Coping and wellbeing in bereavement: two core outcomes for evaluating bereavement support in palliative care

The matter of grief, loss and bereavement in families of those living and dying in residential aged care setting: A systematic review

The grief, loss and bereavement needs of the families of those living and dying in residential aged care setting is not very well understood. This systematic review examines grief, loss, and bereavement experience of, and interventions relating to, family caregivers of those entering, living and dying in residential aged care. Out of 2023 papers that were identified, 35 met the inclusion criteria which included (n=28) qualitative and (n=7) quantitative intervention studies. The qualitative findings indicated quality of care provided to the resident at the end of their life, and after death care influenced family caregivers' grief reactions. The intervention studies revealed that educational interventions have the potential to lead to some benefits in the context of grief loss and bereavement outcomes. Recognizing the emotional experiences and support needs of families and carers may enhance the understanding of the ageing, caring, dying, grieving pathway for older people and their families.

Grieving the Loss of a Child and the Use of Online Social Support: An Exploratory Survey Study

PURPOSE

To describe social media online grief supports, accessing behaviors, psychosocial variables, and feelings of support among individuals grieving the loss of a child aged <18 years.

METHOD

This online survey study recruited 26 adults grieving the loss of a child using social media. Dependent variables included feelings of support and frequency of access. Independent variables included sleep disturbance, cognitive function, depression, anxiety, and self-efficacy to manage emotions (SEMA). Data were collected from May to September 2018.

RESULTS

Participants' T scores were higher in level of sleep disturbance (mean = 59.4, SD = 6.1), depression (mean = 62.1, SD = 6.1), and anxiety (mean = 62.8, SD = 7.9), and lower in cognitive function (mean = 37.4, SD = 7.3) and SEMA (mean = 39.3, SD = 5.7). SEMA showed a positive correlation with feeling emotionally supported (p = 0.034). Participants who were accessing online grief supports more frequently reported higher levels of emotional support (F = 9.31, p = 0.006).

CONCLUSION

Current findings will help guide the design of online grief support interventions for individuals grieving the loss of a child. [Journal of Psychosocial Nursing and Mental Health Services, 62(8), 47-55.].

Evaluating the Effect of Participation in Bereavement Support Groups on Perceived Mental Well-Being and Grief Reactions

The study aimed to evaluate the effect of participating in bereavement support groups on mental well-being and levels of grief and to gather information about participants´ experiences of participation. The programme consisted of six sessions over six weeks. Data were collected with the Warwick Edinburgh Mental Well-Being Scale (WEMWBS) and the Adult Attitude to Grief scale (AAG) as well as demographic and open-ended questions. 64 bereaved spouses returned at least parts of the study´s questionnaires before participating in the programme while 39 returned the complete WEMWBS and 36 the complete AAG both before and after participation. Most participants were women >60 years old. Participation in the programme resulted in a significant increase in perceived mental well-being and significantly lower levels of vulnerability in grief. Responses to open-ended questions revealed both positive and negative experiences. A lowered WEMWBS score and a relatively high AAG underscore the importance of providing services to the recently bereaved. Routine screening for complicated grief before participating in the bereavement support group sessions is recommended.

'It was never about me': A qualitative inquiry into the experiences of psychological support and perceived support needs of family caregivers of people with high-grade glioma

BACKGROUND

Family caregivers of people with high-grade glioma often report high rates of psychological distress, which has been attributed to the unique aspects of the disease and onerous care demands. Clinical practice guidelines advocate for caregiver support from diagnosis through to end-of-life and bereavement. Yet, research has identified that caregivers' support needs are often overlooked.

AIM

To explore caregivers' experiences of psychological support and perceptions of what constitutes optimal psychological support for caregivers in the context of high-grade glioma.

DESIGN

Qualitative study involving semi-structured interviews with data analysed using reflexive thematic analysis.

SETTING/PARTICIPANTS

Eighteen current (n = 11) and bereaved (n = 7) family caregivers (73% female, aged 33-69 years) of adults with high-grade glioma participated. Interviews explored caregivers' perceptions of psychological support.

RESULTS

Two major themes were generated. The first theme, 'It was never about me', reflected caregivers prioritise for people with high-grade glioma to be well supported despite experiencing their own unmet psychological support needs. The second theme, 'Continuous, coordinated and personalised support', highlighted the importance of timely and tailored interventions addressing caregivers' practical, educational and emotional support needs throughout the illness journey.

CONCLUSIONS

Caregivers commonly prioritise the support needs of people with high-grade gliomas; yet, have their own distinct needs that vary throughout the illness. Primary care providers have a potential role in facilitating timely access to palliative care, practical support and brain tumour-specific psychological support to meet caregivers' diverse needs across the care continuum in the context of high-grade glioma.

Music therapy for supporting informal carers of adults with life-threatening illness pre- and post-bereavement; a mixed-methods systematic review

BACKGROUND

Music therapy interventions with informal carers of individuals with life-threatening illness at pre- and post-bereavement is an increasingly important clinical area. This systematic review is the first to synthesise and critically evaluate the international evidence associated with music therapy with adult informal carers pre- and post-bereavement. Specifically, the objectives were: i) to describe the characteristics and effectiveness of music therapy interventions which aim to improve health-related outcomes for adult informal carers of adults with life-threatening illness (pre- and post-bereavement), and ii) to describe the experience of music therapy for adult informal carers of adults with life-threatening illness (pre- and post-bereavement).

METHODS

Eligibility: adult informal carers of adults at end of life or bereaved; music therapy interventions for improving health-related outcomes; qualitative; mixed-method; and quantitative studies including comparators of any other intervention; published in English from 1998 onwards. Six databases were searched up to July 2022. A JBI mixed-methods systematic review approach was followed throughout, including quality appraisal, data extraction and a convergent segregated approach to synthesis and integration.

RESULTS

A total of 34 studies were included, published between 2003 and 2022. Most were conducted in North America (n = 13), Australia (n = 10), or Europe (n = 8). No studies were conducted in low- and middle-income countries or in the UK. The majority were qualitative (n = 17), followed by quasi-experimental (n = 8), mixed-methods (n = 7) and two RCTs. The majority focused on carers of individuals with dementia (n = 21) or advanced cancer (n = 7). Seventeen studies were purely quantitative or included a quantitative component. During meta-synthesis, findings were aligned to core outcomes for evaluating bereavement interventions in palliative care and previously identified risk factors for complicated grief. Commonly targeted outcomes in quantitative studies included quality of life and mental wellbeing, showing equivocal effectiveness of music therapy with significant and non-significant results. Twenty-two studies either purely qualitative or with a qualitative component underwent meta synthesis and suggested a diverse range of improved pre- and post-bereavement outcomes for informal carers across all core outcomes, and across all risk and protective factors, including psychological, spiritual, emotional, and social outcomes.

CONCLUSIONS

Qualitative studies provide moderate to strong evidence for improved health-related outcomes for adult informal carers of adults with life-threatening illness pre-bereavement. Limited studies including those bereaved negates conclusions for the bereavement phase. Comparisons and explanations for effectiveness across quantitative and qualitative studies are equivocal, with a high risk of bias and small samples in the limited number of quantitative studies, demonstrating a need for high-quality RCTs.

SYSTEMATIC REVIEW PRE-REGISTRATION

PROSPERO [CRD42021244859].

Developing a best-practice agenda for music therapy research to support informal carers of terminally ill patients pre- and post-death bereavement: a world café approach

BACKGROUND

Informal carers of terminally ill patients play a vital role in providing palliative care at home, which impacts on their pre- and post-death bereavement experience and presents an up to 50% greater risk for mental-health problems. However, developing and implementing effective bereavement support remains challenging. There is a need to build the evidence base for music therapy as a potentially promising bereavement support for this vulnerable population. This study aimed to co-design an international best practice agenda for research into music therapy for informal carers of patients pre- and post-death bereavement.

METHODS

Online half day workshop using a World Café approach; an innovative method for harnessing group intelligence within a group of international expert stakeholders (music therapy clinicians and academics with experience of music therapy with informal carers at end-of-life). Demographics, experience, key priorities and methodological challenges were gathered during a pre-workshop survey to inform workshop discussions. The online workshop involved four rounds of rotating, 25-minute, small group parallel discussions using Padlet. One final large group discussion involved a consensus building activity. All data were analysed thematically to identify patterns to inform priorities and recommendations.

RESULTS

Twenty-two consented and completed the pre-event survey (response rate 44%), from countries representing 10 different time zones. Sixteen participated in the workshop and developed the following best practice agenda. The effectiveness of music therapy in supporting informal carers across the bereavement continuum should be prioritised. This should be done using a mixed methods design to draw on the strengths of different methodological approaches to building the evidence base. It should involve service users throughout and should use a core outcome set to guide the choice of clinically important bereavement outcome measures in efficacy/effectiveness research.

CONCLUSIONS

Findings should inform future pre- and post-death bereavement support research for informal caregivers of terminally ill patients. This is an important step in building the evidence base for commissioners and service providers on how to incorporate more innovative approaches in palliative care bereavement services.

The NeoPACE study: study protocol for the development of a core outcome set for neonatal palliative care

BACKGROUND

Neonatal death is the leading category of death in children under the age of 5 in the UK. Many babies die following decisions between parents and the neonatal team; when a baby is critically unwell, with the support of healthcare professionals, parents may make the decision to stop active treatment and focus on ensuring their baby has a 'good' death. There is very little evidence to support the clinical application of neonatal palliative care and/or end-of-life care, resulting in variation in clinical provision between neonatal units. Developing core outcomes for neonatal palliative care would enable the development of measures of good practice and enhance our care of families. The aim of this study is to develop a core outcome set with associated tools for measuring neonatal palliative care.

METHOD

This study has four phases: (1) identification of potential outcomes through systematic review and qualitative interviews with key stakeholders, including parents and healthcare professionals (2) an online Delphi process with key stakeholders to determine core outcomes (3) identification of outcome measures to support clinical application of outcome use (4) dissemination of the core outcome set for use across neonatal units in the UK. Key stakeholders include parents, healthcare professionals, and researchers with a background in neonatal palliative care.

DISCUSSION

Developing a core outcome set will standardise minimum reported outcomes for future research and quality improvement projects designed to determine the effectiveness of interventions and clinical care during neonatal palliative and/or end-of-life care. The core outcome set will provide healthcare professionals working in neonatal palliative and/or end-of-life support with an increased and consistent evidence base to enhance practice in this area.

TRIAL REGISTRATION

The study has been registered with the COMET initiative ( https://www.comet-initiative.org/Studies/Details/1470 ) and the systematic review is registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023451068).

Best Practice in Telephone Bereavement Support: A Thematic Analysis of Bereavement Support Providers' Perspectives

Telephone bereavement support is recommended in bereavement care policy and practice; however, little is known about what constitutes best practice. To explore how best practice in telephone bereavement support is conceptualized by those who provide the service, 26 healthcare professionals working in Australian hospitals, hospices, and other palliative care settings were interviewed. Thematic analysis was used to construct seven themes: A Valuable Service with Limited Resources, The First Call, The Dance of Rapport, A Space to Share, Identifying and Responding to Risk, Maintaining Contact, and Training and Development Needs. Participants viewed telephone bereavement support as an effective and accessible tool in supporting individuals' processing of and adaptation to loss; however, concerns remain regarding the quality and consistency of care provided. Greater resourcing of bereavement care is required, and telephone bereavement care providers' perspectives offer a foundation to ensure the service is evidence-based, pragmatic, and supported by quality training.

An integrative literature review examining the key elements of bereavement follow-up interventions in critical care

PURPOSE OF REVIEW

The aim of this review is to examine bereavement follow-up intervention studies in critical care, with the purpose of integrating results on the timing, content, aims and outcomes of interventions. The impact of a death in critical care is well documented, and bereavement follow-up is recognised as an important topic, but there is limited research with little consensus on the content and structure of interventions.

RECENT FINDINGS

A total of 18 papers were selected; 11 are intervention studies, with only one randomised control trial. Six papers were from national surveys and are not the focus of this review. Bereavement follow-up mainly consisted of information giving, condolence interventions, telephone calls and meetings with families. The timing, content, aims and outcomes depended on the intervention and were influenced by the design of the study.

SUMMARY

Overall, bereavement follow-up is acceptable for relatives but outcomes are mixed. Calls for more research are valid, but how do we utilise the current research to better inform the critical care community? Researchers suggest that bereavement follow-up interventions need to be designed with specific aims and outcomes, in collaboration with bereaved families that are appropriate to the intervention.

Engaging and supporting the public on the topic of grief and bereavement: an evaluation of Good Grief Festival

Background

Good Grief Festival was originally planned as a face-to-face festival about grief and bereavement. Due to COVID-19, it was held online over 3 days in October 2020.

Objective

To evaluate the festival's reach and impact.

Design

Pre/post evaluation.

Methods

Pre-festival online surveys assessed reasons for attending and attitudes to bereavement across four items (fear of saying the wrong thing, avoiding talking to someone bereaved, knowing what to do if someone bereaved was struggling, knowing how to help). Post-festival online surveys evaluated audience experiences and the four attitude items. Free-text responses, analysed using thematic analysis, generated suggestions for improvement and general comments.

Results

Between 5003 and 6438 people attended, with most attending two to five events. Pre-festival survey participants (n = 3785) were mostly women (91%) and White (91%). About 9% were from Black or minoritised ethnic communities. About 14% were age ⩾65 years, 16% age ⩽34 years. Around 75% were members of the public, teachers, students or 'other'; 25% academics, clinicians or bereavement counsellors. A third had been bereaved in the last year; 6% had never been bereaved. People attended to learn about grief/bereavement (77%), be inspired (52%) and feel part of a community (49%). Post-festival participants (n = 685) reported feeling part of a community (68%), learning about grief/bereavement (68%) and being inspired (66%). 89% rated the festival as excellent/very good and 75% agreed that they felt more confident talking about grief after attending. Higher ratings and confidence were associated with attending more events. Post-festival attitudes were improved across all four items (p < 0.001). Attendees appreciated the festival, particularly valuing the online format, opportunities for connection during lockdown and the diversity and quality of speakers. Suggestions included improving registration, more interactive events and less content.

Conclusion

Good Grief Festival successfully reached a large public audience, with benefit in engagement, confidence and community-building. Evaluation was critical in shaping future events. Findings suggest festivals of this nature can play a central role in increasing death- and grief-literacy within a public health approach.

Hospital-Based Interventions to Address Provider Grief: A Narrative Review

CONTEXT

Provider grief, i.e., grief related to the death of patients, often forms an ongoing and profound stressor impacting healthcare providers' ability to maintain their sense of well-being, avoid feeling overwhelmed, and sustain quality and compassionate patient care over time.

OBJECTIVES

This narrative review presents findings on the types of interventions hospitals have offered to physicians and nurses to address provider grief.

METHODS

Searches of PubMed and PsycINFO were conducted for articles (e.g., research studies, program descriptions and evaluations) focused on hospital-based interventions to help physicians and nurses cope with their own grief.

RESULTS

Twenty-nine articles met inclusion criteria. The most common adult clinical areas were oncology (n = 6), intensive care (n = 6), and internal medicine (n = 3), while eight articles focused on pediatric settings. Nine articles featured education interventions, including instructional education programs and critical incident debriefing sessions. Twenty articles discussed psychosocial support interventions, including emotional processing debriefing sessions, creative arts interventions, support groups, and retreats. A majority of participants reported that interventions were helpful in facilitating reflection, grieving, closure, stress relief, team cohesion, and improved end-of-life care, yet mixed results were found related to interventions' effects on reducing provider grief to a statistically significant degree.

CONCLUSION

Providers largely reported benefits from grief-focused interventions, yet research was sparse and evaluation methodologies were heterogenous, making it difficult to generalize findings. Given the known impact provider grief can have on the individual and organizational levels, it is important to expand providers' access to grief-focused services and to increase evidence-based research in this field.

Factors Associated With Higher Levels of Grief and Support Needs Among People Bereaved During the Pandemic: Results from a National Online Survey

We identified factors associated with higher levels of grief and support needs among 711 people bereaved during the COVID-19 pandemic in the UK (deaths 16 March 2020-2 January 2021). An online survey assessed grief using the Adult Attitude to Grief (AAG) scale, which calculates an overall index of vulnerability (IOV) (range 0-36), and practical and emotional support needs in 13 domains. Participants' mean age was 49.5 (SD 12.9); 628 (88.6%) female. Mean age of deceased 72.2 (SD 16.1). 311 (43.8%) deaths were from confirmed/suspected COVID-19. High overall levels of grief and support needs were observed; 28.2% exhibited severe vulnerability (index of vulnerability ≥24). Grief and support needs were higher for close relationships with the deceased (vs. more distant) and reported social isolation and loneliness (p < 0.001), and lower when age of deceased was above 40-50. Other associated factors were place of death and health professional support post-death (p < 0.05).

[Grief and palliative home-care services for patients at the end of life during the COVID-19 pandemic in Colombia. Analysis from the relatives´ perspective]

INTRODUCTION

End-of-life care is one of the most crucial experiences for both the patient and their loved ones. However, as a result of the changes generated by the COVID 19 pandemic, the dynamics of the end-of-life process has undergone changes at both the family, social and health levels. In turn, this has altered the perception and development of the grief of relatives of patients who died during the pandemic regardless of the cause of death. Then, the aim of this study is to analyze the perceptions and some aspects of bereavement of died patients` relatives during the pandemic of Covid 19.

METHODS

Through the admission evaluation and follow-up of the relatives with an adapted version of the international Care Of the Dying Evaluation (iCODE) questionnaire.

RESULTS

239 relatives were surveyed, of which 112 completed the follow-up questionnaire. Most of the patients died at home and their family members were highly involved in their care. Medical attention was considered adequate and the symptom with the highest perception was pain. 87% of those surveyed participated in funeral rites, and 42% rated them as very sober. Regarding grief, the scale of personal growth predominates, however, in the negative aspects, the feeling of pressure in the chest and frequent crying predominates.

CONCLUSIONS

The end of life of home-care patients during the pandemic was perceived as adequate, allowing family support and symptom control. The grieving process shows no complications. The training of health professionals in these fundamental aspects of patient care is important.

Effectiveness of Brief Contact Interventions for Bereavement: A Systematic Review

Brief contact interventions are an efficient and cost-effective way of providing support to individuals. Whether they are an effective bereavement intervention is not clear. This systematic review included articles from 2014 to 2021.711 studies were identified, with 15 meeting inclusion criteria. The brief contact interventions included informational and emotional supports. Narrative synthesis identified that participants valued brief contact interventions, however some did not find them helpful. Exposure to a brief contact intervention was typically associated with improvements in wellbeing. Studies with comparison groups typically found significant but modest improvements in grief, depression symptoms and wellbeing associated with the intervention. However, one intervention was associated with significant deterioration of depression symptoms. Existing brief contact interventions for bereavement appear feasible, generally acceptable to the target population and are associated with improvements in wellbeing. Further development and evaluation to account for why improvements occur, and to identify any unintended impacts, is required.

Living with Loss: study protocol for a randomized controlled trial evaluating an internet-based perinatal bereavement program for parents following stillbirth and neonatal death

BACKGROUND

Stillbirth and neonatal death are devastating pregnancy outcomes with long-lasting psychosocial consequences for parents and families, and wide-ranging economic impacts on health systems and society. It is essential that parents and families have access to appropriate support, yet services are often limited. Internet-based programs may provide another option of psychosocial support for parents following the death of a baby. We aim to evaluate the efficacy and acceptability of a self-guided internet-based perinatal bereavement support program "Living with Loss" (LWL) in reducing psychological distress and improving the wellbeing of parents following stillbirth or neonatal death.

METHODS

This trial is a two-arm parallel group randomized controlled trial comparing the intervention arm (LWL) with a care as usual control arm (CAU). We anticipate recruiting 150 women and men across Australia who have experienced a stillbirth or neonatal death in the past 2 years. Participants randomized to the LWL group will receive the six-module internet-based program over 8 weeks including automated email notifications and reminders. Baseline, post-intervention, and 3-month follow-up assessments will be conducted to assess primary and secondary outcomes for both arms. The primary outcome will be the change in Kessler Psychological Distress Scale (K10) scores from baseline to 3-month follow-up. Secondary outcomes include perinatal grief, anxiety, depression, quality of life, program satisfaction and acceptability, and cost-effectiveness. Analysis will use intention-to-treat linear mixed models to examine psychological distress symptom scores at 3-month follow-up. Subgroup analyses by severity of symptoms at baseline will be undertaken.

DISCUSSION

The LWL program aims to provide an evidence-based accessible and flexible support option for bereaved parents following stillbirth or neonatal death. This may be particularly useful for parents and healthcare professionals residing in rural regions where services and supports are limited. This RCT seeks to provide evidence of the efficacy, acceptability, and cost-effectiveness of the LWL program and contribute to our understanding of the role digital services may play in addressing the gap in the availability of specific bereavement support resources for parents following the death of a baby, particularly for men.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12621000631808 . Registered prospectively on 27 May 2021.

Risk factors associated with poorer experiences of end-of-life care and challenges in early bereavement: Results of a national online survey of people bereaved during the COVID-19 pandemic

BACKGROUND

Experiences of end-of-life care and early bereavement during the COVID-19 pandemic are poorly understood.

AIM

To identify clinical and demographic risk factors for sub-optimal end-of-life care and pandemic-related challenges prior to death and in early bereavement, to inform clinical practice, policy and bereavement support.

DESIGN

Online national survey of adults bereaved in the UK (deaths between 16 March 2020 and 2 January 2021), recruited via media, social media, national associations and organisations.

SETTING/PARTICIPANTS

711 participants, mean age 49.5 (SD 12.9, range 18-90). 628 (88.6%) were female. Mean age of the deceased was 72.2 (SD 16.1, range miscarriage to 102 years). 311 (43.8%) deaths were from confirmed/suspected COVID-19.

RESULTS

Deaths in hospital/care home increased the likelihood of poorer experiences at the end of life; for example, being unable to visit or say goodbye as wanted (p < 0.001). COVID-19 was also associated with worse experiences before and after death; for example, feeling unsupported by healthcare professionals (p < 0.001), social isolation/loneliness (OR = 0.439; 95% CI: 0.261-0.739), and limited contact with relatives/friends (OR = 0.465; 95% CI: 0.254-0.852). Expected deaths were associated with a higher likelihood of positive end-of-life care experiences. The deceased being a partner or child also increased the likelihood of positive experiences, however being a bereaved partner strongly increased odds of social isolation/loneliness, for example, OR = 0.092 (95% CI: 0.028-0.297) partner versus distant family member.

CONCLUSIONS

Four clear risk factors were found for poorer end-of-life care and pandemic-related challenges in bereavement: place, cause and expectedness of death, and relationship to the deceased.

Risk factors for complicated grief among family members bereaved in intensive care unit settings: A systematic review

BACKGROUND

Families of intensive care unit (ICU) decedents are at increased risk of experiencing complicated grief. However, factors associated with complicated grief in ICU and bereavement needs assessment are not available routinely. We aimed to conduct a systematic review identifying risk factors associated with complicated grief among family members of ICU decedents.

MATERIALS AND METHODS

MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library and Web of Science were searched to identify relevant articles. Observational studies and randomised and non-randomised controlled trials were included. Studies were screened and quality appraised in duplicate. Risk of bias was assessed using Newcastle-Ottawa Scale. A narrative synthesis was undertaken.

RESULTS

Seven studies conducted across three continents were eligible. Four studies were of high quality. 61 risk factors were investigated across the studies. Factors associated with a decreased risk of complicated grief included age, patient declining treatment and involvement in decision-making. Factors associated with increased risk included living alone, partner, dying while intubated, problematic communication, and not having the opportunity to say goodbye.

CONCLUSION

This systematic review has identified risk factors which may help identify family members at increased risk of complicated grief. Many of the studies has small sample sizes increasing the risk of erroneously reporting no effect due to type II error. Some factors are specific to the ICU setting and are potentially modifiable. Bereavement services tailored to the needs of bereaved family members in ICU settings are required. (PROSPERO registration ID 209503).

In-Hospital Bereavement Services as an Act of Care and a Challenge: An Integrative Review

CONTEXT

Globally, people most often die within hospitals. As such, healthcare providers in hospitals are frequently confronted with dying persons and their bereaved relatives.

OBJECTIVES

To provide an overview of the current role hospitals take in providing bereavement care. Furthermore, we want to present an operational definition of bereavement care, the way it is currently implemented, relatives' satisfaction of receiving these services, and finally barriers and facilitators regarding the provision of bereavement care.

METHODS

An integrative review was conducted by searching four electronic databases, from January 2011 to December 2020, resulting in 47 studies. Different study designs were included and results were reported in accordance with the theoretical framework of Whittemore and Knafl (2005).

RESULTS

Only four articles defined bereavement care: two as services offered solely post loss and the other two as services offered pre and post loss. Although different bereavement services were delivered the time surrounding the death, the follow-up of bereaved relatives was less routinely offered. Relatives appreciated all bereavement services, which were rather informally and ad-hoc provided to them. Healthcare providers perceived bereavement care as important, but the provision was challenged by numerous factors (such as insufficient education and time).

CONCLUSION

Current in-hospital bereavement care can be seen as an act of care that is provided ad-hoc, resulting from the good-will of individual staff members. A tiered or stepped approach based on needs is preferred, as it allocates funds towards individuals-at-risk. Effective partnerships between hospitals and the community can be a useful, sustainable and cost-effective strategy.

Bereavement Experiences of Families in the Cardiac Intensive Care Unit

BACKGROUND

Losing a loved one in the intensive care unit is associated with complicated grief and increased psychologic distress for families. Providing bereavement support may help families during this time. However, little is known about the bereavement experiences of families of patients in the cardiac intensive care unit.

OBJECTIVE

To describe the bereavement experiences of families of patients in the cardiac intensive care unit.

METHODS

In this secondary analysis, an exploratory, descriptive design was used to understand the families' bereavement experiences. Families from 1 cardiac intensive care unit in a tertiary medical center in the western United States participated. Audiotaped telephone interviews were conducted by using a semistructured interview guide 13 to 15 months after the patient's death. A qualitative, descriptive technique was used for data analysis. Two independent researchers coded the interview transcripts and identified themes.

RESULTS

Twelve family members were interviewed. The majority were female (n = 8, 67%), spouses (n = 10, 83%), and White (n = 10, 83%); the mean age (SD) was 58.4 (16.7) years. Five main themes emerged: (1) families' bereavement work included both practical tasks and emotional processing; (2) families' bereavement experiences were individual; (3) these families were resilient and found their own resources and coping mechanisms; (4) the suddenness of a patient's death influenced families' bereavement experiences; and (5) families' experiences in the intensive care unit affected their bereavement.

CONCLUSIONS

This study provided insight into the bereavement experiences of families of patients in the cardiac intensive care unit. These findings may be useful for professionals working with bereaved families and for cardiac intensive care units considering adding bereavement support.

Outcomes and measures of delirium interventional studies in palliative care to inform a core outcome set: A systematic review

BACKGROUND

Trials of interventions for delirium in various patient populations report disparate outcomes and measures but little is known about those used in palliative care trials. A core outcome set promotes consistency of outcome selection and measurement.

AIM

To inform core outcome set development by examining outcomes, their definitions, measures and time-points in published palliative care studies of delirium prevention or treatment delirium interventions.

DESIGN

Prospectively registered systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

We searched six electronic databases (1980-November 2020) for original studies, three for relevant reviews and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We included randomised, quasi-randomised and non-randomised intervention studies of pharmacological and non-pharmacological delirium prevention and/or treatment interventions.

RESULTS

From 13/3244 studies (2863 adult participants), we identified 9 delirium-specific and 13 non-delirium specific outcome domains within eight Core Outcome Measures in Effectiveness Trials (COMET) taxonomy categories. There were multiple and varied outcomes and time points in each domain. The commonest delirium specific outcome was delirium severity (n = 7), commonly using the Memorial Delirium Assessment Scale (6/8 studies, 75%). Four studies reported delirium incidence. Non-delirium specific outcomes included mortality, agitation, adverse events, other symptoms and quality of life.

CONCLUSION

The review identified few delirium interventions with heterogeneity in outcomes, their definition and measurement, highlighting the need for a uniform approach. Findings will inform the next stage to develop consensus for a core outcome set to inform delirium interventional palliative care research.

Support needs and barriers to accessing support: Baseline results of a mixed-methods national survey of people bereaved during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic is a mass bereavement event which has profoundly disrupted grief experiences. Understanding support needs and access to support among people bereaved at this time is crucial to ensuring appropriate bereavement support infrastructure.

AIM

To investigate grief experiences, support needs and use of formal and informal bereavement support among people bereaved during the pandemic.

DESIGN

Baseline results from a longitudinal survey. Support needs and experiences of accessing support are reported using descriptive statistics and thematic analysis of free-text data.

SETTING/PARTICIPANTS

711 adults bereaved in the UK between March and December 2020, recruited via media, social media, national associations and community/charitable organisations.

RESULTS

High-level needs for emotional support were identified. Most participants had not sought support from bereavement services (59%, n = 422) or their General-Practitioner (60%, n = 428). Of participants who had sought such support, over half experienced difficulties accessing bereavement services (56%, n = 149)/General-Practitioner support (52%, n = 135). About 51% reported high/severe vulnerability in grief; among these, 74% were not accessing bereavement or mental-health services. Barriers included limited availability, lack of appropriate support, discomfort asking for help and not knowing how to access services. About 39% (n = 279) experienced difficulties getting support from family/friends, including relational challenges, little face-to-face contact and disrupted collective mourning. The perceived uniqueness of pandemic bereavement and wider societal strains exacerbated their isolation.

CONCLUSIONS

People bereaved during the pandemic have high levels of support needs alongside difficulties accessing support. We recommend increased provision and tailoring of bereavement services, improved information on support options and social/educational initiatives to bolster informal support and ameliorate isolation.

Using the Delphi technique to achieve consensus on bereavement care in palliative care in Europe: An EAPC White Paper

BACKGROUND

The WHO definition of palliative care includes bereavement support as integral to palliative care, yet a previous survey of bereavement support in palliative care in Europe has shown a range of service responses to loss. A rigorous approach to agreeing and implementing a palliative care bereavement framework was required.

AIM

The aim of this study was to develop consensus on best-practice recommendations for bereavement care principles, structures, processes and delivery based on current practice and evidence.

DESIGN

In accordance with Guidance on Conducting and Reporting Delphi Studies, a consensus-building five-round Delphi technique was performed. A scoping review of research literature informed drafting of 54 statements by the EAPC Bereavement Task Force. Evaluation of the statements was performed by an expert panel using a 5-point Likert scale. ⩾80% agreement were defined as essential items and 75%-79% agreement were defined as desirable items. Items with a consensus rating <75% were revised during the process.

SETTING/PARTICIPANTS

The Delphi study was carried out by an expert panel among membership organisations of the European Association for Palliative Care.

RESULTS

In total, 376 email requests to complete Delphi questionnaire were distributed with a response rate of 23% (n = 87) and a follow-up response-rate of 79% (n = 69). Of the initial 54 statements in six dimensions, 52 statements were endorsed with 26 essential statements and 26 desirable statements.

CONCLUSIONS

The six dimensions and 52 statements agreed through this Delphi study clarify a coherent direction for development of bereavement services in palliative care in Europe.

Longitudinal family caregiving experiences in heart failure: Secondary qualitative analysis of interviews

BACKGROUND

Considering the potential impacts of family caregivers on heart failure management and the costs of healthcare, health professionals need to pay attention to the challenges faced by family caregivers.

OBJECTIVE

This study longitudinally explored the caregiving experiences of family caregivers of persons with heart failure.

METHODS

Serial interview scripts collected from 53 family caregivers were analyzed using a content analysis method.

RESULTS

The following themes emerged: (1) accumulating knowledge and skills for caregiving; (2) losing a sense of control; (3) balancing an unstable life; (4) constructing illness memory; (5) centering the patient in daily life; (6) accepting the loss of a family member; (7) coping with grief by drawing on social support; (8) facing financial responsibility; and (9) rethinking hospice care.

CONCLUSION

Family caregivers experience concern about unpredictable caregiving years, disease's fluctuating symptoms and poor prognosis. More educational opportunities, financial counseling programs, and palliative care consultations should be provided.

What is good grief support? Exploring the actors and actions in social support after traumatic grief

Social support seems to enhance wellbeing and health in many populations. Conversely, poor social support and loneliness are a social determinant of poor health outcomes and can adversely affect physical, emotional, and mental well-being. Social support is especially important in traumatic grief. However, the ways in which grieving individuals interpret and define social support is not well understood, and little is known about what specific behaviours are perceived as helpful. Using qualitative description and content analysis, this study assessed bereaved individuals’ satisfaction of social support in traumatic grief, using four categories of social support as a framework. Findings suggest inadequate satisfaction from professional, familial, and community support. Pets emerged with the most satisfactory ratings. Further, findings suggest that emotional support is the most desired type of support following traumatic loss. Implications for supporting bereaved individuals within and beyond the context of the COVID-19 pandemic are discussed.

Bereavement interventions to support informal caregivers in the intensive care unit: a systematic review

Background

Informal caregivers of critically ill patients in intensive care unit (ICUs) experience negative psychological sequelae that worsen after death. We synthesized outcomes reported from ICU bereavement interventions intended to improve informal caregivers’ ability to cope with grief.

Data sources

MEDLINE, EMBASE, CINAHL and PsycINFO from inception to October 2020.

Study selection

Randomized controlled trials (RCTs) of bereavement interventions to support informal caregivers of adult patients who died in ICU.

Data extraction

Two reviewers independently extracted data in duplicate. Narrative synthesis was conducted.

Data synthesis

Bereavement interventions were categorized according to the UK National Institute for Health and Clinical Excellence three-tiered model of bereavement support according to the level of need: (1) Universal information provided to all those bereaved; (2) Selected or targeted non-specialist support provided to those who are at-risk of developing complex needs; and/or (3) Professional specialist interventions provided to those with a high level of complex needs. Outcome measures were synthesized according to core outcomes established for evaluating bereavement support for adults who have lost other adults to illness.

Results

Three studies of ICU bereavement interventions from 31 ICUs across 26 hospitals were included. One trial examining the effect of family presence at brain death assessment integrated all three categories of support but did not report significant improvement in emotional or psychological distress. Two other trials assessed a condolence letter intervention, which did not decrease grief symptoms and may have increased symptoms of depression and post-traumatic stress disorder, and a storytelling intervention that found no significant improvements in anxiety, depression, post-traumatic stress, or complicated grief. Four of nine core bereavement outcomes were not assessed anytime in follow-up.

Conclusions

Currently available trial evidence is sparse and does not support the use of bereavement interventions for informal caregivers of critically ill patients who die in the ICU.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00763-w.

Domains and outcomes of the core outcome set of congenital melanocytic naevi for clinical practice and research (the OCOMEN project): part 2

Background

Congenital melanocytic naevi (CMN) can have a great impact on patients’ lives owing to perceived stigmatization, and the risk of melanoma development and neurological complications. Development of a core outcome set (COS) for care and research in CMN will allow standard reporting of outcomes. This will enable comparison of outcomes, allowing professionals to offer advice about the best management options. In previous research, stakeholders (patients, parents and professionals) reached consensus on the core domains of the COS. To select the appropriate measurement instruments, the domains should be specified by outcomes.

Objectives

To reach consensus on the specific core outcomes describing the core domains pertaining to clinical care and research in CMN.

Methods

A list of provisional outcomes (obtained earlier) was critically reviewed by the Outcomes for COngenital MElanocytic Naevi (OCOMEN) research team and by relevant stakeholders through an online questionnaire, to refine this list and provide clear definitions for every outcome. When needed, discussion with individual participants was undertaken over the telephone or by email. During an online consensus meeting, stakeholders discussed the inclusion of potential outcomes. After the meeting, participants voted in two rounds for the inclusion of outcomes.

Results

Forty‐four stakeholders from 19 countries participated. Nine core outcomes were included in the COS relative to clinical care and 10 core outcomes for research.

Conclusions

These core outcomes will enable standard reporting in future care and research of CMN. This study facilitates the next step of COS development: selecting the appropriate measurement instruments for every outcome.

What is already known about this topic?

Congenital melanocytic naevi (CMN) can be associated with psychosocial burden and increased risk of melanoma and/or neurological complications.

Outcomes measured for research and care in CMN are heterogeneous, impeding comparison.

A core outcome set (COS) may enhance standardized use and reporting, and reduce selective reporting bias.

In previous research, relevant stakeholders reached consensus on what domains should be included in the core domain set (CDS).

What does this study add?

To select the appropriate measurement instruments for the domains included in the CDS, the domains should be further specified by outcomes.

We reached consensus on what outcomes should describe the domains of the CDS of CMN care and research.

Through a consensus procedure, including online discussions, online consensus meeting and voting, relevant stakeholders reached consensus on a limited number of core outcomes describing the core domains.

What are the clinical implications of this work?

Development of a COS will allow standard reporting of outcomes in future care and research of CMN.

This will enable pooling and comparison of outcomes, allowing guideline development of optimal management policy.

Linked Comment: M.V. Heppt et al. Br J Dermatol 2021; 185:881–882.

Plain language summary available online

What elements of a systems' approach to bereavement are most effective in times of mass bereavement? A narrative systematic review with lessons for COVID-19

BACKGROUND

The global COVID-19 pandemic has left health and social care systems facing the challenge of supporting large numbers of bereaved people in difficult and unprecedented social conditions. Previous reviews have not comprehensively synthesised the evidence on the response of health and social care systems to mass bereavement events.

AIM

To synthesise the evidence regarding system-level responses to mass bereavement events, including natural and human-made disasters as well as pandemics, to inform service provision and policy during the COVID-19 pandemic and beyond.

DESIGN

A rapid systematic review was conducted, with narrative synthesis. The review protocol was registered prospectively (www.crd.york.ac.uk/prospero, CRD 42020180723).

DATA SOURCES

MEDLINE, Global Health, PsycINFO and Scopus databases were searched for studies published between 2000 and 2020. Reference lists were screened for further relevant publications, and citation tracking was performed.

RESULTS

Six studies were included reporting on system responses to mass bereavement following human-made and natural disasters, involving a range of individual and group-based support initiatives. Positive impacts were reported, but study quality was generally low and reliant on data from retrospective evaluation designs. Key features of service delivery were identified: a proactive outreach approach, centrally organised but locally delivered interventions, event-specific professional competencies and an emphasis on psycho-educational content.

CONCLUSION

Despite the limitations in the quantity and quality of the evidence base, consistent messages are identified for bereavement support provision during the pandemic. High quality primary studies are needed to ensure service improvement in the current crisis and to guide future disaster response efforts.

The impacts and effectiveness of support for people bereaved through advanced illness: A systematic review and thematic synthesis

BACKGROUND

Bereavement support is a key component of palliative care, with different types of support recommended according to need. Previous reviews have typically focused on specialised interventions and have not considered more generic forms of support, drawing on different research methodologies.

AIM

To review the quantitative and qualitative evidence on the effectiveness and impact of interventions and services providing support for adults bereaved through advanced illness.

DESIGN

A mixed-methods systematic review was conducted, with narrative synthesis of quantitative results and thematic synthesis of qualitative results. The review protocol is published in PROSPERO ( www.crd.york.ac.uk/prospero , CRD42016043530).

DATA SOURCES

The databases MEDLINE, Embase, PsycINFO, CINAHL and Social Policy and Practice were searched from 1990 to March 2019. Studies were included which reported evaluation results of bereavement interventions, following screening by two independent researchers. Study quality was assessed using GATE checklists.

RESULTS

A total of 31 studies were included, reporting on bereavement support groups, psychological and counselling interventions and a mix of other forms of support. Improvements in study outcomes were commonly reported, but the quality of the quantitative evidence was generally poor or mixed. Three main impacts were identified in the qualitative evidence, which also varied in quality: 'loss and grief resolution', 'sense of mastery and moving ahead' and 'social support'.

CONCLUSION

Conclusions on effectiveness are limited by small sample sizes and heterogeneity in study populations, models of care and outcomes. The qualitative evidence suggests several cross-cutting benefits and helps explain the impact mechanisms and contextual factors that are integral to the support.