliative care can best be understood as a specific set of tasks directed at mitigating suffering. By understanding these tasks; learning to identify predictable times and settings of suffering; and learning to collaborate with multidisciplinary specialists, use communication skills, and identify clinical resources, the pediatrician can more effectively support children with life-threatening illnesses and their families. In this article, we define palliative care as a focus of care integrated in all phases of life and as a set of interventions aimed at easing suffering associated with life-threatening conditions. We detail an approach to these interventions and discuss how they can be implemented by the pediatrician with the support of specialists in hospice and palliative medicine. We discuss common and predictable times of suffering when these interventions become effective ways to treat suffering and improve quality of life. Finally, we discuss those situations that pediatricians most commonly and intensely interface with palliative care-the care of the child with complex, chronic conditions and severe neurologic impairment (SNI).

Gender imbalance in pediatric palliative care research samples

We assessed the sampling performance of research on parental perspectives in pediatric palliative care and examined if and how gender imbalance was treated. We undertook a systematic review of parental perspectives research in pediatric palliative care using MEDLINE, CINAHL, and PsycINFO. Study selection inclusion criteria were: (1) published between 1988 and 2008; (2) in English; (3) conducted in North America; (4) focused on parents of children aged 0-18 years who were expected to die or had died; (5) had 'parent' in the title; and (6) focused on parents' experiences or on parents' perspectives regarding the child's illness/death. Keyword searches produced a list of 2103 studies, of which 45 met the criteria for inclusion. The ratio of mothers to fathers participating in the studies was examined. We found that there has been an increase in research on parental perspectives in pediatric palliative care over the last 5 years, but what constitutes 'parental' in this literature continues to be primarily 'maternal'. Mothers constituted 75% of the overall sample of parents. In only four studies was the gender imbalance addressed as one of the limitations of the study. There is a growing interest in parental perspectives in pediatric palliative care, but the research does not equally reflect the experiences and needs of mothers and fathers. Gender can shape experiences of both parenthood and grief; balanced gender sampling and accurate analysis is essential for research on 'parental perspectives'. Gender imbalance in research samples, designs, recruitment strategies, and data gathering methods must be addressed.

Giving birth to life--again!: bereaved parents' experiences with children born following the death of an adult son

This article is based on a qualitative study examining the experiences of parents that lost a son during military service in Israel and consequently choose to give birth to another child. Seven couples and 3 mothers were interviewed for the study, and their interviews were analyzed using a phenomenological-hermeneutic approach. Three main themes were extracted from parents' descriptions of their experiences: (a) "From the place where pain and sadness was sown, a new smile was grown," relating to transforming the experience of loss into a new meaning for life; (b) "No to a child memorial," focusing on parents' awareness of the burden placed on the child who was born; and (c) "Different parenting," dealing with participant's parenting following their loss. The study's findings are discussed in the context of literature dealing with reconstructing meaning through coping and bereavement.

What makes a phenomenological study phenomenological? An analysis of peer-reviewed empirical nursing studies

This article contributes to the debate about phenomenology as a research approach in nursing by providing a systematic review of what nurse researchers hold as phenomenology in published empirical studies. Based on the assumption that presentations of phenomenological approaches in peer-reviewed journals have consequences for the quality of future research, the aim was to analyze articles presenting phenomenological studies and, in light of the findings, raise a discussion about addressing scientific criteria. The analysis revealed considerable variations, ranging from brief to detailed descriptions of the stated phenomenological approach, and from inconsistencies to methodological clarity and rigor. Variations, apparent inconsistencies, and omissions made it unclear what makes a phenomenological study phenomenological. There is a need for clarifying how the principles of the phenomenological philosophy are implemented in a particular study before publishing. This should include an articulation of methodological keywords of the investigated phenomenon, and how an open attitude was adopted.

"Trying to be a good parent" as defined by interviews with parents who made phase I, terminal care, and resuscitation decisions for their children

PURPOSE

When a child's cancer progresses beyond current treatment capability, the parents are likely to participate in noncurative treatment decision making. One factor that helps parents to make these decisions and remain satisfied with them afterward is deciding as they believe a good parent would decide. Because being a good parent to a child with incurable cancer has not been formally defined, we conducted a descriptive study to develop such a definition.

METHODS

In face-to-face interviews, 62 parents who had made one of three decisions (enrollment on a phase I study, do not resuscitate status, or terminal care) for 58 patients responded to two open-ended questions about the definition of a good parent and about how clinicians could help them fulfill this role. For semantic content analysis of the interviews, a rater panel trained in this method independently coded all responses. Inter-rater reliability was excellent.

RESULTS

Among the aspects of the definition qualitatively identified were making informed, unselfish decisions in the child's best interest, remaining at the child's side, showing the child that he is cherished, teaching the child to make good decisions, advocating for the child with the staff, and promoting the child's health. We also identified 15 clinician strategies that help parents be a part of making these decisions on behalf of a child with advanced cancer.

CONCLUSION

The definition and the strategies may be used to guide clinicians in helping parents fulfill the good parent role and take comfort afterward in having acted as a good parent.

Working with Children in End-of-Life Decision Making

Traditionally, physicians and parents made decisions about children’s health care based on western practices. More recently, with legal and ethical development of informed consent and recognition for decision making, children are becoming active participants in their care. The extent to which this is happening is however blurred by lack of clarity about what children — of diverse levels of cognitive development — are capable of understanding. Moreover, when there are multiple surrogate decision makers, parental and professional conflict can arise concerning children’s ‘best interest’. Giving children a voice and offering choice promotes their dignity and quality of life. Nevertheless, it also presents with many challenges. Case studies using pseudonyms and changed situational identities are used in this article to illuminate the complexity of ethical challenges facing nurses in end-of-life care with children and families.

Bereaved parents' experiences of the use of 'cold bedrooms' following the death of their child

INTRODUCTION

Children's hospices have the facilities to enable a child to remain at the hospice following their death until the time of the funeral if desired by the family. The use of cold bedrooms (or beds) to reduce the rate of the body's physical deterioration enables the family to have unrestricted access and close proximity to the child throughout the 24-hour period.

AIM

To explore how bereaved families experience the child remaining in a cold bedroom following the child's death in the period January 2002-March 2005.

OBJECTIVE

To survey all the families whose child had been cared for in a cold bedroom in one children's hospice in South-East England (n=34).

METHOD

A retrospective cross-sectional survey using a postal questionnaire was conducted. Questionnaires were sent to the 31 bereaved families who were considered eligible for participation.

RESPONSE

Sixteen completed questionnaires were returned (51.6%); four families declined participation (12.9%); eleven families did not reply (35.5%).

RESULTS

The experiences of sixteen families were obtained. The families expressed that they found the experience physically, practically and emotionally supportive, as they were able to continue to act as the child's parents, to choose and control how their child's care occurred, to say their farewells at their own pace and to plan the funeral of their choice. These results must be interpreted with the clear recognition that the experiences of 48.4% of the sample are unknown. Reasons for non-participation were explored.

CONCLUSION

The study has methodological limitations but presents an investigation into the experiences of parents whose child has been cared for in a cold bedroom. These families all described the experience positively.

Talking With Others Who “Just Know”: Perceptions of Adolescents With Cancer Who Participate in a Teen Group

Adolescents with cancer have social support needs that are challenging to meet. A qualitative descriptive study was done using in-person interviews with 11 participants between the ages of 14 and 20. The purpose of the study was to explore and describe adolescent's perceptions of a teen support group. Two main themes emerged: Satisfying Elements and Challenges in the teen group. The subthemes under Satisfying Elements include participants being able to talk to others who “just know,” sharing experiences while having fun as a normal teenager, and giving or receiving inspiration. Subthemes under Challenges as identified by participants include ensuring that activities during teen events meet the needs of all participants and dealing with the death of a group member. Study findings suggest that adolescent's feel supported when they are among others in similar circumstances while engaging in normal activity. Offering this type of group for adolescents with cancer provides them with the ongoing opportunities for connection with their peers that is often needed throughout the treatment journey.