Trends in Pediatric Palliative Care 2018; Issue #2

By Susan Cadell, MSW, PhD. Professor, School of Social Work, Renison, University of Waterloo.

Feature Article: Hollingsworth, C. E.; Wesley, C.; Huckridge, J.; Finn, G. M. & Griksaitis, M. J. (2018), ‘Impact of child death on paediatric trainees‘, Archives of Disease in Childhood 103(1), 14–18.

Other Feature Articles Referenced: Shankar, S.; Nolte, L. & Trickey, D. (2017), ‘Continuing bonds with the living: bereaved parents’ narratives of their emotional relationship with their children‘, Bereavement Care 36(3), 103–111.

Rolbiecki, A. J.; Washington, K. & Bitsicas, K. (2017), ‘Digital Storytelling: Families’ Search for Meaning after Child Death‘, J Soc Work End Life Palliat Care 13(4), 239–250.

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I have been thinking a lot about grief lately as I am currently doing a project on memorial tattoos It is fascinating how people choose to celebrate a person by inking their skin. But that is a story for another time. And it will be a story with pictures. It has to be as the images are an integral part of it. And they are beautiful! One of the most striking aspects of the project so far is that the stories told around the tattoos are celebrations of the lives of the people who have died. Much of my earlier research has concerned positive aspects of stressful experiences and the tattoos are turning out to be an embodied example of that.

I start by mentioning grief and memorial tattoos to give some idea of my mindset as I went through the citation list. I was delighted to see that 10 of the 30 articles concern some degree of family grief and bereavement. As has been noted in these blogs already, the breadth of the list is very pleasing. I was tempted to comment on the article about continuing bonds, or on digital storytelling. I have tucked them away for future reference and reading in greater depth.

The article that caught my eye to explore concerns the impact of child death on pediatric medical trainees. The research took place in the UK and measured stress reactions and post-traumatic stress disorder in 303 trainees via a survey. I am particularly interested in it for three reasons.

First, is it child death or death in general that is stressful? I wonder whether trainees in other areas of medicine report the same about adults dying? It would be interesting to compare the pediatric trainees with others. My reading and research indicates that most health care practitioners do not receive a great deal of training to prepare them for death at any age. In general, in our grief-denying culture, we do not do a very good job of preparing anyone to deal with death and dying.

Second, the authors only measured negative aspects of the experience. Stress and negative reactions are incredibly well documented. Positive processes and outcomes receive little attention. Post-traumatic growth is an area that has garnered increasing attention. The literature is inconclusive about the relationship between stress and growth, but the researchers are potentially missing something by only examining one possible outcome, which in this case is a negative one. In research, it is important to think about what is not being measured or examined.

Third, the authors conclude that there need to be guidelines about debriefing sessions. The research demonstrated that those trainees who had attended a formal debriefing session were more likely to demonstrate symptoms indicative of post-traumatic stress disorder than those who did not attend one. However, it is important to note that this is based on less than half of the sample. Debriefs only took place after 48% of the deaths and only 92 trainees of 303 attended those. The authors point out that medical trainees are likely to be looked to for future leadership in such sessions but only 19 had received training. They cite numerous sources that recommend that single debriefing sessions not be undertaken, and especially not be led by someone without thorough training. Despite the impressive literature questioning its efficacy, there are no national guidelines regarding the practice of debriefing in the UK. While I have always wondered about post-traumatic growth in relation to debriefing, it has not been studied as extensively as stress in the same context.

Overall, the article is well-written and easy to read. I would be interested in hearing more details about the choices made in the research, such as why only pediatrics and whether they considered positive outcomes. The authors raise an interesting point about guidelines for debriefing that makes me wonder: Do we have any such guidelines in Canada and, in particular, in pediatric palliative care?