"Trying to Find North": Fathers Voice the Nature of Their Bereavement

Fathers' lived experience of bereavement is not well understood. This article presents findings from a Heidegerrian phenomenological study, which aimed to describe fathers' bereavement. Fathers' bereavement is a life-long journey along which a father navigates through devastating and traumatic loss with great strength; has profound grief that mirrors the profound love he has for his child; chooses to live life with intention and engages in meaningful activities that create purpose aimed at honoring his child, continuing his child's legacy, and using his own suffering for the good of others; is anchored by a continuing bond of love that fuels an ongoing relationship with his child; and needs a supportive community to sustain him as he travels down the healing road where it is possible to find faith, hope, and love while being forever transformed by loss. Findings amplify fathers' voice so nurses gain a deeper understanding of their experience.

Best Practices for Notification of Unexpected, Violent, and Traumatic Death: A Scoping Review

BACKGROUND

Death reporting is a delicate task. The ways in which it is carried out can have a significant impact on both the recipient and the notifier, especially in the event of a sudden, violent, and traumatic death. Empathetic, sensitive, and attentive communication with survivors can represent a first opportunity to support the bereavement process. The acquisition of specific skills for the delivery of the death notification is necessary for the professional who carries out the communication to increase self-efficacy, knowledge, and perception of competence in this area.

OBJECTIVE

To map what the literature has produced on the theme of best practices for the notification of unexpected, violent, and traumatic deaths and to provide guidance for the formulation of appropriate best practices and the development of effective educational programs.

METHODS

A review was conducted using the PRISMA Scoping Review extension on English language literature published between 1966 and 2022.

RESULTS

Starting from the initial 3781 titles, 67 articles were selected. From a thematic point of view, the analysis of the contents made it possible to identify five dimensions: (1) general guidelines in relation to various professional figures; (2) specific protocols; (3) guidelines for notifying death to children; (4) guidelines for notification of death by telephone; and (5) recommendations and suggestions for death notification training programs.

DISCUSSION

Death notification is configured as a process, divided into sequential phases. The act of notification constitutes the central phase during which communication is carried out. The communication of death is context-specific; therefore, it should require the creation of specific protocols for the various professions involved in the task, along with targeted theoretical and practical training.

CONCLUSIONS

The importance of defining specific guidelines for the various professionals and standardized programs of theoretical and practical training emerges. The implementation of future sectoral studies will allow evaluations of the effectiveness of these protocols and programs.

Evaluation of the CARES Skills Framework as a Peer Support Model in the Paramedic Undergraduate Curriculum: Facilitating Challenging Discussions in a Safe Environment

OBJECTIVE

Infant or child death is reported as being the most distressing type of case paramedics attend. Student paramedics also identify supporting bereaved families as an area associated with low confidence. This study evaluated the CARES skills framework (Connect to emotion, Attention training, Reflective listening, Empathy, Support help seeking) as a peer support model to encourage student paramedics to talk about grief and death related to infants and children.

METHOD

A convenience sample of first-year paramedic students (target n = 154) was recruited from a single Australian regional university. A modified nominal group technique method was used following a student debriefing session designed to identify problems, generate solutions, and make decisions regarding the efficacy of the CARES skills framework.

RESULTS

Of 154 eligible participants, 141 participated (92% response rate). Peer social support normalized students' emotions related to death and dying. Although naming emotions was challenging, students reported that the CARES model facilitated a safe environment to talk about death and dying. Students reported feeling heard and connected to their peers during the exercise and an enhanced sense of belonging after the exercise.

CONCLUSIONS

Findings contribute to evidence that suggests the CARES model is a useful mechanism to enhance peer social support in paramedic students.

Receiving Notification of Unexpected and Violent Death: A Qualitative Study of Italian Survivors

(1) Background: The loss of a significant person can be especially traumatic when death comes without warning and is due to causes such as suicide, murder and accidents. The way an individual is informed about the loss can affect the way of adapting to the loss and the quality of life of survivors. Communication modalities of the notifier may deeply influence the bereavement process. Aim: The present investigation aimed to explore the experience of those who received communication of such a type of death by a professional figure. (2) Method: Snowball sampling was used to recruit the participants to this qualitative study. Social networks, word of mouth and researchers' acquaintances were used, including clients of the NGO De Leo Fund. A total of 52 Italian people (eight males and forty four females, mean age = 49.44; SD = 14.23) who received notification of the death of a loved one by police officers or by health professionals participated in the study. Deaths involved cases of suicide, murder, road accident and mountain accident. (3) Results: The following four key themes were identified: (a) how the communication took place; (b) reactions; (c) support; and (d) coping strategies. Only 22 participants reported having received clear information about the dynamics of what happened; the rest of the sample obtained only poor or ambiguous information. The majority of participants sought or received informal support from family and friends immediately after notification; however, some participants experienced a total lack of support. The opportunity to see the body of the loved one for the last farewell, when denied, caused discomfort in recipients of the news. (4) Conclusions: Even the impactful notification of a traumatic death such as suicide or road accident can be mitigated by the appropriate behaviour and attitude of notifiers, who should always avoid providing generic or ambiguous information about what happened. The notification process should not end with the simple transmission of the communication, but should also look at the following phases by including referral to supportive networks or bereavement services, aimed at assisting individuals in the immediate aftermath but also in the long term.

Guidance for Pediatric End-of-Life Care

The final hours, days, and weeks in the life of a child or adolescent with serious illness are stressful for families, pediatricians, and other pediatric caregivers. This clinical report reviews essential elements of pediatric care for these patients and their families, establishing end-of-life care goals, anticipatory counseling about the dying process (expected signs or symptoms, code status, desired location of death), and engagement with palliative and hospice resources. This report also outlines postmortem tasks for the pediatric team, including staff debriefing and bereavement.

Metaphors that shape parents' perceptions of effective communication with healthcare practitioners following child death: a qualitative UK study

OBJECTIVES

To offer an interpretation of bereaved parents' evaluations of communication with healthcare practitioners (HCPs) surrounding the death of a child.

DESIGN

Interpretative qualitative study employing thematic and linguistic analyses of metaphor embedded in interview data.

SETTING

England and Scotland.

PARTICIPANTS

24 bereaved parents (21 women, 3 men).

METHODS

Participants were recruited through the True Colours Trust website and mailing list, similar UK charities and word of mouth. Following interviews in person or via video-conferencing platforms (Skype/Zoom), transcripts first underwent thematic and subsequently linguistic analyses supported by NVivo. A focused analysis of metaphors used by the parents was undertaken to allow in-depth interpretation of how they conceptualised their experiences.

RESULTS

The findings illuminate the ways parents experienced communication with HCPs surrounding the death of a child. Key findings from this study suggest that good communication with HCPs following the death of a child should acknowledge parental identity (and that of their child as an individual) and offer opportunities for them to enact this; taking account their emotional and physical experiences; and accommodate their altered experiences of time.

CONCLUSIONS

This study suggests that HCPs when communicating with bereaved parents need to recognise, and seek to comprehend, the ways in which the loss impacts on an individual's identity as a parent, the 'physical' nature of the emotions that can be unleashed and the ways in which the death of a child can alter their metaphorical conceptions of time.

The Impact of Police Behavior During Death Notifications on Mental Health of the Bereaved: A Cross-Sectional Study

The delivery of death notifications may affect the mental health of bereaved individuals. Police officers are often the first people with whom the bereaved have contact in this exceptional situation. Therefore, it is essential to assess the behavior of police officers and the impact on the bereaved. We examined the experiences of 86 individuals who received the notification through the police and assessed symptoms of prolonged grief, depression, and posttraumatic stress symptoms. The interaction with police was associated with posttraumatic avoidance behavior and the presence of another supporting person was associated with higher scores of depression. Handing out information material and staying with the bereaved was related to a positive evaluation of police behavior. It appears important to identify helpful and problematic behavior for a better understanding and for an adaptation of existing guidelines.

Managing Death in the Field: Prehospital End-of-Life Care

CONTEXT

Historically, the focus of prehospital care has been life-saving treatment. In the absence of a nonhospital do-not-resuscitate (DNR) order, prehospital providers have been compelled to begin and continue resuscitation unless or until it was certain that the situation was futile; they have faced conflict when caregivers objected.

OBJECTIVES

The purpose of the study was to explore prehospital providers' perspectives on how legally binding documents (nonhospital DNR order/medical orders for life-sustaining treatment) informed end-of-life decision making and care.

METHODS

This exploratory study used mixed methods in a sequential nondominant two-stage convergent quantitative and qualitative design. Phase I involved the collection of survey data. Phase II involved in-person semistructured interviews.

RESULTS

Surveys were completed by 239 participants, and 50 follow-up interviews were conducted. Survey data suggested that 73.7% felt confident when there was a DNR order and they did not initiate resuscitation, and 58.2% felt confident working through family disagreement when cardiopulmonary resuscitation was requested but there was a DNR; 66.1% felt confident explaining the dying process when death was imminent, and 55.7% felt comfortable telling a family that a patient was dying. Four themes emerged: changing standards of care; eliminating false hope; transitioning care from patient to family; and transferring care after death.

CONCLUSION

Prehospital providers provide support and care when they tell families that someone has died. Being able to comfort and be present with acute grief on scene is an important and evolving role for prehospital providers who manage death in the field.

Notification of Unexpected, Violent and Traumatic Death: A Systematic Review

Background: The way the death of a person is communicated can have a profound impact on the bereavement process. The words and expressions that are used to give the tragic news, the characteristics of who communicates it, the physical setting in which the notification is given, the means used (e.g., in person, via phone call, etc.) are just some of the factors that can influence the way survivors face one of the most difficult moments in their lives. Aim: To review the literature on the topic of death notification to verify the state of the art related to this important procedure. Methods: A systematic review was conducted with PRISMA criteria on English-written materials produced from 1966 to 2019. Results: Out of the initial 3,166 titles considered, 60 articles were extracted for this review. A content analysis has revealed four main areas of interest: (1) protocols and guidelines; (2) emotional reactions of recipients and notifiers; (3) professional figures involved in the notification process; and, (4) types of death. Discussion: The communication of death represents a complex and stressful experience not only for those who receive it but also for those who give it. Alongside the acquisition of a necessary technique and execution methods, the process should involve the selection of notifiers based on personality characteristics and communication styles. Conclusion: Indications for the need of better training and protocols sensitive to different circumstances emerge. Adequate preparation can positively influence the quality of communication and the effects it produces, both on recipients and notifiers. In vocational training, more space should be devoted to this demanding task.

Developing the Comfort Care Case: An End-of-Life Resource for Pediatric Patients, Their Families, and Health Professionals

Caring for a child in hospital who is approaching death, in the terminal phase, requires a focus on caring for the physical, emotional, and spiritual needs of the child and family. Health professionals caring for these children and families may need to shift their focus from a treatment-focused approach aimed at cure or maintaining life to a comfort-focused approach. The Comfort Care Case (CCC) is a collection of resources designed for use in hospital to ease suffering and facilitate comfort within a pediatric end-of-life (EOL) context. The resources are intended to support the child, the family, and the health professionals involved in EOL care. This article describes the development, implementation, and education associated with the CCC in a tertiary pediatric hospital.

Bereaved parents' experiences of the police in the paediatric intensive care unit

BACKGROUND

A child's death in the intensive care unit is often sudden and unexpected, requiring the involvement of the state coroner to investigate both the cause and the circumstances surrounding the death. This process often involves the police, who arrive in intensive care to identify the body and collect statements from the parents. At present, very little is known about parents' experiences of this process.

OBJECTIVES

To explore bereaved parents' experiences of police presence in intensive care, as part of routine coronial investigations. The findings arose from a larger study on bereaved parents' experiences of the death of a child in the intensive care unit.

METHODS

Secondary analysis of incidental data from a larger grounded theory study. Nine bereaved parents from two paediatric intensive care units (PICUs) mentioned police presence in the PICU during their original audio-recorded, semistructured interviews. These data were extracted, and thematic analysis techniques were used to identify key themes.

RESULTS

Three main concepts were identified with the parents' experiences: (i) timing of police interviews; (ii) the impacts of police presence; and (iii) the demeanour of the officers. Overall, the parents' experiences of police presence were negative. They felt that police arrived too soon after their child's death and took too long taking their statements, hindering their ability to say goodbye. The presence of police officers also made parents feel as though they were being accused of involvement in their child's death. Finally, several participants also experienced inappropriate or unsympathetic attitudes from the police officers attending their child's death.

CONCLUSIONS

Findings from our study indicate that parents' experiences of police presence in the PICU as part of a coronial investigation may be negative, leaving lasting impressions on their experiences of their child's death. These findings provide areas for improvements in care delivery and the treatment of newly bereaved parents during the early phases of a coronial investigation.

Which Physicians' Behaviors on Death Pronouncement Affect Family-Perceived Physician Compassion? A Randomized, Scripted, Video-Vignette Study

CONTEXT

Although the death of a loved one is a devastating family event, little is known about which behaviors positively affect families' perceptions on death pronouncements.

OBJECTIVES

The objective of this study was to evaluate the effect of a compassionate death pronouncement on participant-perceived physician compassion, trust in physicians, and emotions.

METHODS

In this randomized, video-vignette study, 92 people (≥50 years) in Tokyo metropolitan area viewed two videos of death pronouncements by an on-call physician with or without compassion-enhanced behaviors, including five components: waiting until the families calm themselves down, explaining that the physician has received a sign-out about information of the patient's condition, performing examination respectfully, ascertaining the time of death with a wristwatch (vs. smartphone), and reassuring the families that the patient did not experience pain. Main outcomes were physician compassion score, trust in physician, and emotions.

RESULTS

After viewing the video with compassion-enhanced behaviors compared with the video without them, participants assigned significantly lower compassion scores (reflecting higher physician compassion) (mean 26.2 vs. 36.4, F = 33.1, P < 0.001); higher trust in physician (5.10 vs. 3.00, F = 39.7, P < 0.001); and lower scores for anger (2.49 vs. 3.78, F = 18.0, P < 0.001), sadness (3.42 vs. 3.85, F = 11.8, P = 0.001), fear (1.93 vs. 2.55, F = 15.8, P < 0.001), and disgust (2.45 vs. 3.71, F = 19.4, P < 0.001).

CONCLUSION

To convey compassion on death pronouncement, we recommend that physicians initiate prompt examination, explain that the physician has received a sign-out, perform examination respectfully, ascertain the time of death with a wristwatch, and reassure the families that the patient did not experience pain.

Patterns in response to chronic terrorism threats: A construct of emotional, cognitive, and behavioral responses among Israeli citizens

Israeli citizens are exposed to unpredictable and chronic terrorism threats that significantly jeopardize their personal sense of safety. The purpose of the present study is to present how Israeli discourse is structured with regard to emotional, cognitive, and behavioral responses to chronic terrorism threats and to understand the range of responses as well as map the risk and protective factors of this existential threat. Semistructured in-depth interviews were conducted with 40 Israeli adults (22 women and 18 men). Qualitative analysis revealed three patterns of responses to ongoing terrorism: emotional, cognitive, and behavioral. Emotional responses include fear, worry, sense of empathy, and detachment. Cognitive responses include situational assessment and pursuit of solutions, the use of traumatic imagining, beliefs in fate and luck, and optimism. Behavioral responses include looking for information, alertness, and habituation. The findings also revealed another response, which combines cognitive and behavioral responses. Some of the responses are innovative and unique to the threat of terrorism. Mapping the responses revealed mental health risk factors, as well as protective factors that can help structure personal and national resilience. These findings have implications on the treatment and prevention of personal and social pathologies, and how to effectively cope with terrorism threats.

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.

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.

Death Notification: Someone Needs To Call the Family

BACKGROUND

The death notification process can affect family grief and bereavement. It can also affect the well-being of involved physicians. There is no standardized process for making death notification phone calls. We assumed that residents are likely to be unprepared before and troubled after.

OBJECTIVE

We investigated current death notification practices to develop an evidence-based template for standardizing this process.

DESIGN

We used results of a literature review and open-ended interviews with faculty, residents, and widows to develop a survey regarding resident training and experience in death notification by phone.

SETTING/SUBJECTS

We invited all internal medicine (IM) residents at our institution to complete the survey.

MEASUREMENTS

Sixty-seven of 93 IM residents (72%) responded to the survey. Eighty-seven percent of responders reported involvement in a death that required notification by phone.

RESULTS

Eighty percent of residents felt inadequately trained for this task. Over 25% reported that calls went poorly. Attendings were involved in 17% of cases. Primary care physicians were not involved. Nurses and chaplains were not involved. Respondents never delayed notification of death until family arrived at the hospital. There was no consistent approach to rehearsing or making the call, advising families about safe travel to the hospital, greeting families upon arrival, or following up with expressions of condolence.

CONCLUSIONS

Poor communication skills during death notification may contribute to complicated grief for surviving relatives and stress among physicians. This study is the first to describe current practices of death notification by IM residents. More training is needed and could be combined with training in disclosure of medical error.

Stillbirth and stigma: the spoiling and repair of multiple social identities

This study investigated mothers' experiences surrounding stillbirth in the United Kingdom, their memory making and sharing opportunities, and the effect these opportunities had on them. Qualitative data were generated from free text responses to open-ended questions. Thematic content analysis revealed that "stigma" was experienced by most women and Goffman's (1963) work on stigma was subsequently used as an analytical framework. Results suggest that stillbirth can spoil the identities of "patient," "mother," and "full citizen." Stigma was reported as arising from interactions with professionals, family, friends, work colleagues, and even casual acquaintances. Stillbirth produces common learning experiences often requiring "identity work" (Murphy, 2012). Memory making and sharing may be important in this work and further research is needed. Stigma can reduce the memory sharing opportunities for women after stillbirth and this may explain some of the differential mental health effects of memory making after stillbirth that is documented in the literature.

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.

Support for mothers, fathers and families after perinatal death

BACKGROUND

Provision of an empathetic, sensitive, caring environment and strategies to support mothers, fathers and their families experiencing perinatal death are now an accepted part of maternity services in many countries. Interventions such as psychological support or counselling, or both, have been suggested to improve outcomes for parents and families after perinatal death.

OBJECTIVES

To assess the effect of any form of intervention (i.e. medical, nursing, midwifery, social work, psychology, counselling or community-based) on parents and families who experience perinatal death.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2013) and article bibliographies.

SELECTION CRITERIA

Randomised trials of any form of support aimed at encouraging acceptance of loss, bereavement counselling, or specialised psychotherapy or counselling for mothers, fathers and families experiencing perinatal death.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility of trials.

MAIN RESULTS

No trials were included.

AUTHORS' CONCLUSIONS

Primary healthcare interventions and a strong family and social support network are invaluable to parents and families around the time a baby dies. However, due to the lack of high-quality randomised trials conducted in this area, the true benefits of currently existing interventions aimed at providing support for mothers, fathers and families experiencing perinatal death is unclear. Further, the currently available evidence around the potential detrimental effects of some interventions (e.g. seeing and holding a deceased baby) remains inconclusive at this point in time. However, some well-designed descriptive studies have shown that, under the right circumstances and guided by compassionate, sensitive, experienced staff, parents' experiences of seeing and holding their deceased baby is often very positive. The sensitive nature of this topic and small sample sizes, make it difficult to develop rigorous clinical trials. Hence, other research designs may further inform practice in this area. Where justified, methodologically rigorous trials are needed. However, methodologically rigorous trials should be considered comparing different approaches to support.

Family Members' Experiences with Viewing in the Wake of Sudden Death

Sudden deaths leave families in crisis and interacting with many professionals from notification through to burial. Whether to view the deceased is often central to discussion. Practice guidelines have evolved over time regarding where, when, how, and why viewing should or should not occur. Unfortunately, there is much contradiction in existing recommendations and a marked absence of a supporting evidence base for the practice of viewing itself, and the influence of this practice on the overall bereavement process. Using a qualitative approach, this study explored the perspectives and experiences of the suddenly bereaved with respect to: viewing or not having viewed; whether or not their viewing experiences have impacted on their bereavement process; and explored particular aspects of their experience such as interactions with various professionals. Results of this study are clustered and presented under three core themes: viewing specifics; intrapersonal responses; and professional interactions.

Support for mothers, fathers and families after perinatal death

BACKGROUND

Provision of an empathetic caring environment, and strategies to enable the mother, father and family to accept the reality of perinatal death, are now an accepted part of standard nursing and social support in most of the developed world. Provision of interventions such as psychological support or counselling, or both, has been suggested to improve outcomes for families after a perinatal death.

OBJECTIVES

The objective of this review was to assess the effects of the provision of any form of medical, nursing, social or psychological support or counselling, or both, to mother, father and families after perinatal death.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 October 2007) and reference lists of articles.

SELECTION CRITERIA

Randomised trials of any form of general support aimed at encouraging acceptance of loss, specific bereavement counselling, or specialised psychological support/counselling including psychotherapy for mother, father and families experiencing perinatal death.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility of trials; a third person subsequently assessed the quality of the identified trials as a part of this review update.

MAIN RESULTS

No trials were included.

AUTHORS' CONCLUSIONS

There is currently insufficient information available from randomised trials to indicate whether there is or is not a benefit from interventions which aim to provide psychological support or counselling for mothers, fathers or families after perinatal death. Methodologically rigorous trials are needed.

The (re)construction of self after the death of a partner to HIV/AIDS

The aim of this study was to explore individuals' self-construals after the loss of a partner from HIV/AIDS for whom they were a caregiver. Seven gay or transsexual bereaved caregivers were interviewed after the death of their partners. The data revealed patterns suggestive of A. Aron and E. N. Aron's (1986) "inclusion of others in the self" (IOS) with partners described as part of participants' identity. Using the metaphor of the IOS, the results illustrate how care-giving became a part of the self as well as aspects of the partner. Upon the death of the partner, the loss resulted in a crisis of meaning due to the loss of the person and relationship that had contributed significance and purpose to life. Regaining meaning involved making sense of both the relationship and the care-giving role.