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Headline
The study found that although considerable numbers of children involved in randomised trials in neonatal and paediatric intensive care go on to die, responses by trial team members and local clinicians to bereavement subsequent to trial participation are varied. Development of a coordinated response should be considered. The study suggests that trial-related research with bereaved parents is valuable and feasible and their exclusion from studies of participants’ view is inappropriate on ethical and scientific grounds.
Abstract
Background:
Researchers have seldom included bereaved parents in studies of participants’ views of randomised controlled trials (RCTs); hence our understanding of the impact of trials is based on skewed and incomplete samples. Little is known about parental experiences of the death of a child subsequent to their enrolment in a trial or of provision made for this experience by clinicians and trial teams. The Bereavement and RAndomised ControlLEd Trials (BRACELET) study was funded to consider bereavement in the context of paediatric intensive care (PIC) and neonatal intensive care (NIC) trials.
Design and methods:
The study comprised three interlinked components: a quantitative survey of RCT activity in UK paediatric intensive care units (PICUs) and neonatal intensive care units (NICUs), UK RCT recruitment and mortality rates, and provision for bereavement during 2002–6; a qualitative interview study involving 51 bereaved parents and 59 clinicians and trial team members associated with five neonatal trials; and a methodological study to inform future research.
Results:
Fifty RCTs were identified as having enrolled babies or children from 2002 to 2006. Approximately 50% of UK NICUs and PICUs (54 NICUs, six PICUs) participated in at least one of these trials. Collectively they enrolled over 3000 children. Most enrolled small numbers, the majority of participants being enrolled by a small group of academic medical units. The proportion of deaths following trial enrolment was 17% in NIC trials and 6% in PIC trials. The qualitative study showed that trial-related decisions were made in a range of circumstances, some after extremely preterm births, others after complicated term deliveries, often under time pressures and in escalating crises. Parents’ interest in trials appeared to recede initially but could re-emerge over time. They often valued opportunities to engage with a trial and were interested in more contact and information than they actually received. Clinicians often saw NICU bereavement policies as meeting parental needs, and trial participation as being of relatively minor significance in bereavement. This view may result from the positioning of clinicians’ encounters with parents only in the initial stages of grief when trials were not a priority. Trial teams used a range of bereavement strategies, from no further contact to a pioneering multipart follow-up package. Communication with bereaved parents was complicated by limited contact opportunities. Trial teams were obliged to work without knowing whether their communications were appreciated, were problematic, or even whether they were received by parents. The methodological component highlighted strategies for recruitment and data collection in this sensitive setting. Recruitment by unsupported postal contact generally failed and a more personal approach via clinicians was more effective, supplemented by publicity material distributed via trusted organisations.
Conclusions:
A co-ordinated response to bereavement is as much a part of the running of trials as recruitment, and needs to be considered at trial inception. BRACELET has demonstrated the value and feasibility of research with bereaved parents involved in NIC trials. In order to respond to bereavement in a fair and sensitive way, as well as to better inform the design of RCTs, it is crucial that we listen to bereaved parents and evaluate new methods for so doing. More research is therefore needed into the experiences of bereavement subsequent to trial enrolment, with study of bereavement strategies in NIC trials as they are introduced. In addition, future studies should determine whether parents and triallists in PIC trials (and trials in adults) face the same issues as in NIC trials. Careful studies are necessary to explore how feedback of trial results are received and understood by bereaved and non-bereaved parents, and how individual trial teams manage this situation. An additional research area for exploring experiences of parenting twins and higher-order births in trials arose from BRACELET. Developmental research should continue to explore means of involving a wider range of parents in future research, including via publicity and specialist websites. Finally, methodological research is needed to ensure that we have the tools to explore, with parents and other relatives, as partners in research, a range of trial-related topics, which might be challenging, as the information is complex or the focus is sensitive.
Funding:
Funding for this study was provided by the Health Technology Assessment programme of the National Institute for Health Research.
Contents
- Scientific summary
- Chapter 1. Introduction
- Chapter 2. Related research and research plan
- Section A
- Section B: Qualitative study of bereavement-related practice and experience in neonatal trials
- Chapter 4. Research methods and samples
- Chapter 5. The research setting
- Chapter 6. Bereaved parents’ initial experiences of neonatal trials
- Chapter 7. Bereaved parents’ subsequent experiences of neonatal trials
- Chapter 8. Bereavement and neonatal trials
- Chapter 9. Parents’ responses to bereavement in neonatal trials in the longer term
- Section C
- Acknowledgements
- References
- Appendix 1 Phase I: the BRACELET study – surveys of mortality in UK neonatal and paediatric intensive care trials (Trials; 2010)
- Appendix 2 Phase I: neonatal intensive care unit questionnaire
- Appendix 3 Phase I: paediatric intensive care unit questionnaire
- Appendix 4 Phase I: pre-notification letter to intensive care unit representatives
- Appendix 5 Phase I: BRACELET study summary to intensive care unit representatives
- Appendix 6 Phase I: cover letter to intensive care unit representatives
- Appendix 7 Phase I: neonatal intensive care unit and paediatric intensive care unit short questionnaire
- Appendix 8 Phase I: letter from the National Perinatal Epidemiology Unit director to intensive care unit representatives
- Appendix 9 Phase I: trial questionnaire to trial representatives
- Appendix 10 Phase I: unit mortality data form to trial representatives
- Appendix 11 Phase II: information booklet for clinicians and trial team members and core centre clinicians
- Appendix 12 Phase II: demographic questionnaire – clinicians and triallists
- Appendix 13 Phase II: demographic questionnaire – bereaved parents (version for women)
- Appendix 14 Leaflet for bereaved parents in the TOBY trial
- Appendix 15 Letter to bereaved parents about the TOBY trial newsletters
- Appendix 16 The TOBY parents’ newsletter issue 4
- Appendix 17 The PROGRAMS parents’ newsletter issue 3
- Appendix 18 The INIS ANZ parents’ newsletter, winter 2008–9
- Appendix 19 The INIS ANZ parents newsletter issue 4
- Appendix 20 Phase II: BRACELET amendment – publicity for parents, version 1 170910
- Appendix 21 Phase II: BRACELET amendment – preparatory letter to parents, version 1 170910
- Appendix 22 Phase II: online BRACELET questionnaire for bereaved parents
- Appendix 23 Phase II: reply slip for bereaved parents
- Appendix 24 Phase II: questionnaire to bereaved parents about contact processes, strategy 1
- Appendix 25 Phase II: questionnaire to bereaved parents about contact processes, strategy 2a
- Appendix 26 Phase II: questionnaire to bereaved parents about contact processes, strategy 2b
- Appendix 27 Phase II: post-interview questionnaire to bereaved parents (version for women)
- Appendix 28 Phase II: code of practice for conduct of the interviews
- Appendix 29 Phase II: support and information card for parents
- List of abbreviations
Article history
The research reported in this issue of the journal was funded by the HTA programme as project number 05/516/06. The contractual start date was in February 2007. The draft report began editorial review in February 2013 and was accepted for publication in June 2013. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.
- NLM CatalogRelated NLM Catalog Entries
- The BRACELET Study: surveys of mortality in UK neonatal and paediatric intensive care trials.[Trials. 2010]The BRACELET Study: surveys of mortality in UK neonatal and paediatric intensive care trials.Snowdon C, Harvey SE, Brocklehurst P, Tasker RC, Platt MP, Allen E, Elbourne D. Trials. 2010 May 26; 11:65. Epub 2010 May 26.
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- Bereaved parents' experiences of research participation.[BMC Palliat Care. 2018]Bereaved parents' experiences of research participation.Butler AE, Hall H, Copnell B. BMC Palliat Care. 2018 Nov 7; 17(1):122. Epub 2018 Nov 7.
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- Review Caring for Parents After the Death of a Child.[Pediatr Crit Care Med. 2018]Review Caring for Parents After the Death of a Child.October T, Dryden-Palmer K, Copnell B, Meert KL. Pediatr Crit Care Med. 2018 Aug; 19(8S Suppl 2):S61-S68.
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