Living Through the Life-Altering Loss of a Child: A Narrative Review

Family characteristics and childcare patterns associated with early social functioning in cancer-bereaved parents

BACKGROUND

Bereaved parents experience life-long grief after the death of their child from cancer. Parents who can integrate their grief and maintain their social functioning early in bereavement, even in the setting of concurrent psychosocial distress, have improved outcomes. Identifying the factors associated with bereaved parents' early social functioning can guide future supportive interventions.

METHODS

The authors surveyed parents of children who died from cancer at two large centers 6-24 months after death, assessing bereavement experiences using validated and pilot tested tools. Univariable and multivariable logistical regression models were used to examine which family and child demographic, treatment, and end-of-life (EOL) factors were associated with maintained parental social functioning (T scores ≥40 on the Patient-Reported Outcomes Measurement Information System Ability to Participate in Social Roles and Activities-Short Form questionnaire).

RESULTS

One hundred twenty-eight parents of 88 children participated (38% household response rate); most parents identified as female (63%) and White (88%). Parents' median age was 47 years (interquartile range, 10 years); and the median time from the child's death to survey completion was 13 months (interquartile range, 10 months). In multivariate modeling, parents without household material hardship and those who felt prepared for EOL circumstances had increased odds of maintained social functioning (odds ratio, 4.7 [95% confidence interval, 1.6-13.7; p < .004] and 5.5 [95% confidence interval, 1.9-15.9; p < .002], respectively).

CONCLUSIONS

Parents who felt prepared for their child's EOL and those without household material hardship were more likely to have maintained social functioning in the first 2 years after their child's death. Interventions targeting EOL preparedness and alleviating household material hardship may improve bereavement outcomes.

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.].

Supporting Bereaved Family Members: A Qualitative Interview Study on the Experience of Bereavement Counselling by the Bereavement Network Lower Saxony (BNLS) in Germany for Parents Who Have Lost Children or Teenagers

The "Trauer Netzwerk Niedersachsen" ("Bereavement Network Lower Saxony" (BNLS)) aims at supporting families after the loss of a child or teenager due to various causes. This study aims to describe the experiences of bereaved family members with the BNLS counsellors. 12 semi-structured interviews were conducted with parents who had received or were currently receiving BNLS counselling. The interviews revealed the vital role counselling played aiding individuals cope with their grief. Participants valued the bereavement support, which was often lacking in their personal support networks. Counselling assisted parents in returning to daily life and caring for loved ones. Discussing "death" and "dying" helped participants find peace with their loss. Our findings suggest that bereavement counselling should be considered an essential component of healthcare for family members dealing with the loss of a child. Additionally, there is need for awareness and publicity for both the BNLS and its bereavement counselling services.

Perinatal Loss and Parents' Grief Amidst the COVID-19 Pandemic: A Mixed-Method Research

Losing a child is a traumatic event, disrupting life's natural cycle, profoundly affecting the family system, and causing enduring grief. Perinatal death, including ectopic pregnancies, miscarriages, stillbirths, and neonatal deaths, exacerbates this distress. Additionally, the COVID-19 pandemic has challenged healthcare systems and supporting services available to individuals in need. Thus, this research explores experiences of parents facing perinatal loss in 2020-2021, further focusing on the pandemic's impact. Using a mixed-methods design with self-reports and qualitative interviews, this paper presents results from the quantitative protocol, involving an update and follow-up of a previous study. It compares measurements across scales: COVID-19: The Impact of Event Scale-Revised; The Prolonged Grief-13; The Parental Assessment of Paternal/Maternal Affectivity; The Dyadic Adjustment Scale (short version); The Daily Spiritual Experiences Scale; and The Inventory of Complicated Spiritual Grief. In the baseline measurement, 45 parents participated (37 mothers and 8 fathers), with 20 (13 mothers and 7 fathers) contributing to the follow-up and 9 engaging in interviews. Baseline results showed higher scores for mothers compared to fathers, with effect sizes ranging from small to medium (ranging from -0.02 to 0.29), though statistical significance was limited due to the small sample size. Multiple regression analysis for distress measures at baseline identified two significant predictors: maternal/paternal affectivity and gestational week. Additionally, positive support from healthcare professionals emerged as a mitigating factor, particularly in relation to Avoidance. A significant reduction in stress measures and parental affectivity was observed at the 6-month follow-up. Qualitative analysis revealed three themes: Shifts in Self-Perception and Post-Loss Growth; Conflicted Relationship with One's Body; and Negative Impact of COVID-19 vs. Unexpectedly Positive Aspects. In conclusion, the findings emphasize the significance of psychological and psychosocial interventions based on meaning-making processes, along with the importance of spiritual care and empowerment for those navigating perinatal loss.

Changes in Relationships in Bereaved Families: Perspectives of Mothers Who Lost a Child to Cancer

The loss of a child greatly affects the dynamics of interpersonal relationships in bereaved families. This study explored the relationships in bereaved Korean families from the perspectives of mothers after the death of a child due to cancer. We conducted in-depth interviews with 15 bereaved mothers of a deceased child with childhood cancer. Thematic analysis identified 12 subthemes related to bereaved mothers' struggles in grief within three significant themes based on family relationships: (a) relationship with husband; (b) relationship with surviving child or children; and (c) relationships with extended family members. Findings highlight bereaved mothers' need to build supportive family relationships while acknowledging bereaved family members' different grieving styles and their own challenges in grieving the loss of a child.

Early Bereavement Psychosocial Outcomes in Parents of Children Who Died of Cancer With a Focus on Social Functioning

PURPOSE

The early grief experience of parents of children who died of cancer remains understudied. Understanding psychosocial symptomology and functioning of parents early in their bereavement is essential to developing supportive interventions aimed at offsetting poor mental and physical outcomes.

METHODS

Parents of children from two centers who died of cancer 6 to 24 months before were mailed a survey that included validated tools and additional Likert scale-based questions. We used correlation and univariate and multiple regression analyses to assess the associations between psychosocial and grief outcomes and parental social functioning.

RESULTS

One hundred twenty-five parents representing 88 children completed the survey. Most respondents identified as female (63%), White (84%), and non-Hispanic (91%). The mean time since child's death was 14.7 (range, 8-26) months. Bereaved parents' mean score for social functioning was only slightly below normative values, and most parents indicated post-traumatic growth and adaptive coping. Parents had high symptom levels for depression, anxiety, post-traumatic stress, and prolonged grief, with those identifying as female having significantly higher symptom scores. Using multivariate analysis, parental scores for resilience and continuing bonds were associated with higher social functioning scores and parental scores for depressive symptoms and prolonged grief were associated with lower social functioning scores.

CONCLUSION

Although bereaved parents exhibit resilience and positive coping, they also show high levels of psychosocial distress in the first 2 years after their child's death, which may reflect the typical parental bereavement experience. Screening for low parental social functioning may identify parents who would benefit from additional support early in bereavement.

L’expérience à long terme des parents endeuillés en oncologie pédiatrique : une étude rétrospective de 2 à 18 ans après le décès d’un enfant

Objectifs : Cette étude rétrospective et transversale vise à comprendre l’expérience à long terme des parents endeuillés en oncologie pédiatrique et les différences du deuil parental en fonction du genre.

Matériel et méthodes : Un questionnaire multisectionnel coconstruit avec des cliniciens et intervenants en suivi de deuil a été tenu en ligne en 2018 et 2019. Les participants au sondage étaient des parents dont l’enfant était décédé au service d’hématologie-oncologie du CHU Sainte-Justine 2 à 18 ans auparavant. Des sections spécifiques sur les réactions, les changements et les souvenirs ont fait l’objet d’analyses descriptives.

Résultats : Les réponses de 48 parents ont été analysées. Les résultats indiquent que les mères ont tendance à modifier certaines de leurs activités sociales, alors que les pères cherchent plutôt à retrouver leurs habitudes. Les réactions initialement fortes des parents s’atténuent au fil du temps sans disparaître, en particulier la tristesse et les troubles du sommeil. Les parents ont des souvenirs apaisants des interactions et des soins reçus des intervenants en milieux clinique et communautaire même plusieurs années après le décès de leur enfant.

Conclusion : L’offre de soutien psychosocial communautaire et professionnel à long terme est pertinente, de même aux besoins des couples et aux besoins individuels des parents en fonction du genre.

Experiences of Adolescents with Cancer Attending a Tertiary Care Cancer Centre: A Thematic Analysis

Introduction:

Adolescents with cancer experience several psychosocial concerns. Cancer among adolescents contributes to one-fifth of cancers in India. Most of the published empirical literature on adolescents’ views about their cancer experience is from high-income countries.

Objectives:

The objectives of the study were to explore the experiences of adolescents with cancer in India.

Materials and Methods:

Twenty-eight adolescents were purposively recruited and participated in prospectively conducted qualitative interviews conducted at the Tata Memorial Hospital, Mumbai, between 2013 and 2015. Interview data were transcribed and analysed using Braun and Clarke’s reflexive thematic analysis.

Results:

Two themes and several subthemes were generated during the analysis. The transition to the new reality of illness was traumatic. It embodied fear about the unknown, disease and symptoms. The experience was isolating and disfigurement further led to peer separation. Inadequate information made the adolescents anxious and worried, and children and parents experienced moments of severe distress. The love and support received from parents, siblings and extended family facilitated positive coping. Peer support was reassuring and enabled them to have a normalising experience. Discovering their inner strength, acceptance of the situation and faith in God made them resilient and hopeful.

Conclusion:

Adolescents with cancer experience significant emotional concerns, which are often unexplored and unaddressed. An adolescent-specific communication framework and psychosocial programme contextual to the Indian setting may be developed based on the study findings.

Palliative Care in Paediatric Oncology: an Update

Purpose of this Review

The purpose of this review is to describe the evolution of palliative care in paediatric oncology, the needs of children and their families in a paediatric oncology setting, palliative care referral practices in paediatric oncology, outcomes of palliative care referral in paediatric oncology and models of palliative care in paediatric oncology.

Recent Findings

Cancer constitutes 5.2% of the palliative care needs in children. Approximately, 90% of children with cancer lives in low and middle-income countries, constituting 84% of the global burden of childhood cancers. Children in low and middle-income countries have low cure rates and high death rates making palliative care relevant in a paediatric oncology setting. Children with cancer experience pain and physical symptoms, low mood, anxiety, and fear. They feel less resilient, experience low self-worth, and have challenges coping with the illness. The families lead very stressful lives, navigating the hospital environment, and dealing with uncertainties of the future. Palliative care referral in children with cancer improves physical symptoms, emotional support, and quality of life. It enables communication between families and health care providers. It improves end-of-life care support to children and their families and facilitates less invasive diagnostic and therapeutic interventions at the end of life. Worldwide children with cancer are infrequently referred to palliative care and referred late in the illness trajectory. Most of the children referred to palliative care receive some form of cancer-directed therapy in their last days. Children in low and low-middle income countries are less likely to access palliative care due to a lack of awareness amongst paediatric oncologists about palliative care and the reduced number of services providing palliative care. A three-tier model is proposed to provide palliative care in paediatric oncology, where most children with palliative care needs are managed by paediatric oncologists and a smaller number with complex physical and psychosocial needs are managed by paediatric palliative care specialists. There are several palliative care models in paediatric oncology practised globally. However, no one model was considered better or superior, and the choice of model depended on the need, preferences identified, and available resources.

Summary

Children with cancer are sparingly referred to palliative care and referred late and oncologists and haematologists gatekeep the referral process. Knowledge on palliative care referral in paediatric oncology settings might enhance collaboration between paediatric oncology and paediatric palliative care.

Death of children by domestic accidents: unveiling the maternal experience

ABSTRACT Objectives: to unveil the meanings of mothers whose children died as a result of domestic accidents in childhood. Methods: a qualitative research, in the light of Heideggerian phenomenology, with ten mothers whose children died from domestic accidents. It was carried out in a municipality of the Northeast Region of Brazil through phenomenological interviews between May and June 2017. The existential analytic was constituted by the comprehensive moments of the Heideggerian method. Results: the meanings unveiled pointed out that, to understand the sudden death of her child, the mother oscillates between feeling guilty, pointing and denying guilt. She reports emptiness, permanent pain, non-acceptance of her child’s death, and the desire to keep him in her life. In this journey, the fear that brings limitations to her life and that of her other children is revealed. Final Considerations: it was revealed that the death of the child in infancy compromises the integrality of being a mother, indicating the need for systematic and continuous care for the adequate management of the emotional and social effects.

The meaning of losing a child in older adults: a qualitative study

BACKGROUND

After losing their child, elderly parents look for a meaning in this phenomenon. This meaning comes out from their experiences, and their responses to and actions in life are shaped based on this meaning. Therefore, this study was conducted with the aim of "understanding the meaning of losing a child in older adults."

METHODS

This qualitative study was conducted using conventional content analysis method. Using semi-structured face-to-face interviews, data were collected from 15 older adults who had experienced of losing their adult child. Data analysis was performed according to the steps proposed by Graneheim and Lundman, 2004. To prove the trustworthiness of the data, credibility, dependability, confirmability and transferability were used.

RESULTS

The age range of participants was between 61 and 83 years and 73.3% of them were female. The two main categories of "tasting the bitter flavor of life" and "searching for a positive meaning in losing a child" together with the theme of "finding hope in the heart of darkness" were extracted from the participants' experiences.

CONCLUSIONS

Despite the grief of losing a child, which had cast a dark shadow over the parents' lives, the child's liberation from worldly sufferings, his/her presence in a better world, and being hopeful about the grace of God had caused the elderly parents to find hope in the heart of darkness. After identifying the parents with a deceased child, they should be helped through psychological counseling and care of the healthcare team so that they can adapt to this situation by finding a positive meaning in losing their child.

The parental role before and after SIDS

Role confusion is a prominent constituent symptom of Prolonged Grief Disorder in parents after their infants die from sudden infant death syndrome (SIDS). We interviewed 31 parents of SIDS infants 2-5 years post-loss examining the parental role before death, at the time of loss, and in bereavement. Thematic analysis found disruption of the role and re-imagined responsibilities for their child's physical security, emotional security, and meaning. Tasks within these domains changed from concrete and apparent to representational and self-generated. Parents in bereavement locate ongoing, imperative parental responsibilities, particularly asserting their child's meaningful place in the world and in their family.

Informing mothers of neonatal death and the need for family-centered bereavement care: A phenomenological qualitative study

PURPOSE

To understand the lived experience of mothers surrounding the time of being informed of neonatal deaths in intensive care units.

DESIGN

A phenomenological qualitative approach was employed.

METHODS

Twelve mothers (age 24-41 years) were identified from the neonatal mortality records of two large neonatal intensive care units with high neonate turnover rates in Amman, Jordan. Data were collected using semistructured interviews with the participants. Interpretive phenomenology was used to generate themes regarding the essence of the mother's experience.

RESULTS

Critical analyses of mothers' accounts revealed three major themes: (a) Minimize the hurt, which described how mothers intuited overprotection by their families while the news was conveyed indirectly to them; (b) The striking reality of death, which captured mothers' distressing experiences while realizing the loss of their neonates; and (c) Farwell my baby, which accentuated mothers' needs and experiences while neonates' bodies were honored and prepared for burial per the cultural norms in Jordan.

PRACTICE IMPLICATIONS

Our findings highlighted the complex dynamics of familial interactions and cultural influences on mothers' bereavement experiences at the time of neonatal death. The grieving mothers expressed unfulfilled needs of receiving professional bereavement support at the time of neonatal death. Strategies are needed to optimize the supportive role of specialized nurses in providing family-centered bereavement care to mothers and their families who experience neonatal death.

Palliative and end of life care for a child: Understanding parents' coping strategies

AIM

Understanding of coping strategies that parents use before the death of their child is crucial and will enable us to best provide support. The current study aimed to explore parents' coping strategies, and map these onto an existing theoretical framework.

METHODS

Bereaved parents and parents of a child with a life-limiting/threatening condition were interviewed to investigate coping strategies, recruited through Intensive Care Units (2 Neonatal, 2 Paediatric, 1 Paediatric Cardiac) and a children's hospice. Analysis focused on coping strategies and mapping these onto the framework.

RESULTS

24 parents of 20 children were interviewed and identified. Parents use a variety of coping strategies (n = 25) such as humour, staying positive, advocating and staying strong for others, expressing emotions and preparing, while also living life to the full, supported by others. The themes were successfully mapped onto the theoretical framework, which focuses on the constructs of approach and avoidance, as well as coping for self and others.

CONCLUSION

The findings have provided a detailed account of the breadth and depth of coping strategies parents use, including those classed as avoidance. The strategies were successfully mapped onto the theoretical framework. Future research should investigate changes over times, and associations to negative long-term outcomes.

An Evaluation of By My Side: Peer Support in Written Form is Acceptable and Useful for Parents Bereaved by Childhood Cancer

CONTEXT

Cancer is the leading cause of nonaccidental death in childhood, with the death of a child representing a devastating loss for families. Peer support offers a valuable way to support parents' adjustment in bereavement. The By My Side book provides written peer support by sharing bereaved parents' stories to normalize grief experiences and reduce parents' isolation. It is available free of charge.

OBJECTIVES

This project evaluated the acceptability, relevance, emotional impact, and usefulness of By My Side.

DESIGN

Bereaved parents and health care professionals (HCPs) provided feedback via a questionnaire. We used descriptive statistics and qualitative analysis of open-ended responses to analyze the data.

SETTING/PARTICIPANTS

We mailed a study invitation and evaluation questionnaire to parents and HCPs who ordered a copy of By My Side.

RESULTS

About 24 bereaved parents and seven HCPs provided feedback. Parents thought the book's length (91.7%) and amount of information (83.3%) was just right. About 75% of parents reported that the book made them feel that their reactions to their child's death were normal and/or appropriate. Parents reported positive and negative emotional reactions to the book (e.g., 87.5% felt comforted, 87.5% felt sadness). All parents and HCPs reported that the book provided useful information about grief. About 83.4% of parents and 85.7% of HCPs would recommend it to others.

CONCLUSION

By My Side was acceptable and useful to bereaved parents and HCPs. Results suggest that peer support in written form may help normalize aspects of grief and comfort parents bereaved by childhood cancer.

Duelo en el cuidador del niño fallecido por cáncer: revisión exploratoria

El objetivo de esta revisión fue sintetizar el abordaje metodológico de estudio e integrar los hallazgos del proceso de duelo en cuidadores de niños fallecidos por cáncer. Se realizó una revisión exploratoria de literatura de 19 estudios publicados en revistas indexadas entre el 2010 y 2017. Los hallazgos fueron tratados con técnicas de codificación abierta inductiva. Los resultados evidenciaron un abordaje mayormente cualitativo, con participación de padre y madre, con un año entre la muerte del niño y el ingreso al estudio. Los resultados de los estudios revelaron que debido a que el duelo se vive como respuesta a la ruptura física del vínculo con el niño, es a través del trabajo sobre vínculos que el duelo puede superarse. Los vínculos clave son los que se tienen con el niño fallecido, con los hijos vivos, con el cónyuge, con la familia y el equipo de salud. Por lo que se requiere acompañamiento continuo y compasivo al cuidador desde el momento del diagnóstico del niño con cáncer, que permita construir vínculos asertivos. Posterior a la muerte del niño, es necesario mantener la continuidad del cuidado y propender por que el cuidador participe en grupos de apoyo.

Lived experience of a child's chronic illness and death: A qualitative systematic review of the parental bereavement trajectory

To understand the lived experience of parents who have lost their child to a chronic life-limiting condition, six major databases were searched by adhering to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Articles were screened for appropriateness using the Sample, Phenomenon of Interest, Design, Evaluation, Research type tool, and relevant qualitative studies were selected for full-text data analysis using Thematic Synthesis. Findings were categorized into 13 themes that were further organized into a four-phase trajectory of parental bereavement experience of child loss, namely: Liminal Margin, Holding Space, Navigating Losses, and Reconstructing Lives. The findings are discussed in the light of existing literature with practical recommendations for enhancing parental bereavement support services.

Parental coping in the context of having a child who is facing death: A theoretical framework

Objective:

While improvements in healthcare have resulted in children with complex and life-threatening conditions living longer, a proportion of them still die. The death of a child puts parents at increased risk for anxiety, depression, and complicated grief. Increasing our understanding of the coping strategies that parents use under such extreme circumstances will enable us to best provide support to families, before and after a child's death. Our aim herein was to develop a theoretical framework of parental coping.

Method:

Evidence from the literature was employed to develop a theoretical framework to describe parental coping in the context of having a child with a life-limiting illness who is declining and facing eventual death.

Results:

The reasoning and argument consists of three guiding elements: (1) the importance of approach as well as avoidance (as coping strategies) in the context of managing the extreme emotions; (2) the importance of the social aspect of coping within a family, whereby parents cope for others as well as for themselves; and (3) the importance of a flexible and balanced coping profile, with parents using different coping strategies simultaneously. Central to the proposed framework is that effective coping, in terms of adjustment, is achieved by balancing coping strategies: accessing different coping strategies simultaneously or in parallel with a specific focus on (1) approach and avoidance and (2) coping aimed at self and others.

Significance of results:

Understanding of parental coping strategies is essential for health professionals in order to support parents effectively.

Empowering Bereaved Parents Through the Development of a Comprehensive Bereavement Program

Parents who experience the loss of a child have unique and valuable insights into the grief journey and can help health care providers identify key components intrinsic to the development, implementation, and maintenance of a comprehensive bereavement program. The bereavement program at St. Jude Children's Research Hospital was developed by pediatric palliative care experts in collaboration with bereaved parents to standardize and improve the institutional support provided to families around and after the death of a child. This article describes the components of a parent-derived bereavement program and presents early results on the effects of specific program components. The program, under the leadership of the bereavement coordinator, includes clinical and supportive interventions offered throughout the grief journey, parent-created bereavement support materials, and opportunities for parents and families to participate in research, quality improvement initiatives and educational interventions. Parents report that services and interventions provided through the bereavement program are beneficial to families after the death of their child. In addition, both health care providers and bereaved parents report that participation in educational interventions positively impacts their experiences as clinicians and parents, respectively. The innovative nature of this parent-driven, comprehensive bereavement program may serve as a paradigm for the development of bereavement programs in the fields of pediatrics, palliative oncology and hospice and palliative medicine.

Helping parents live with the hole in their heart: The role of health care providers and institutions in the bereaved parents' grief journeys

BACKGROUND

Bereaved parents experience significant psychosocial and health sequelae, suggesting that this population may benefit from the ongoing extension of support and resources throughout the grief journey. The interaction of hospital staff with patients and families at the end of a child's life and after death profoundly affects parental grief, offering a unique opportunity for the medical community to positively impact the bereavement experience. The current study was conducted to explore the role of the health care team and medical institutions in the grief journeys of parents whose child died a cancer-related death.

METHODS

Eleven bereaved parents participated in 2 focus groups. Responses to each of the 3 main prompts were coded and analyzed independently using semantic content analysis techniques.

RESULTS

Four main concepts were identified within the parental narratives, including the importance of strong and ongoing relationships between providers and bereaved families, the importance of high-quality communication, the effect of negative experiences between providers and families on parental grief, and the importance of the institution's role in the grief journeys of bereaved parents.

CONCLUSIONS

Bereaved parents consistently identified the critical role played by medical staff and medical institutions throughout the grief journey. Key components of bereavement support identified by parents should serve to guide the actions of providers as well as provide a template for the development of a comprehensive bereavement program within an institution. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2757-2765. © 2016 American Cancer Society.