A nationwide survey of bereavement care for siblings provided by paediatric palliative care teams

Background

Bereavement support is considered a core standard of care for paediatric palliative care (PPC) teams. Support for grieving siblings can present unique challenges. Developmentally appropriate care can help children navigate their grief experience.

Objectives

To describe the provider perspectives (mission and development) of bereavement care for siblings, and to describe the bereavement follow-up interventions offered for siblings by hospital-based PPC teams nationwide.

Design and methods

Qualitative study conducted by semidirected telephone interviews. At least one member from each PPC team was interviewed. Interviews transcribed verbatim were analysed using grounded theory.

Results

Twenty-one teams participated (response rate 91%). Most teams (80%) provided individual psychotherapy to families, and a few (28%) offered group interventions. PPC teams endeavour to expand their bereavement services and create a stronger collaboration network with community services. However, limited human resources, lack of facilities and financing, and geographical distances were frequent obstacles to bereavement care program development.

Conclusion

PPC teams support bereaved siblings as an integral part of palliative care. Although PPC teams cannot meet all the needs of bereaved families, they can serve as important reference points to consolidate knowledge of available local resources and offer well-informed guidance to families and community users. Greater public awareness of childhood bereavement and engaging with community structures could help overcome some of the common obstacles to service development. Further studies are warranted in evaluating bereavement services in France and in other healthcare systems.

The experiences of grandparents involved in the home-based end-of-life care of their grandchild with cancer: A qualitative secondary data analysis

While grandparents are often a valuable resource in home-based pediatric end-of-life care, they may also experience psychological consequences when faced with their grandchild's illness and death. In this qualitative study, we performed semi-structured interviews with seven bereaved grandparents of four children with cancer who received home-based end-of-life care and died at home at age <18. Through qualitative content analysis we identified the overarching theme: "Navigating complex and unclear roles to support the family" and five themes: (1) Providing comfort and support; (2) Balancing and adapting involvement; (3) Worrying silently; (4) Managing difficult emotions; and (5) Calling for support and understanding. The findings underline the often conflicting roles that grandparents undertake of providing support while respecting parents' autonomy and putting aside their own emotional reactions. Involving grandparents in pediatric end-of-life care may enhance family resources, but should also consider grandparents' perspectives and need for support.

Exploring the benefits of full-time hospital facility dogs working with nurse handlers in a children's hospital

OBJECTIVE

To examine the benefits of full-time hospital facility dogs (HFDs) working with qualified nurse handlers for inpatients in a pediatric medical facility.

METHODS

A questionnaire survey on the evaluation of HFD activities was conducted in a hospital that had introduced HFDs for the first time in Japan and has been using them for 9 years. Of the 626 full-time medical staff, 431 responded, of which 270 who observed HFD activities were included in the analysis. The Questionnaire contained 20 questions, and nine questions were selected for presentation in this paper because they focused on the situations in which HFD activities were thought to have a strong impact on inpatients. A comparison of the respondents' evaluations for each question was made, and differences in the respondents' attributes (such as profession, length of clinical experience and experience of dog ownership) for those items were examined.

RESULTS

The impact of HFDs in terminal care was ranked highest among the respondents. Similarly, HFDs increased patient cooperation for clinical procedures. The responses to these two items did not differ statistically depending on the respondents' attributes. The results imply that patients were more cooperative even for highly invasive examinations and procedures with the support of HFD activities.

CONCLUSIONS

Healthcare providers considered that HFDs were useful, especially for providing support during the terminal phase and for gaining patients' cooperation for procedures. The fact that the handler was a nurse and the HFD team worked full-time may have enhanced the effectiveness of the program.

Acceptability and feasibility of a pilot randomized controlled trial of Narrative e-Writing Intervention (NeW-I) for parent-caregivers of children with chronic life-threatening illnesses in Singapore

Background

Narrative e-Writing Intervention (NeW-I) is a novel psycho-socio-spiritual intervention which aims to bridge gaps in paediatric palliative care by providing anticipatory grief support to parent-caregivers who are looking after their child with a chronic life-threatening illness in Singapore. This is done via a therapist-facilitated smartphone app that focuses on strengths and meaning derived from parents’ caregiving journey. NeW-I is empirically informed by an international systematic review and a Singapore-based qualitative inquiry on the lived experience of parental bereavement and supported by anticipatory grief interventions literature for improving the holistic well-being for parent-caregivers of seriously ill children. NeW-I is implemented in Singapore as an open-label two-armed randomized controlled trial comprising an intervention and control group.

Methods

This study examined the acceptability (via analysis of participants’ post-intervention qualitative feedback and responses to a post-intervention evaluation survey) and feasibility (via records and memos of therapists’ experience of delivering the intervention) of NeW-I among 26 intervention participants drawn from the larger trial.

Results

Framework analysis of participants’ post-intervention feedback revealed four themes, namely: (i) Meaningful opportunity for reflection, (ii) Congruity with parent-caregivers’ needs, (iii) Compatibility of online narrative writing and (iv) Sustainability and enhancement recommendations. The post-intervention evaluation survey showed that participants were overall satisfied with their NeW-I experience with a large number of participants acknowledging that NeW-I had improved their spiritual well-being, hopefulness about the future and perception of social support that was available to them, as well as lessened their feelings of sadness and depression, caregiver burden and fear and anxiety about their child’s illness. The research team found it feasible to deliver the intervention in the current setting.

Conclusion

NeW-I is an innovative e-health tool that could immeasurably value-add to paediatric palliative care services for Asian families in Singapore and around the world.

Trial registration

ClinicalTrials.gov, ID: NCT03684382, Verified: September 2018.

Insight into the content of and experiences with follow-up conversations with bereaved parents in paediatrics: A systematic review

Aim

A follow‐up conversation with bereaved parents is a relatively well‐established intervention in paediatric clinical practice. Yet, the content and value of these conversations remain unclear. This review aims to provide insight into the content of follow‐up conversations between bereaved parents and regular healthcare professionals (HCPs) in paediatrics and how parents and HCPs experience these conversations.

Methods

Systematic literature review using the methods PALETTE and PRISMA. The search was conducted in PubMed and CINAHL on 3 February 2021. The results were extracted and integrated using thematic analysis.

Results

Ten articles were included. This review revealed that follow‐up conversations are built around three key elements: (1) gaining information, (2) receiving emotional support and (3) facilitating parents to provide feedback. In addition, this review showed that the vast majority of parents and HCPs experienced follow‐up conversations as meaningful and beneficial for several reasons.

Conclusion

An understanding of what parents and HCPs value in follow‐up conversations aids HCPs in conducting follow‐up conversations and improves care for bereaved parents by enhancing the HCPs' understanding of parental needs.

"Still Caring for the Family": Condolence Expression Training for Pediatric Residents

CONTEXT

Insufficient communication from the medical team following a child's death may compound parental grief. Pediatric residents care for children who die, yet the landscape of condolence expression education within residency programs has not been studied.

OBJECTIVES

The objective of this study was to evaluate pediatric residents' levels of experience and comfort with condolence expression and to assess their needs and desires for training in condolence expression.

METHODS

A cross-sectional, mixed-methods survey was developed by palliative care clinicians in collaboration with bereaved parents. In 2020, following pilot testing, an electronic survey measuring resident experience with, comfort with, and training on condolence expression was distributed to 202 third-year pediatric residents across 17 Accreditation Council for Graduate Medical Education-accredited programs representing varying sizes and geographic regions.

RESULTS

Ten percent of pediatric residents surveyed reported having training on condolence expression. Almost all residents considered condolence expression to be beneficial for bereaved families and most for clinicians, too, yet very very few had formally expressed condolences in their roles as physicians: 83.1% had never written a condolence letter; 85% had never made a condolence phone call; and 90.5% had never attended a memorial event. Commonly reported barriers to condolence expression included lack of experience and training, as well as concern about upsetting families.

CONCLUSIONS

Pediatric residents lack comfort with and training in condolence expression and desire education to address these gaps. These findings should inform development and investigation of educational resources and training opportunities for residents to learn and practice compassionate provision of condolences to grieving families.

An Interdisciplinary Hospital-Based Committee to Improve Pediatric Bereavement Care

Although frequently overshadowed by adult mortality rates and bereavement care needs, the death of a child can significantly jeopardize the physical, psychosocial, and emotional health of surviving parents, caregivers, and family members. Unfortunately, researchers have only recently begun to explore the trajectory of pediatric bereavement care needs. As an ongoing public health concern, health care institutions and related organizations must partner with interdisciplinary care providers and bereaved families to design effective and sustainable bereavement supports in their communities. Therefore, the purpose of this article is to describe the development and accomplishments of an interdisciplinary bereavement committee at a children's hospital within an academic medical center. By relying on available empirical evidence and close collaboration with bereaved parent members, this effort has generated sizeable practice improvements and new service offerings within the organization, local community, and the individual patients and families the institution serves.

Parental bereavement - impact of death of neonates and children under 12 years on personhood of parents: a systematic scoping review

BACKGROUND

Losing a child tragically impacts the well-being and functioning of parents. With these effects extending beyond emotional, physical morbidity and compromising self-perceptions, appropriate, longitudinal, timely and personalised support is key to effective care of bereaved parents. However, in the absence of a comprehensive understanding of parental bereavement, effective support of bereaved parents remains suboptimal. To address this gap, we scrutinise prevailing data on the effects of a child's death, aged 0-12 years, through the lens of the Ring Theory of Personhood (RToP).

METHODS

To study prevailing accounts of bereaved parents following the death of a child, we adopt Krishna's Systematic Evidence Based Approach (SEBA) to structure our Systematic Scoping Review (SSR in SEBA).

RESULTS

Three thousand seventy-four abstracts were reviewed, 160 full text articles were evaluated, and 111 articles were included and analysed using thematic and content analysis. Four themes/categories were identified relating to the four rings of the RToP. Findings reveal that static concepts of protective and risk factors for grief are misplaced and that the support of healthcare professionals is key to assisting bereaved parents.

CONCLUSION

In the absence of consistent support of bereaved parents, this study highlights the need for effective training of healthcare professionals, beginning with an appreciation that every aspect of an individual parent's personhood is impacted by the loss of their child. Acknowledging grief as a complex, evolving and personalised process subjected to parental characteristics, settings, context and available support, this SSR in SEBA calls attention to effective nurturing of the relationship between parents and healthcare professionals, and suggests use of the RToP to assess and direct personalised, timely, specific support of parents in evolving conditions. We believe the findings of this review also call for further studies to support healthcare professionals as they journey with bereaved parents.

Bereaved parents' needs regarding hospital based bereavement care after the death of a child to cancer

The purpose of this study was to investigate the needs of bereaved parents in Greece (N = 56) regarding the provision of hospital based bereavement services after the death of their child to cancer. The participants did not receive formal or informal hospital based bereavement services. The majority of the parents (84%) stated that, given the opportunity, they would attend a bereavement program. Continuity of care in bereavement from the health care team, availability, individualized care, interdisciplinary approach and contact with other bereaved parents were described as key elements for the provision of bereavement services.

A Novel Narrative E-Writing Intervention for Parents of Children With Chronic Life-Threatening Illnesses: Protocol for a Pilot, Open-Label Randomized Controlled Trial

Background

A novel evidence-based Narrative e-Writing Intervention (NeW-I) has been developed and tested in Singapore to advance psychosociospiritual support for parents of children with chronic life-threatening illnesses. NeW-I is informed by an international systematic review and a Singapore-based qualitative inquiry on the lived experience of parental bereavement and supported by literature on anticipatory grief interventions for improving the holistic well-being of parent caregivers of seriously ill children.

Objective

This study's aim was to provide an accessible platform, NeW-I—which is a strengths- and meaning-focused and therapist-facilitated mobile app and web-based counseling platform—that aims to enhance quality of life, spiritual well-being, hope, and perceived social support and reduce depressive symptoms, caregiver burden, and risk of complicated grief among parents of children with chronic life-threatening illnesses.

Methods

The NeW-I therapist-facilitated web-based platform comprises a mobile app and a website (both of which have the same content and functionality). NeW-I has been implemented in Singapore as a pilot open-label randomized controlled trial comprising intervention and control groups. Both primary and secondary outcomes will be self-reported by participants through questionnaires. In collaboration with leading pediatric palliative care providers in Singapore, the trial aims to enroll 36 participants in each group (N=72), so that when allowing for 30% attrition at follow-up, the sample size will be adequate to detect a small effect size of 0.2 in the primary outcome measure, with 90% power and two-sided significance level of at least .05. The potential effectiveness of NeW-I and the accessibility and feasibility of implementing and delivering the intervention will be assessed.

Results

Funding support and institutional review board approval for this study have been secured. Data collection started in January 2019 and is ongoing.

Conclusions

NeW-I aspires to enhance holistic pediatric palliative care services through a structured web-based counseling platform that is sensitive to the unique cultural needs of Asian family caregivers who are uncomfortable with expressing emotion even during times of loss and separation. The findings of this pilot study will inform the development of a full-scale NeW-I protocol and further research to evaluate the efficacy of NeW-I in Singapore and in other Asian communities around the world.

Trial Registration

ClinicalTrials.gov NCT03684382; https://clinicaltrials.gov/ct2/show/NCT03684382

International Registered Report Identifier (IRRID)

DERR1-10.2196/17561

Parent moral distress in serious pediatric illness: A dimensional analysis

BACKGROUND

Moral distress is an important and well-studied phenomenon among nurses and other healthcare providers, yet the conceptualization of parental moral distress remains unclear.

OBJECTIVE

The objective of this dimensional analysis was to describe the nature of family moral distress in serious pediatric illness.

DESIGN AND METHODS

A dimensional analysis of articles retrieved from a librarian-assisted systematic review of Scopus, CINAHL, and PsychInfo was conducted, focusing on how children, parents, other family members, and healthcare providers describe parental moral distress, both explicitly through writings on parental moral experience and implicitly through writings on parental involvement in distressing aspects of the child's serious illness.

ETHICAL CONSIDERATIONS

To promote child and family best interest and minimize harm, a nuanced understanding of the moral, existential, emotional, and spiritual impact of serious pediatric illness is needed. The cases used in this dimensional analysis come from the first author's IRB approved study at the Children's Hospital of Philadelphia and subsequent published studies; or have been adapted from the literature and the authors' clinical experiences.

FINDINGS

Three dimensions emerged from the literature surrounding parent moral distress: an intrapersonal dimension, an interpersonal dimension, and a spiritual/existential dimension. The overarching theme is that parents experience relational solace and distress because of the impact of their child's illness on relationships with themselves, their children, family, healthcare providers, their surrounding communities, and society.

DISCUSSION

Elucidating this concept can help nurses and other professionals understand, mitigate, or eliminate antecedents to parental moral distress. We discuss how this model can facilitate future empirical and conceptual bioethics research, as well as inform the manner in which healthcare providers engage, collaborate with, and care for families during serious pediatric illness.

CONCLUSION

Parent moral distress is an important and complex phenomenon that requires further theoretical and empirical investigation. We provide an integrated definition and dimensional schematic model that may serve as a starting point for future research and dialogue.

The experiences of pediatric social workers providing end-of-life care

Pediatric social workers working in acute care hospital settings may care for children and their families in end-of-life circumstances. This qualitative study is part of a larger study focusing on the experiences of health care providers working with dying children. This study consisted of 9 semi-structured interviews of acute care pediatric social workers who work with dying children and their families. Themes included the role of social work with dying children, the impact of their work and coping strategies. Authors suggest a hospital-worker partnership in supporting staff and promotion of supportive resources.

The Long Road to Farewell: The Needs of Families With Dying Children

Families of dying children are profoundly impacted by numerous interactions with health-care providers before, during, and after their child’s death. However, there is a dearth of research on these families’ direct, qualitative experiences with health-care providers. This study presents findings from interviews with 18 family members, predominantly parents, regarding their experiences with health-care providers during a child’s terminal illness, from diagnosis to death. The importance of compassion emerged as a salient theme, manifested in myriad ways, and connected to participants’ perception of caregiver presence in multiple domains. Families were likewise negatively affected by a wide variety of situations and behaviors that represented individual or institutional abandonment or nonpresence, and thus compounded the experience of loss. Specifics and implications for practice are explored.

Caring for Pediatric Patients' Families at the Child's End of Life

Nurses play an important role in supporting families who are faced with the critical illness and death of their child. Grieving families desire compassionate, sensitive care that respects their wishes and meets their needs. Families often wish to continue relationships and maintain lasting connections with hospital staff following their child's death. A structured bereavement program that supports families both at the end of their child's life and throughout their grief journey can meet this need.

Feasibility of group intervention for bereaved siblings after pediatric cancer death

This study evaluated the feasibility (acceptability, recruitment, retention rates, treatment fidelity, and outcome measures) of implementing a manualized group intervention for bereaved siblings after pediatric cancer death. A convenience sample of 10 siblings participated. The intervention consisted of eight 2-hour sessions that focused on strategies for coping with grief, relationships, and emotional growth. Positive outcomes were obtained with respect to acceptability, recruitment, retention rates, and treatment fidelity. Preliminary outcomes were mixed. Parent pre- and post-intervention outcomes suggested improvements in siblings' overall emotional and social quality of life. Siblings' self-reports reflected no improvements. These data support the feasibility of conducting this intervention and suggest beneficial outcomes based on parental reports. Further research is recommended to evaluate the group intervention efficacy with a large sample using a randomized controlled trial to address the needs of bereaved siblings.

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.

Hospital-based bereavement services following the death of a child: a mixed study review

BACKGROUND

There has been a breadth of research on the grief experience of parents following the death of a child. However, the role and impact of hospital-based bereaved services remain unclear.

AIM

To identify services offered to bereaved families in perinatal, neonatal, and pediatric hospital settings and summarize the psychosocial impact of these services and published recommendations for best practice hospital-based bereavement care.

DESIGN

Systematic review of qualitative, quantitative, and mixed method studies guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist and methodological quality appraised in accordance with the Mixed Method Appraisal Tool.

DATA SOURCES

MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health, and PsychINFO were searched to find studies describing hospital-based bereavement services/interventions for parents, siblings, and grandparents.

RESULTS

In all, 14 qualitative, 6 quantitative, and 10 mixed method studies were identified. Nine descriptive articles were also included. Qualitatively, family members described feeling cared for and supported by staff, a reduction in sense of isolation, and improved coping and personal growth. Quantitatively, bereavement services have most effect for parents experiencing more complex mourning. It is recommended that bereavement services be theoretically driven and evidence based, offer continuity of care prior to and following the death of a child, and provide a range of interventions for the "whole family" and flexibility in service delivery.

CONCLUSIONS

There is a role for transitional hospital-based services/interventions for families in the lead up to and following the death of a child. Further mixed method research is required to inform best practice bereavement care guidelines in the perinatal, neonatal, and pediatric hospital settings.

The duty of the physician to care for the family in pediatric palliative care: context, communication, and caring

Pediatric palliative care physicians have an ethical duty to care for the families of children with life-threatening conditions through their illness and bereavement. This duty is predicated on 2 important factors: (1) best interest of the child and (2) nonabandonment. Children exist in the context of a family and therefore excellent care for the child must include attention to the needs of the family, including siblings. The principle of nonabandonment is an important one in pediatric palliative care, as many families report being well cared for during their child's treatment, but feel as if the physicians and team members suddenly disappear after the death of the child. Family-centered care requires frequent, kind, and accurate communication with parents that leads to shared decision-making during treatment, care of parents and siblings during end-of-life, and assistance to the family in bereavement after death. Despite the challenges to this comprehensive care, physicians can support and be supported by their transdisciplinary palliative care team members in providing compassionate, ethical, and holistic care to the entire family when a child is ill.