Trajectory of parental hope when a child has difficult-to-treat cancer: a prospective qualitative study

Parental and Young Adult Perspectives on Investigative Genomic Tumor Profiling in High-Risk, Recurrent, or Rare Pediatric Cancers: A Qualitative Study

BACKGROUND

Although research has improved the prognosis of childhood cancer, many challenges remain, especially for high-risk, recurrent, and rare cancers. The recognition that diverse cancer types may share molecular alterations that can be therapeutically targeted has stimulated "precision medicine" approaches in research. Understanding parent and patient interest in genomic-derived therapeutic options in the clinical setting is limited and offers a potential for improved care.

METHODS

A qualitative study was conducted to explore how young adult (YA) patients and parents of children and adolescent patients regard targeted therapy options. These patients had high-risk, recurrent, or rare cancer for which there was no known curative therapy and were enrolled in a study evaluating investigational genomic tumor profiling. Clinical data were retrieved from medical records, and interviews were conducted.

RESULTS

Seventeen participants were interviewed (11 parents and six YA patients). Six themes emerged: (i) Genomic Understanding, (ii) Partnerships in Decision-Making, (iii) Connection with and Trust in Providers, (iv) Quality-of-Life (QOL) Considerations, (v) Understanding of Prognosis, and (vi) Nurturing Hope. Treatment decision-making is complex and depends on the connection (with providers and others), understanding (of prognosis, genomic literacy), care goals (QOL considerations), and planning for the future (hope).

CONCLUSIONS

Participants favored partnership in decision-making, expressed trust in their providers, and recognized the value of research. Engaging parents and YA patients in the planning of precision medicine translational research may be a path to designing an integrated research and care model that maximizes translational research implemented in real time, leading to improved outcomes.

Functions of communication during emergency care of children with medical complexity: Caregiver perspectives

OBJECTIVE

We investigated communication experiences of caregivers of children with medical complexity (CMC) during emergency care.

METHODS

Fifteen caregivers of CMC participated in semi-structured interviews regarding communication while seeking care for their child in the emergency department (ED). Thematic analysis was applied using a previously established functional communication model as an a priori framework.

RESULTS

Each of the previously established 8 core functions of communication were identified in this population. "Building relationships" manifested as clinicians soliciting caregiver input and responding to the needs of the caregiver. "Exchanging information" included clearly explaining next steps to caregivers. "Responding to emotions" acknowledged the inherent distress of seeking emergency care. "Providing validation" included recognizing caregivers as the expert of their own child. "Enabling self-management" manifested as identifying caregiver needs and directing toward resources. "Making decisions" manifested as involving caregivers in the decision-making process and recognizing caregiver decision fatigue. "Managing uncertainty" involved developing plans with caregivers. "Supporting hope" was the least commonly described function and manifested as emphasizing positive aspects of a child's condition. Many caregivers described negative communication experiences in which their concerns and insights were unheard or invalidated.

CONCLUSION

Caregivers of CMC described communication experiences and goals that align with 8 communication functions that were identified in other serious childhood illnesses with unique operationalizations.

PRACTICE IMPLICATIONS

This communication framework can support ED clinicians in better understanding the communication needs of caregivers of CMC during emergency care.

Hope and relationship dynamics among couples faced with their child's cancer: A dyadic phenomenological interpretative analysis

PURPOSE

The onset of paediatric cancer leads to changes in the functioning of the parental couple. The interactions and interdependence between partners affect their individual and dyadic adjustments. Hope can enable parents to cope with difficulties and alleviate their distress. The aim of this study is to explore how both partners experience their relationship dynamics and hope within the couple.

METHOD

This qualitative study focused on 7 couples whose child was in remission from cancer; each parent was interviewed separately. The semi-structured interviews were subjected to interpretative phenomenological analysis.

RESULTS

Three themes were found to characterise the experiences of couples faced with their child's cancer. "Captain and first mate" emphasises the gendered and hierarchical distribution of roles based on the analogy of a crew struggling against the threat of cancer. "The emotional compass" focuses on how emotions guide each partner's attempts to meet their own need for emotional expression and that of their partner. "In the same boat, with divergent hope sails" reflects the complex and diverse ways in which hope and forms of hope are expressed, perceived as a resource which is often precious, sometimes viewed as unthinkable because it reflects the violence associated with the despair of the situation and transferred from one parent to the other.

DISCUSSION

These findings highlight the need to focus on the organisation of role, the interaction of emotional needs and the dynamics of hope within parental dyads to optimise the management of couples faced with their child's cancer.

The implementation and strategy of triadic communication in pediatric oncology: a scoping review

Triad child-parent-professional communication is considered a priority in evaluating and optimizing therapeutic alliance in pediatric oncology. This scoping review aimed to map the existing evidence in implementation, influencing factors, and strategies of triadic communication in pediatric oncology. Using Arksey and O'Malley's framework, we searched 5 databases and grey literature until June 15th, 2024. Two researchers selected studies and extracted data independently. The PAGER framework was employed to summarize the implications of existing research to inform future research and practice. A total of 24 articles were included. Healthcare professionals usually initiate triadic communication. Communication topics rarely focused on prognosis, emotions, and end-of-life care. The triad child-parent-professional exhibited similarities in language, emotional, and decision-making communication preferences but differed regarding skills and information preferences. The roles of the triad parts were unclear, especially nurses' role, responsibilities, and contributions were seldom specified. Factors influencing the implementation spanned individual, organizational, and socio-cultural levels. Five types including 21 specific suggested strategies were identified to facilitate implementation, yet few strategies were adopted by patients and caregivers, and limited effectiveness studies have evaluated specific strategies. Overall, while triadic communication has received considerable attention in the world, its practical implementation in real-world settings remains largely underdeveloped. IMPACT: Our research has mapped the global trajectories of triadic communication between child-parent-professional throughout the cancer journey. A precise delineation of roles and responsibilities within the triadic communication framework in pediatric oncology is crucial for augmenting collaborative efforts and achieving optimal coordination among stakeholders. Healthcare professionals could partner with families to comprehend individual communication preferences, cultivating a collaborative relationship that honors each participant's needs and enhances informed decision-making. The findings equip healthcare professionals with a range of strategies to navigate communication with children with cancer and their parents.

Experiences of paediatric terminal oncology patients and their parents in palliative care: A qualitative systematic review

PROBLEM

The terminal phase of childhood cancer poses profound physical and mental challenges for children, simultaneously influencing parents and rendering them particularly susceptible to psychosocial issues.

ELIGIBILITY CRITERIA

This review included studies exploring the experiences of either: (1) paediatric terminal oncology patients aged under 18 years, (2) parents with a child facing terminal cancer undergoing palliative care, or (3) parents with a child who had undergone palliative care and died. English language, qualitative journal studies or grey literature of any care settings, geographical locations and publication years were included. Studies exploring the experiences of (1) paediatric terminal oncology not receiving palliative care from qualified healthcare professionals, and (3) non-biological parents or non-parental family members, were excluded.

SAMPLE

A total of 22 studies were included, published between January 2000 and December 2023. Seventy-two children (aged between 5 and 18 years old) and 236 parents (aged between 24 and 57 years old) participated across all studies. Palliative care settings mostly comprised oncology centres, hospitals and homes.

RESULTS

Two themes were identified from the 22 included studies: (1) Navigating rough waters and enduring hardships, and (2) Preparing for end-of-life amidst the looming threat of death.

CONCLUSIONS

This review underscored the importance of integrating palliative childhood cancer care in a holistic, age-specific, family-centred, person-centred and timely manner.

IMPLICATIONS

Paediatric oncology nurses should attend to physical and psychosocial needs of children and parents, fostering familial and social ties while recognising cultural and spiritual needs. Future research could recruit participants of varying ages, genders, and cultures.

Hope experiences in parents of children with cancer: A qualitative meta-synthesis

PURPOSE

To synthesise qualitative research on the parental hope experiences for children with cancer and identify the levels of parental hope experiences and psychosocial adjustment during cancer events.

METHODS

Five electronic databases (Cochrane Library, PubMed, Embase, Web of Science, and CINAHL) and three Chinese databases (CNKI, Wanfang, and VIP) were used to retrieve qualitative studies on the hope experiences of parents of children with cancer from inception to February 2023. The Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) was used to assess the methodological quality of the included studies. Data were synthesised using a thematic analysis.

RESULTS

Four analytical themes were identified: the process and way hope exists, sources of hope, positive effects of hope, and obstacles to hope maintenance.

CONCLUSIONS

Maintaining hope is crucial for parents who are caring for their children with cancer. There are different sources of hope, and targeted interventions can enhance the experience of hope for parents of children with cancer. Families, healthcare providers, and society should pay more attention to the parents of children with cancer and provide them with psychological, social, and financial support to improve their level of hope and quality of care.

The mediating effects of hope on the relationships of social support and self-esteem with psychological resilience in patients with stroke

PURPOSE

To explore the mediating effect of hope in the relationships between social support and self-esteem with psychological resilience among patients with stroke survivors in early rehabilitation.

METHODS

A cross-sectional study design was adopted. Data from a cross-sectional survey of 210 patients undergoing early stroke rehabilitation were analyzed using structural equation modeling. The variables of interest were measured using the Connor Davidson Resilience Scale, the Social Support Rating Scale, the Herth Hope Index, and the Self-Esteem Scale. This article reports according to the STROBE checklist.

RESULTS

A positive relationship was found between social support and psychological resilience (β1 = 0.548), which was mediated by hope (β2 = 0.114), and social support had significant direct effect on resilience (β3 = 0.434). A positive relationship was also found between self-esteem and psychological resilience (β4 = 0.380), which was mediated by hope (β5 = 0.200), and self-esteem had significant direct effect on resilience (β6 = 0.179).

CONCLUSION

According to the results of this study, some strategies can be incorporated into the rehabilitation process to enhance psychological resilience, such as cultivating individual personality characteristics and improving patients' social relationships. In the future, we need to explore methods for improving psychological resilience among patients with stroke in combination with their risk factors to improve their quality of life and reduce the incidence of post-stroke depression.

Experiences with the end-of-life decision-making process in children with cancer, their parents, and healthcare professionals: A systematic review and meta-ethnography

BACKGROUND

Decision-making during the end-of-life (EOL) phase for children with cancer is extremely difficult for parents. We synthesized the qualitative experiences of children with cancer, parents, and healthcare professionals (HCPs), and their social interactions during the EOL decision-making process in the pediatric oncology setting.

METHODS

Meta-ethnography was used to conduct a systematic review and meta-synthesis. We searched four online databases to identify original studies published in English and Japanese and examined 21 relevant studies. Two Japanese reviewers discussed the differences/relationships and included studies that synthesized the translated qualitative findings. A conceptual model of social interactions was created.

RESULTS

We identified four themes regarding children's, parents', and HCPs' experiences: hope and confrontation with the child's death, guidance and support during uncertainty, awareness of being protected and having hope, and mutual unspoken integration of values.

CONCLUSIONS

These themes evince the experiences of children, parents, and HCPs during the EOL decision-making process and suggests a complex three-way social interaction model. While considering such distinctive social interactions during a child's EOL, this study revealed the sharing of prudent information and psychosocial support by HCPs. The findings indicate that hope and uncertainty are key elements for effectively understanding the experiences of children and parents and that EOL decision-making should not be rushed but should be supported by leaving room for uncertainty and acknowledging parents' emotional needs and fostering new hope. Further research into how hope can be further supported in situations that are rife with uncertainty is needed.

Depressive and Anxiety Disorders of Parents of Children with Cancer

Every year in Poland there are approximately 1200 new cases of malignant tumours in children and adolescents. Leukaemia, CNS tumours, and lymphomas are the most frequently diagnosed cancers. Coping with a child’s illness is challenging, which is why many parents suffer from anxiety, depression disorders, and even PTSD (post-traumatic stress disorder). The aim of this study is to assess the anxiety and depression levels of carers of children with cancer. Method: The study participants were 101 carers of children suffering from cancer. The study was conducted using standardized questionnaires: the Zung ccale, HADS scale, and Karnofsky scale, and three questionnaires designed by the author. Results: According to the results of the Karnofsky scale, carers’ anxiety and depression levels were negatively affected by their children’s poor performance. The younger age of children significantly correlated with the severity of depression in their parents. HADS and Zung scale anxiety levels were observed to have statistically significant effect on the severity of depressive disorders. Conclusions: Receiving a diagnosis of childhood cancer contributes to the incidence of depression and anxiety disorders among carers. Carers’ anxiety and depression levels were strongly associated with their child’s age and their child’s performance.

Looking back: Identifying supportive care and unmet needs of parents of children receiving specialist paediatric palliative care from the bereavement perspective

BACKGROUND

This study examined care needs and utilisation of psychosocial support services among parents of children who had received specialist paediatric palliative care, as well as the relationship between need fulfilment and grief. Possible differences between parents of children who died of cancer versus a non-cancer disease were explored.

METHODS

This exploratory study, conducted in two specialist paediatric palliative care facilities, included parents who had lost a child within a period of 0.5 to 8 years before this investigation. From the bereavement perspective, parents reported their needs during paediatric palliative care using the Family Inventory of Needs - Peadiatric II (FIN-PED II). Utilisation of psychosocial support services during paediatric palliative care and after the child's death, as well as potential barriers to accessing services were assessed. Grief symptoms were measured using the Inventory of Complicated Grief - German Version (ICG-D).

RESULTS

Overall, 56 of 157 approached parents participated in the study. Mean time interval after the child's death was 3.2 years. Of the 17 FIN-PED II needs, 13 needs were reported to be very/extremely important to more than 75% of the parents each. Highest ranked needs related to asking questions at any time (100%), sincere care for the child (100%), and information about changes in the child's condition (98%). The highest ranked unmet needs related to hope (61%), interactions with siblings (41-42%), and trust in the health care system (39%). Comparisons showed no significant differences between parents whose child died of cancer (n = 18) versus a non-cancer disease (n = 38). During paediatric palliative care, 61% of the parents had accessed at least one psychosocial support service and 84% had done so after the child's death. The most prominent barriers for accessing services were sufficient informal support (38%), no subjective need (23%), and lack of time (20%). Overall, 52% of the parents showed noticeable symptoms for complicated grief (ICG-D > 25). A higher level of grief symptoms significantly correlated with a lower fulfilment of the need to say goodbye to the child (p = .042) with a medium correlational effect.

CONCLUSIONS

Our findings may help to guide health care professionals in their assessment of parental needs and provision of support to parents during paediatric palliative care.

Parent and Adolescent Perspectives on the Impact of COVID on the Care of Seriously Ill Children

CONTEXT

Few studies have explored the impact of the Coronavirus Pandemic (COVID-19) on the care of seriously ill children which may be especially affected due to the child's vulnerability, complexity of care, and high reliance on hospital-based care.

OBJECTIVE

To explore parental and adolescent perspectives on the impact of COVID-19 on care of seriously children.

METHODS

We recruited a convenience sample of families of seriously ill children between September and December 2020. The study involved a semi-structured interview through Zoom followed by an online sociodemographic survey. Interviews were transcribed and coded using the constant comparison method. The sample intended to represent diversity in child age and diagnoses, and family sociodemographic characteristics.

RESULTS

Sixty-four families were approached; 29 enrolled (response rate 45%), including 30 parents and three AYAs. Most parents and AYAs identified as white (62%). Some families reported new financial hardships, with 17.2% having difficulty paying bills after March 2020 compared to 6.9% before. Emerging themes from interviews included additional roles parents managed due to cancelled services or shifting to telehealth, increased isolation, high emotional distress due increased in-home demands, uncertainty, and visitor restrictions in medical facilities, and benefits and challenges to telehealth. One positive outcome was the use of a hybrid care model whereby families choose telehealth appointments and in-person services, when necessary.

CONCLUSION

Families caring for seriously ill children during COVID-19 face increased challenges. Health systems should consider long-term telehealth/in-person hybrid care models that have potential to improve access to and satisfaction with care.

Therapeutic letters: A qualitative study exploring their influence on the hope of parents of children receiving pediatric palliative care in Portugal

PURPOSE

The purpose of this qualitative descriptive study was to explore the hope experiences of parents of children diagnosed with complex chronic conditions (CCCs) who received therapeutic letters.

DESIGN AND METHODS

A purposive sample of 10 parents of inpatient children with CCCs was recruited from a pediatric palliative care unit in a Portuguese public hospital. A demographic form and audio-recorded semi-structured, face-to-face interviews were conducted with each participant to explore the experiences, processes, and meanings of hope, and to describe how parents of children receiving pediatric palliative care perceived the usefulness of receiving therapeutic letters. The interviews were transcribed verbatim, and using a thematic analysis, a systematic approach to data analysis was completed.

FINDINGS

Data analysis resulted in three main themes including Trust in the Future; Strengthening Hope; and Moments of Hope. Findings highlight the positive influence of therapeutic letters including supporting parental hope, facilitating personal inner-strengthening, recognition of parental skills, and promotion of self-efficacy during hospitalization. The themes and related subthemes add value to the existing literature and highlight the need for supportive palliative nursing care aimed at promoting parental hope.

PRACTICE IMPLICATIONS

To optimize the value of supporting parental hope, therapeutic letters can be delivered at the time of diagnosis, during times of celebration, and when learning the difficult tasks of daily childcare. Additional research can inform the development of a formal hope-based intervention to provide an evidence base from which to enhance the well-being of parental caregivers of children who have CCCs.

Experiences and needs of parents of palliative paediatric oncology patients: A meta-synthesis

INTRODUCTION

Despite palliative care being offered to paediatric cancer patients, it has limited utilisation and often excludes parental support. Therefore, this review aims to consolidate evidence regarding experiences and needs of parents of end-of-life palliative paediatric oncology patients.

METHODS

Six electronic databases were searched as follows: CINAHL, The Cochrane Library, Embase, PubMed, Scopus and PsycINFO. Included studies were appraised using the Critical Appraisal Skills Programme Checklist. They were then analysed using a two-step approach comprising firstly meta-summaries followed by meta-synthesis for generating fresh insights to the topic.

RESULTS

Thirteen studies were included. Three themes emerged as follows: (1) normalising the pain; (2) failure as a parent; and (3) importance of communication and social support. Parental experiences included moving on despite the pain and harbouring hopes for their children. However, parents felt immense guilt and a sense of failure in carrying out their parental roles. Effective communication with healthcare providers, availability of family support and religion were necessary to help them cope.

CONCLUSIONS

Given the emotional challenges faced by parents, healthcare policies and practices should be revised to include parental support in paediatric palliative care services. Future healthcare communication trainings should consider parental need for sensitivity in communication, empathy and kindness from healthcare professionals.

Hope in Iranian mothers of children with cancer: a descriptive correlational study

PURPOSE

This study aims to examine the relationship between the level of hope in mothers who have a child with cancer and its related factors in Iran.

METHOD

A cross-sectional and descriptive correlational design was used in this study. A demographic questionnaire and the Herth Hope Index (HHI) were administered to a sample of 240 mothers who have a child with cancer to assess level of hope. Mothers were also asked to indicate their highest priority hopes such as view of their supportive resources including financial support, psychosocial support, religiosity and spirituality. Data was analysed using descriptive statistics, Spearman's rho, independent sample t test and one-way ANOVA.

RESULTS

The mean HHI score was 35.44 (n = 237). There was a positive correlation between HHI total score and spirituality (r = 0.267, P < 0.001), and psychosocial support (r = 0.281, P < 0.001). No significant differences were found between HHI total score and respondents who saw themselves as a religious person and the family financial support. There was a significant difference in HHI total scores for a mother who has a disabled child (M = 32.92, SD = 2.75; t (235) = 2.00, P = 0.046) and mothers of a child who do not have any disability besides their cancer (M = 35.59, SD = 4.91). No significant differences were found in the HHI total score and different group of the child's diagnoses and the mother's age or/and child's age.

CONCLUSION

Mothers who have a child with cancer with better psychosocial and spiritual support showed a higher level of hope. A thorough knowledge of factors associated with hope in mothers caring for children suffering from cancer could provide a means to further advance the support delivered and the available resources given to the parents, especially the mothers.

A Systematic Mixed-Studies Review of Hope Experiences in Parents of Children With Cancer

BACKGROUND

Hope is negatively associated with parental psychosocial distress and psychological maladjustment as well as an important aspect of emotional well-being and coping for adults with cancer and their caregivers. Yet, little is known about hope experiences of parents of children with cancer.

OBJECTIVE

The aim of this study was to comprehensively describe hope experiences in parents of children with cancer using a systematic mixed-studies review.

INTERVENTION/METHODS

Psych INFO, PubMed, Academic Search Premier, and CINAHL databases were used to retrieve articles published in English between January 2005 and October 2019. Using the systematic mixed-studies review convergent design, qualitative and quantitative data were collected and extracted followed by qualitative synthesis. Seventeen articles met the inclusion criteria. Exclusion criteria were systematic reviews, nonresearch articles, case reports, and abstracts.

RESULTS

Hope is a fundamental source of strength and inner guidance for parents. Findings suggest that hope is negatively correlated with parental psychological distress symptoms and coping dysfunctions. Religiosity, spirituality, and adequate provider-parent communication may strengthen hope in parents.

CONCLUSION

Parental hope may help minimize psychological distress and maladjustment after a child's cancer diagnosis. Open communication channels between providers and parents are critical in preserving hope. An understanding of religiosity, spirituality, optimism, and sociodemographic variables may inform parental psychosocial interventions.

IMPLICATIONS FOR PRACTICE

Early identification of parents with psychological distress is critical as they may struggle more in the absence of hope. Targeted psychosocial interventions may help parents of children with cancer cope better. Ongoing assessments of spiritual needs may be important in sustaining hope.

Bereaved Parents' Perceptions of Infant Suffering in the NICU

CONTEXT

It is challenging to provide supportive intensive care to infants in the neonatal intensive care unit (NICU), giving them every chance for survival, while also trying to minimize suffering for both the infant and parents. Parents who believe their infant is suffering may alter treatment goals based on their perceptions; however, it is unknown how parents come to believe that their infant may be suffering.

OBJECTIVES

To examine bereaved parents' perceptions of infant suffering in the NICU.

METHODS

Parents completed a qualitative interview exploring their perceptions of the level of suffering that their infant experienced at the end of life. Parents whose infant died in a large Midwestern Level IV regional referral NICU from July 2009 to July 2014 were invited to participate. Thirty mothers and 16 fathers from 31 families (31 of 249) participated in telephone interviews between three months and five years after their infant's death.

RESULTS

Four themes emerged from the qualitative analysis: 1) the presence/absence of suffering, 2) indicators of suffering, 3) temporal components of suffering (trajectory), and 4) influence of perceived suffering on parents, infants, and clinical decision making.

CONCLUSION

Parents used signs exhibited by infants, as well as information they received from the health care team to form their perceptions of suffering. Perceived suffering followed different trajectories and influenced the decisions that parents made for their infant. Soliciting parent perspectives may lead to improvements in the understanding of infant well-being, particularly suffering, as well as how parents rely on these perceptions to make treatment decisions for their infant.

Parental experience of hope in pediatric palliative care: Critical reflections on an exemplar of parents of a child with trisomy 18

The purpose of this study is to analyze the experience of hope that appears in a parent's blog presenting everyday life while caring for a child with Trisomy 18 (Edwards syndrome). The author, Rebekah Peterson, began her blog on 17 March 2011 and continues to post information on her son Aaron's care. The analysis of hope in the blog is carried out using a mixed methodology: initial and focused coding using Charmaz's constructed grounded theory and elements of Colaizzi's method. Each aspect of hope is coded through the blog author's statements, from which three main aspects of hope emerge: hope for the longest possible presence of Aaron with his family, hope for control over situations, pain, and symptoms, and existential facets of hope. These various aspects reveal to what extent the experience of hope is unique. Additionally, analyzing the experience of parental hope uncovers the additional problem of inappropriate communication by health care professionals (HCPs) in intensive care units, particularly when discussing the termination of causal treatment. The problem may be solved through proper education for HCPs and serious consideration of parental involvement in order to properly elaborate guidelines on this issue. The three main aspects of parental hope discussed in this paper might expand knowledge on the issue, helping HCPs to better understand the parents' experience of care and to help sustain parental hope in pediatric palliative care.

A conceptual model of barriers and facilitators to primary clinical teams requesting pediatric palliative care consultation based upon a narrative review

BACKGROUND

Despite evidence that referral to pediatric palliative care reduces suffering and improves quality of life for patients and families, many clinicians delay referral until the end of life. The purpose of this article is to provide a conceptual model for why clinical teams delay discussing palliative care with parents.

DISCUSSION

Building on a prior model of parent regoaling and relevant research literature, we argue for a conceptual model of the challenges and facilitators a clinical team might face in shifting from a restorative-focused treatment plan to a plan that includes palliative aspects, resulting in a subspecialty palliative care referral. Like patients and families, clinicians and clinical teams may recognize that a seriously ill patient would benefit from palliative care and shift from a restorative mindset to a palliative approach. We call this transition "clinician regoaling". Clinicians may experience inhibitors and facilitators to this transition at both the individual and team level which influence the clinicians' willingness to consult subspecialty palliative care. The 8 inhibitors to team level regoaling include: 1) team challenges due to hierarchy, 2) avoidance of criticizing colleagues, 3) structural communication challenges, 4) group norms in favor of restorative goals, 5) diffusion of responsibility, 6) inhibited expression of sorrow, 7) lack of social support, 8) reinforcement of labeling and conflict. The 6 facilitators of team regoaling include: 1) processes to build a shared mental model, 2) mutual trust to encourage dissent, 3) anticipating conflict and team problem solving, 4) processes for reevaluation of goals, 5) sharing serious news as a team, 6) team flexibility.

CONCLUSIONS

Recognizing potential team level inhibitors to transitioning to palliative care can help clinicians develop strategies for making the transition more effectively when appropriate.

Long-Term Mental Health Outcomes in Mothers and Siblings of Children With Cancer: A Population-Based, Matched Cohort Study

PURPOSE

Although a diagnosis of childhood cancer can have a profound effect on the entire family unit, its impact on the long-term mental health of family members is not well characterized.

METHODS

A provincial childhood cancer registry in Ontario, Canada, was linked to birth records to identify separate population-based cohorts of mothers and siblings of children diagnosed with cancer between 1998 and 2014. The mother and sibling cohorts were matched to corresponding population controls and linked to health services data. The rate of mental health-related outpatient visits (family physician, psychiatrist) and the incidence of severe psychiatric events (psychiatric emergency department visit, psychiatric hospitalization, suicide) were compared between mothers and siblings and their controls. Possible predictors of mental health outcomes were examined, including demographics, characteristics of the cancer-affected child, and cancer treatment.

RESULTS

We identified 4,773 mothers and 7,897 siblings of children diagnosed with cancer during the study period. Compared with controls, both groups experienced elevated rates of outpatient visits (mothers: rate ratio [RR], 1.4; P < .0001; siblings: RR, 1.1; P < .0001). The risk of severe psychiatric events was not increased in either cohort. Mother and sibling demographic factors associated with increased risk of adverse mental health included younger maternal age at cancer diagnosis, low socioeconomic status, and rural residence among mothers and older sibling age among siblings. Treatment-related variables pertaining to the cancer-affected child were not associated with mental health outcomes. Mental health outcomes clustered within families.

CONCLUSION

Both mothers and siblings experience elevated and prolonged need for mental health-related health care as compared with the general population. Demographic risk factors predict subpopulations at highest risk. Increased psychosocial support for family members during and after cancer therapy is warranted.

Challenges and Priorities for Pediatric Palliative Care Research in the U.S. and Similar Practice Settings: Report From a Pediatric Palliative Care Research Network Workshop

CONTEXT

To dramatically advance the evidence base for pediatric palliative care (PPC) interventions, practices, and programs in the U.S. and similar practice settings, the field needs to better understand the challenges and opportunities for rigorous scholarship.

OBJECTIVES

The Pediatric Palliative Care Research Network conducted a workshop to clarify challenges and identify key priorities.

METHODS

The workshop focused on PPC research topics and methods, including outcomes measurement, qualitative inquiry, analyses of big data, prospective collection of research data, case series and cohort studies, and intervention trials, with synthesizing summary and follow-up discussions. All attendees reviewed and approved the final report.

RESULTS

Five common challenges were identified: patient diversity and small population size; interdependencies and dynamic interactions between child, family members, and disease processes over time; outcomes and measurement; workforce and infrastructure limitations; and presumed burden of PPC research on participants. Seven priorities emerged: bolster training and development of PPC investigators; develop core resources; advance symptom measurement (and measurements of other exposures and outcomes); improve symptom management and quality of life interventions; improve communication, elicitation of goals of care, and decision making; understand family impact and facilitate or improve family adaptation and coping; and analyze and improve systems of care, policy, and education.

CONCLUSION

These challenges and priorities identify key research areas that can guide individual investigators and research funders to advance the field.

The experience of hope in families of children and adolescents living with chronic illness: A thematic synthesis of qualitative studies

AIM

To synthesize qualitative studies on the experience of hope in families of children and adolescents living with chronic illness.

BACKGROUND

Hope is multidimensional, dynamic, and varies according to experienced events, cultural environments and stage of life. The qualitative synthesis of the experience of hope in the paediatric population with chronic conditions is scarce.

DESIGN

Thematic synthesis of qualitative studies.

DATA SOURCES

A systematic literature search in PubMed, CINAHL, LILACS, PsycINFO, Scopus, and Web of Science was performed supplemented by manual search strategies. Thirty-one studies from fifteen countries, published between 1981-2018, were included.

FINDINGS

Findings were integrated into an analytical theme "FAMILY HOPE: KEEPING THE DAY-TO-DAY BALANCE", encompassing the following five descriptive themes: Uncertainty; Support; Information; Between "dark thoughts" and positive thoughts; and Hoping to go back to normality.

CONCLUSION

This thematic synthesis brings a new dimension of hope among families of children and adolescents living with chronic illness. "Family Hope" highlights the influence of the relationships between relatives and the chronically ill child in the balance of hope. It is recommended that health professionals use a family-focused approach to support these families.

IMPACT

Shifting the focus to a family dimension of hope is a promising pursuit that has the potential to inform future nursing practices to support the experiences of families living with chronic illness in the paediatric context. A better understanding of the role and characteristics of family hope will promote the development of more effective interventions for families to adapt to long-term paediatric conditions.

The Influence of Parents' Religiosity or Spirituality on Decision Making for Their Critically Ill Child: An Integrative Review

Background: Religion and/or spirituality are important values for many parents of critically ill children; however, how religion and/or spirituality may influence which treatments parents accept or decline for their child, or how they respond to significant events during their child's illness treatment, remains unclear. Objective: To summarize the literature related to the influence of parents' religiosity or spirituality on decision making for their critically ill child. Design: Integrative review, using the Whittemore and Knafl approach. Setting/Subjects: Data were collected from studies identified through PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL plus), Embase, Scopus, and PsychInfo. Databases were searched to identify literature published between 1996 and 2016. Results: Twenty-four articles of variable methodological quality met inclusion criteria. Analysis generated three themes: parents' religiosity or spirituality as (1) guidance during decision making, (2) comfort and support during the decision-making process, and (3) a source of meaning, purpose, and connectedness in the experience of decision making. Conclusion: This review suggests that parents' religiosity and/or spirituality is an important and primarily positive influence on their decision making for a critically ill child.

Changes Over Time in Good-Parent Beliefs Among Parents of Children With Serious Illness: A Two-Year Cohort Study

CONTEXT

Parents of seriously ill children hold personal beliefs about what they should do to be good parents. How these beliefs change over time is unknown.

OBJECTIVES

The objectives of this study were to describe the pattern of Good-Parent Beliefs over time, and determine whether parents' hopeful patterns of thinking, affect, and perceived child's health are associated with changes in beliefs at 12 and 24 months.

METHODS

Our longitudinal sample included 124 parents of 100 children hospitalized with serious illness. We used latent transition models to classify parents into groups with similar Good-Parent Beliefs during the baseline and follow-up periods and modeled the change in good-parent beliefs over time as a function of covariates using generalized linear mixed models.

RESULTS

Two parent belief profiles emerged from the latent transition model: Loved ("Making sure my child feels loved," n = 61 at baseline) and Informed ("Making informed decisions," n = 63 at baseline). At 12 months, 21 parents (20.4%) had moved into the Loved group and no parents transitioned to the Informed group. By 24 months, eight parents transitioned to the Loved group and four to the Informed group (13.04%). Transition into the Loved group was associated with parents' baseline degree of hopeful thinking and positive perceptions of child's health at baseline.

CONCLUSION

Some parents change their parenting priorities over time. Hopeful patterns of thinking and perception of child health appear to predict change. Clinicians should regularly reevaluate Good-Parent Beliefs over time to promote priority-congruent dialogue.

Prevalence of anxiety, depression, and posttraumatic stress disorder in parents of children with cancer: A meta-analysis

BACKGROUND

For parents, a diagnosis of cancer in their child is a traumatic experience. However, there is conflicting evidence about the risk of developing mental illness among parents following diagnosis. Our objective was to conduct a meta-analysis to determine the prevalence of mental illness in parents of children with cancer.

METHODS

Four databases were searched to identify articles describing the prevalence of anxiety, depression, or posttraumatic stress disorder (PTSD) in parents of pediatric cancer patients. Two reviewers independently screened and extracted data. Subgroup analyses by gender and phase of cancer experience were selected a priori. Studies were reviewed in accordance with PRISMA guidelines.

RESULTS

Of 11 394 articles identified, 58 met inclusion criteria. Reported prevalence was highly heterogeneous, ranging from 5% to 65% for anxiety (pooled prevalence 21% [95% CI, 13%-35%]), 7% to 91% for depression (pooled prevalence 28% [95% CI, 23%-35%]), and 4% to 75% for PTSD (pooled prevalence 26% [95% CI, 22%-32%]). Prevalence was consistently higher than noncancer parental controls. Heterogeneity was not explained by parental gender or child's cancer phase and was instead likely due to significant methodological differences in measurement tools and defined thresholds.

CONCLUSIONS

Parents of children with cancer have a higher prevalence of anxiety, depression, and PTSD compared with population controls. Yet, the reported prevalence of mental illness was highly variable, hampering any conclusive findings on absolute prevalence. To better understand the risk of long-term mental illness in this population and target interventions, future studies must adhere to standardized reporting and methods.

Supporting parental caregivers of children living with life-threatening or life-limiting illnesses: A Delphi study

BACKGROUND

The impact of a child s life-limiting or life-threatening illness is significant on parents who experience a great deal of emotional, physical, and spiritual upheaval. Hope has been identified as an important inner resource for parental caregivers. Specifically, parental hope has been described as having four subproceses including Accepting Reality, Establishing Control, Restructuring Hope, and Purposive Positive Thinking.

PURPOSE

The purpose of this Delphi study was to gather expert opinions from parents and formal care providers about the four subproceses essential to parental hope, to increase understanding of parental caregivers current support needs. As Phase one of a three-phase study, the findings provided direction in the development of a theory-based hope intervention.

DESIGN AND METHODS

A Delphi study consisting of three rounds of survey questions and controlled feedback to experts was employed. Experts suggested strategies for each subprocess and ranked them in order of highest to lowest according to feasibility and effectiveness.

RESULTS

Sixty-eight experts consisting of parental caregivers of children diagnosed with life-limiting or life-threatening illnesses and those who care for them (community members, nurses, social workers, and physicians) were recruited to participate. Through three rounds of survey questions, response rates ranged from 92-97%. A consensus revealed eight major themes that support parental hope: Organize Basic Needs; Connect with Others; Prioritize Self-care; Obtain Meaningful Information; Take Things Day by Day; Advocate for Parental Participation; Manifest Positivity; and Celebrate Milestones.

PRACTICE IMPLICATIONS

This study identified a wide variety of psychosocial needs for parental caregivers. Results also offered direction for a theory-based hope intervention while highlighting the need for additional research in this area. These results will provide the foundation for a booklet parents can work through in their journey of caring for a child with a life-limiting or life-threatening illness.

Sources of parental hope in pediatric oncology

BACKGROUND

Hope is a multidimensional concept that is important for all parents of children with cancer. However, most work has focused on advanced cancer and poor prognoses. We examined hopes of all parents of children with cancer longitudinally during the first year of treatment.

PROCEDURE

Prospective, longitudinal, questionnaire-based cohort study of parents and physicians of children with cancer at two academic pediatric hospitals. Parents reported on general sense of hopefulness and specific hopes at time of diagnosis (N = 374); a subset of parents (N = 164) were followed longitudinally at 4 and 12 months.

RESULTS

Fifty-five percent of parents (N = 206/374) reported being extremely hopeful in general at baseline. Hopefulness did not significantly change over time, and most parents (51-58%) reported being extremely hopeful regardless of prognosis (P = 0.66). Most parents (N = 327/356) considered hope for cure to be an extremely important source of hope; most also reported hope that the child would feel loved (N = 328/356), that the child would have the best possible quality of life (N = 316/356), and that they would always do all they could for the child (N = 300/356). Hope for cure was slightly lower among parents of children with less than a 50% chance of cure at baseline (N = 53/63) when compared to those with better prognoses (moderately likely cure, N = 76/78; very likely cure, N = 198/215) (P = 0.02).

CONCLUSIONS

Many hopes contribute to parental hopefulness, not just hope for cure. This hopefulness persists over time, even when the prognosis is poor. Clinicians should focus on supporting the myriad hopes that contribute to overall hopefulness.

Changes in Parental Hopes for Seriously Ill Children

BACKGROUND

Hopes of parents of children with serious illness play an important role in decision-making and coping. Little is known about how parent hopes change over time. We describe the changes in parent hopes across multiple domains and time intervals, examine hopes in a subgroup of parents whose child died, and explore the maintenance of domains over time.

METHODS

In a mixed-methods prospective cohort study on decision-making, parents of seriously ill children reported demographic characteristics and hopes at baseline and reported any changes in hopes at 4-, 8-, 12-, 16-, and 20-month follow-up visits. Hopes were coded into 9 domains. Hope changes and domain changes were identified for each parent at each visit.

RESULTS

One hundred and ninety-nine parents of 158 patients most often reported hopes in the domains of quality of life (75%), physical body (69%), future well-being (47%), and medical care (34%). Hope percentages increased over time for quality of life (84%), future well-being (64%), and broader meaning (21%). The hope domains reported by parents of children who died were similar to the rest of the sample. The majority of parents who completed 5 to 6 follow-up visits changed at least 1 domain. At the individual parent level, some domains revealed considerable change over time, whereas other domains were stable among a subset of parents.

CONCLUSIONS

The specific hopes and overall areas of hope of parents of seriously ill children vary over time, although most hopes fall within 4 major areas. Accordingly, clinicians should regularly check with parents about their current hopes.

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.

Parents' Experience of Hope When Their Child Has Cancer: Perceived Meaning and the Influence of Health Care Professionals

OBJECTIVE

This study examined the role and importance of hopefulness for parents of children with cancer, how hope relates to parents' experience with the diagnosis, and the influence nurses and other health care professionals have on parents' hope.

METHOD

Using an interview format, 50 parents of children diagnosed with cancer were given the Reaction to Diagnosis Interview, and asked 5 open-ended questions about hope. Answers were analyzed using content analysis. Parents' adaptation to their child's diagnosis was compared with answers to the hope questions.

RESULTS

Parents defined hope as a knowing, belief, or wish regarding their child's health. They emphasized the importance of hope over the course of their child's treatment. Staff increased parents' hope by providing care to children and families, educating parents, and by connecting with and providing a positive outlook for families. Most parents felt there was nothing staff did to decrease their hope.

CONCLUSION

Understanding parents' experiences validates the quality care and connections we make with children and families, and encourages us to consider the effects of our interactions. This underscores the importance of education and support as a means of instilling hope in parents, who are valued, critical members of their child's health care team.

The under reporting of recruitment strategies in research with children with life-threatening illnesses: A systematic review

BACKGROUND

Researchers report difficulties in conducting research with children and young people with life-limiting conditions or life-threatening illnesses and their families. Recruitment is challenged by barriers including ethical, logistical and clinical considerations.

AIM

To explore how children and young people (aged 0-25 years) with life-limiting conditions or life-threatening illnesses and their families were identified, invited and consented to research published in the last 5 years.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, PsycINFO, Web of Science, Sciences Citation Index and SCOPUS were searched for original English language research published between 2009 and 2014, recruiting children and young people with life-limiting conditions or life-threatening illness and their families.

RESULTS

A total of 215 studies - 152 qualitative, 54 quantitative and 9 mixed methods - were included. Limited recruitment information but a range of strategies and difficulties were provided. The proportion of eligible participants from those screened could not be calculated in 80% of studies. Recruitment rates could not be calculated in 77%. A total of 31% of studies recruited less than 50% of eligible participants. Reasons given for non-invitation included missing clinical or contact data, or clinician judgements of participant unsuitability. Reasons for non-participation included lack of interest and participants' perceptions of potential burdens.

CONCLUSION

All stages of recruitment were under reported. Transparency in reporting of participant identification, invitation and consent is needed to enable researchers to understand research implications, bias risk and to whom results apply. Research is needed to explore why consenting participants decide to take part or not and their experiences of research recruitment.

Parental Concordance Regarding Problems and Hopes for Seriously Ill Children: A Two-Year Cohort Study

CONTEXT

Parents of a seriously ill child may have different concerns and hopes for their child, and these concerns and hopes may change over time.

OBJECTIVES

In a mixed-method prospective cohort of parental dyads of children with serious illness, to describe the major problems and hopes perceived for their child, examine the degree of concordance between parents, and assess whether prevalence and concordance change over time.

METHODS

Eighty-four parents (42 dyads) of seriously ill children reported the major problems and hopes for their children at baseline. Thirty-two parents (16 dyads) answered the same questions at 24 months. Problems and hopes were classified into nine domains. Observed concordance was calculated between parents on each domain. Data for parents of 11 children who died are reported separately.

RESULTS

The most common major problem and hope domains at baseline were physical body, quality of life, future health and well-being, and medical care. Parental dyads demonstrated a moderately high percentage of concordance (69%) regarding reported problem domains and a slightly lower percentage of concordance on hopes (61%), with higher concordance for more common domains. Domain prevalence and concordance changed considerably at 24 months. Parents of children who later died showed markedly different patterns of domain prevalence and more extreme patterns of concordance.

CONCLUSION

Parents of children with serious illness may have different perspectives regarding major problems and hopes, and these perspectives change over time. Parents of sicker children are more likely to be in either complete agreement or disagreement regarding the problems and hopes they identify.

Towards culturally competent paediatric oncology care. A qualitative study from the perspective of care providers

In order to gain more insight on the influence of ethnic diversity in paediatric cancer care, the perspectives of care providers were explored. Semi-structured interviews were conducted among 12 paediatric oncologists and 13 nurses of two different paediatric oncology wards and were analysed using a framework method. We found that care providers described the contact with Turkish and Moroccan parents as more difficult. They offered two reasons for this: (1) language barriers between care provider and parents hindered the exchange of information; (2) cultural barriers between care provider and parents about sharing the diagnosis and palliative perspective hindered communication. Care providers reported different solutions to deal with these barriers, such as using an interpreter and improving their cultural knowledge about their patients. They, however, were not using interpreters sufficiently and were unaware of the importance of eliciting parents' perspectives. Communication techniques to overcome dilemmas between parents and care providers were not used and care providers were unaware of stereotypes and prejudice. Care providers should be offered insight in cultural barriers they are unaware of. Training in cultural competence might be a possibility to overcome manifest barriers.

Parental spirituality in life-threatening pediatric cancer

This study addressed parental spirituality in the context of pediatric cancer with a poor prognosis. Drawing upon previous research implementing a longitudinal grounded theory design examining parental hope, 35 parents were interviewed regarding their experiences with an emergent description of the role of spirituality in parents' daily lives. Spirituality included religious beliefs and practices, notions of a higher force or cosmos, relationship with a divine being, as well as elements emerging from meaning-making and relationships. Parental expectations of spirituality remained relatively constant across data collection time points (3-9 months postdiagnosis), although limited variation occurred relative to shifting circumstance (e.g., deterioration of the child's condition). Spirituality appeared to offer: greater acceptance of parents' inability to protect their child from harm related to her/his life-threatening illness, guidance and emotion decompression, and support from one's faith community. Recommendations for integrating spiritual assessment in clinical care practice are offered.

Participation in a clinical trial for a child with cancer is burdensome for a minority of children

AIM

This study explored how parents who had lost a child to cancer felt about them taking part in a clinical trial.

METHODS

A retrospective questionnaire was sent to parents who had lost a child to cancer. They were asked whether their child took part in a clinical trial during their palliative phase, their motives for their child's participation, how they perceived their child's burden and whether they would, hypothetically speaking, enrol again.

RESULTS

The 24 parents of 16 deceased children who had participated in a clinical trial explained their motives for their child's participation. The most common answers, with multiple responses, were treatment for future patients (n = 16), hope for a cure (n = 9) and prolonging their child's life (n = 6). Eight parents said that participating was not burdensome for their child and four said it was very burdensome, with others answering in between. None of the parents would decline participation if they would be in the same situation again.

CONCLUSION

Performing clinical trials, even in a vulnerable population, such as children with cancer at the end of life, may not always lead to increased burden. None of the parents would in future, given the same circumstances, decline participation in a clinical trial.

Children with cancer share their views: tell the truth but leave room for hope

AIM

One in five children diagnosed with cancer will die from the disease. The aim of the study was to explore how children with cancer want to receive bad news about their disease, such as when no more treatment options are available.

METHODS

We conducted individual interviews with ten children with cancer, aged seven to 17 years, at a single paediatric oncology unit in central Sweden. Interviews were audio-taped and analysed with systematic text condensation. Bad news was defined as information about a potentially fatal outcome, such as a disease relapse, or information that the treatment administered was no longer working and that there was no more treatment possible.

RESULTS

All children expressed that they wanted truthful information and they did not want to be excluded from bad news regarding their illness. They wanted to be informed as positively as possible, allowing them to maintain hope, and in words that they could understand. They also wanted to receive any bad news at the same time as their parents.

CONCLUSION

Children with cancer want to be fully informed about their disease, but they also wanted it to be relayed as positively as possible so that they could stay hopeful.

Children with minimal chance for cure: parent proxy of the child's health-related quality of life and the effect on parental physical and mental health during treatment

To assess health-related quality of life (HRQOL) from the time of diagnosis until disease progression in a cohort of children with diffuse intrinsic pontine glioma (DIPG). The assessment was collected from the perspectives of the child and their parents and evaluated the effect of the child's HRQOL on their parents' physical and mental well-being, thus providing insight into the optimal timing of palliative consultation, including anticipatory grief and bereavement services. This longitudinal study assessed 25 parents and their children, ages 2-17 years of age with DIPG across five time-points, baseline and weeks 2, 4, 6, 16, 24. Assessments included the PedsQL 4.0 Core Scales, PedsQL 3.0 Brain Tumor Scale, and Short-Form 36. HRQOL instruments were completed by the child (age ≥5 years) and parent-proxy (ages 2-17 years), with the parent completing the SF-36. Children's reports and parents' proxy of their child's HRQOL indicated poor physical functioning and increased anxiety at the initiation of therapy. A trending improvement in the children's HRQOL was reported by children and parents from baseline to week 6, with a decline at week 16. The childs' parent proxy reported cognitive problems, procedural anxiety and lower overall brain tumor HRQOL were assoicated with poorer self-reported parental mental status. Palliative care consultation should be initiated at the time of diagnosis and is supported in the high physical and emotional symptom burden reported by our patients, with heightened involvement initiated at 16 weeks. Prompt palliative care involvement, mitigating anxiety associated with clinic visits and procedures, management of brain tumor specific symptoms, advanced care planning, anticipatory grief and bereavement services, and care coordination may maximize HRQOL for patients and ensure positive long-term outcomes for parents of children with DIPG.

Pediatric oncologists' coping strategies for dealing with patient death

This research examined pediatric oncologists coping strategies when their patients died of cancer. Twenty-one pediatric oncologists at 2 Canadian pediatric academic hospitals were interviewed about their coping strategies when patients died or were in the process of dying. The grounded theory method of data collection and data analysis were used. Line-by-line coding was used to establish codes and themes and constant comparison was used to establish relations among emerging codes and themes. Pediatric oncologists used engagement coping strategies with primary and secondary responses including emotional regulation (social support and religion), problem solving (supporting families at end of life), cognitive restructuring (making a difference and research), and distraction (breaks, physical activity, hobbies and entertainment, spending time with own children). They also used disengagement coping strategies that included voluntary avoidance (compartmentalization and withdrawing from families at end of life). Given the chronic nature of patient death in pediatric oncology and the emotionally difficult nature of this work, medical institutions such as hospitals have a responsibility to assist pediatric oncologists in coping with this challenging aspect of their work. Future research is needed to evaluate how best to implement these changes on the institutional level to help oncologists cope with patient death and the effect of using these strategies on their quality of life.

Parent Outlook: How Parents View the Road Ahead as They Embark on Hematopoietic Stem Cell Transplantation for Their Child

Pediatric hematopoietic stem cell transplantation (HSCT) offers cure for high-risk malignancies and other conditions, but carries a risk of complications. Parental outlook regarding their child's transplantation course and future health has been largely unexplored. This report presents the Parent Outlook Scale, describes its properties, and examines the outlook of parents embarking on their child's transplantation course and the associated variables. Parents of children scheduled to undergo HSCT (n = 363) at 8 US transplantation centers completed the Parent Outlook Scale, comprising 4 items assessing frequency of the parent's thoughts about the potential difficulty of the child's transplantation (Transplant Difficult subscale) and worsened health (Health Worse subscale). Item responses were rated on a 5-point Likert scale (ranging from "none" to "all of the time") and, along with scale/subscale scores, transformed to 100-point scales, with higher scores connoting greater thought frequency. Psychometrics were explored. Multivariable models identified personal and clinical characteristics associated with scale and subscale scores. The Parent Outlook Scale (α = 0.75) and subscales were found to have sound psychometric properties. Factor loading supported the single scale with 2 subscales representing distinct aspects of overall outlook. Mean scores (Parent Outlook, 52.5 ± 21.7; Transplant Difficult, 64.4 ± 25.6; Health Worse, 40.7 ± 25.7) revealed variability within and across scale/subscales. Significantly different mean subscale scores (P < .001) indicated more frequent Transplant Difficult thoughts than Health Worse thoughts. Clinical factors (solid tumor diagnosis and unrelated donor transplant) and a parent factor (worse emotional functioning) were associated with higher scale and subscale scores. Our findings show that the outlook of parents embarking on their child's HSCT course is varied and not solely a product of clinical factors readily apparent to clinicians. Referring and transplantation clinicians should create opportunities to explore with parents their perspectives and concerns before and during the course of HSCT.

Good-parent beliefs of parents of seriously ill children

IMPORTANCE

Parents' beliefs about what they need to do to be a good parent when their children are seriously ill influence their medical decisions, and better understanding of these beliefs may improve decision support.

OBJECTIVE

To assess parents' perceptions regarding the relative importance of 12 good-parent attributes.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, discrete-choice experiment was conducted at a children's hospital. Participants included 200 parents of children with serious illness.

MAIN OUTCOMES AND MEASURES

Ratings of 12 good-parent attributes, with subsequent use of latent class analysis to identify groups of parents with similar ratings of attributes, and ascertainment of whether membership in a particular group was associated with demographic or clinical characteristics.

RESULTS

The highest-ranked good-parent attribute was making sure that my child feels loved, followed by focusing on my child's health, making informed medical care decisions, and advocating for my child with medical staff. We identified 4 groups of parents with similar patterns of good-parent-attribute ratings, which we labeled as: child feels loved (n=68), child's health (n=56), advocacy and informed (n=55), and spiritual well-being (n=21). Compared with the other groups, the child's health group reported more financial difficulties, was less educated, and had a higher proportion of children with new complex, chronic conditions.

CONCLUSIONS AND RELEVANCE

Parents endorse a broad range of beliefs that represent what they perceive they should do to be a good parent for their seriously ill child. Common patterns of how parents prioritize these attributes exist, suggesting future research to better understand the origins and development of good-parent beliefs among these parents. More important, engaging parents individually regarding what they perceive to be the core duties they must fulfill to be a good parent may enable more customized and effective decision support.

Regoaling: a conceptual model of how parents of children with serious illness change medical care goals

BACKGROUND

Parents of seriously ill children participate in making difficult medical decisions for their child. In some cases, parents face situations where their initial goals, such as curing the condition, may have become exceedingly unlikely. While some parents continue to pursue these goals, others relinquish their initial goals and generate new goals such as maintaining the child's quality of life. We call this process of transitioning from one set of goals to another regoaling.

DISCUSSION

Regoaling involves factors that either promote or inhibit the regoaling process, including disengagement from goals, reengagement in new goals, positive and negative affect, and hopeful thinking. We examine these factors in the context of parental decision making for a seriously ill child, presenting a dynamic conceptual model of regoaling. This model highlights four research questions that will be empirically tested in an ongoing longitudinal study of medical decision making among parents of children with serious illness. Additionally, we consider potential clinical implications of regoaling for the practice of pediatric palliative care.

SUMMARY

The psychosocial model of regoaling by parents of children with a serious illness predicts that parents who experience both positive and negative affect and hopeful patterns of thought will be more likely to relinquish one set of goals and pursue a new set of goals. A greater understanding of how parents undergo this transition may enable clinicians to better support them through this difficult process.