The Association between Therapeutic Alliance and Parental Health Outcomes following a Child's Death in the Pediatric Intensive Care Unit

Abstract

Therapeutic alliance reflects the strength and quality of the physician–patient/family relationship. We investigated the association between therapeutic alliance and bereaved parents' mental health and perceived overall health following their child's death in a pediatric intensive care unit (PICU). Bereaved parents were surveyed 6 months after their child's death in a PICU affiliated with the Collaborative Pediatric Critical Care Research Network. Parents were evaluated for complicated grief, depression, and post-traumatic stress using the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire (PHQ-8), and the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), respectively. Overall health was evaluated using a single item. Therapeutic alliance between parents and their deceased child's PICU physicians was assessed using the Human Connection scale (HCS). Two hundred and thirty-five parents of 158 deceased children completed surveys. Mean ICG score was 34.4 ± 14.9 with 142 (60.4%) parents screening positive for complicated grief. Mean PHQ-8 score was 9.1 ± 6.2 with 102 (43.4%) screening positive for at least moderate depression. Mean SPRINT score was 14.6 ± 8.2 with 122 (51.9%) screening positive for post-traumatic stress disorder. Overall health was perceived as fair for 47 (20.0%) parents and poor for 10 (4.3%). Using multivariable modeling, higher HCS score (greater therapeutic alliance) was significantly associated with lower (better) ICG score (−0.23, 95% CI −0.42, −0.04, p = 0.018). HCS score was not significantly associated with PHQ-8, SPRINT, or overall health scores. We conclude that bereaved parents experience a high level of adverse mental health symptoms including complicated grief, depression, and post-traumatic stress symptoms. Greater therapeutic alliance with PICU physicians may lessen symptoms of complicated grief during bereavement.

Keywords

therapeutic alliance - bereavement - parent - grief - depression - post-traumatic stress disorder - pediatric intensive care unit

Publikationsverlauf

Eingereicht: 14. Dezember 2020

Angenommen: 20. Februar 2021

Artikel online veröffentlicht:
17. Mai 2021

• References

• 1 Morris S, Fletcher K, Goldstein R. The grief of parents after the death of a young child. J Clin Psychol Med Settings 2019; 26 (03) 321-338
• 2 Arizmendi BJ, O'Connor M-F. What is “normal” in grief?. Aust Crit Care 2015; 28 (02) 58-62 , quiz 63
• 3 Shear MK. Clinical practice. Complicated grief. N Engl J Med 2015; 372 (02) 153-160
• 4 Zisook S, Reynolds III CF. Complicated grief. Focus Am Psychiatr Publ 2017; 15 (04) 12s-13s
• 5 Shear MK. Grief and mourning gone awry: pathway and course of complicated grief. Dialogues Clin Neurosci 2012; 14 (02) 119-128
• 6 Meert KL, Donaldson AE, Newth CJL. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Complicated grief and associated risk factors among parents following a child's death in the pediatric intensive care unit. Arch Pediatr Adolesc Med 2010; 164 (11) 1045-1051
• 7 Meert KL, Shear K, Newth CJL. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Follow-up study of complicated grief among parents eighteen months after a child's death in the pediatric intensive care unit. J Palliat Med 2011; 14 (02) 207-214
• 8 Schenk LK, Eberle KM, Rings JA. Insecure attachment styles and complicated grief severity: applying what we know to inform future directions. Omega 2016; 73: 213-249
• 9 Baumann I, Künzel J, Goldbeck L, Tutus D, Niemitz M. Prolonged grief, posttraumatic stress, and depression among bereaved parents: prevalence and response to an intervention program. Omega (Westport) 2020; 84 (03) 837-855
• 10 Pohlkamp L, Kreicbergs U, Sveen J. Bereaved mothers' and fathers' prolonged grief and psychological health 1 to 5 years after loss—a nationwide study. Psychooncology 2019; 28 (07) 1530-1536
• 11 Lykke C, Ekholm O, Schmiegelow K. et al. Anxiety and depression in bereaved parents after losing a child due to life-limiting diagnoses: a Danish nationwide questionnaire survey. J Pain Symptom Manage 2019; 58 (04) 596-604
• 12 Youngblut JM, Brooten D. Comparison of mothers and grandmothers physical and mental health and functioning within 6 months after child NICU/PICU death. Ital J Pediatr 2018; 44 (01) 89
• 13 Dias N, Brandon D, Haase JE, Tanabe P. Bereaved parents' health status during the first 6 months after their child's death. Am J Hosp Palliat Care 2018; 35 (06) 829-839
• 14 Brooten D, Youngblut JM, Caicedo C, Del Moral T, Cantwell GP, Totapally B. Parents' acute illnesses, hospitalizations, and medication changes during the difficult first year after infant or child NICU/PICU death. Am J Hosp Palliat Care 2018; 35 (01) 75-82
• 15 Horvath AO, Luborsky L. The role of the therapeutic alliance in psychotherapy. J Consult Clin Psychol 1993; 61 (04) 561-573
• 16 Mack JW, Block SD, Nilsson M. et al. Measuring therapeutic alliance between oncologists and patients with advanced cancer: the Human Connection Scale. Cancer 2009; 115 (14) 3302-3311
• 17 An AW, Ladwig S, Epstein RM, Prigerson HG, Duberstein PR. The impact of the caregiver-oncologist relationship on caregiver experiences of end-of-life care and bereavement outcomes. Support Care Cancer 2020; 28 (09) 4219-4225
• 18 Trevino KM, Maciejewski PK, Epstein AS, Prigerson HG. The lasting impact of the therapeutic alliance: patient-oncologist alliance as a predictor of caregiver bereavement adjustment. Cancer 2015; 121 (19) 3534-3542
• 19 Huff NG, Nadig N, Ford DW, Cox CE. Therapeutic alliance between the caregivers of critical illness survivors and intensive care unit clinicians. Ann Am Thorac Soc 2015; 12 (11) 1646-1653
• 20 Meert KL, Templin TN, Michelson KN. et al. The Bereaved Parent Needs Assessment: a new instrument to assess the needs of parents whose children died in the pediatric intensive care unit. Crit Care Med 2012; 40 (11) 3050-3057
• 21 Collaborative Pediatric Critical Care Research Network. . Accessed February 6, 2021 at: https://www.cpccrn.org
• 22 Prigerson HG, Maciejewski PK, Reynolds III CF. et al. Inventory of complicated grief: a scale to measure maladaptive symptoms of loss. Psychiatry Res 1995; 59 (1-2): 65-79
• 23 Shear K, Frank E, Houck PR, Reynolds III CF. Treatment of complicated grief: a randomized controlled trial. JAMA 2005; 293 (21) 2601-2608
• 24 Kroenke K, Spitzer RL, Williams JBW, Löwe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry 2010; 32 (04) 345-359
• 25 Shin C, Lee SH, Han KM, Yoon HK, Han C. Comparison of the usefulness of the PHQ-8 and PHQ-9 for screening for major depressive disorder: analysis of psychiatric outpatient data. Psychiatry Investig 2019; 16 (04) 300-305
• 26 Pressler SJ, Subramanian U, Perkins SM. et al. Measuring depressive symptoms in heart failure: validity and reliability of the Patient Health Questionnaire-8. Am J Crit Care 2011; 20 (02) 146-152
• 27 Connor KM, Davidson Jr JR. SPRINT: a brief global assessment of post-traumatic stress disorder. Int Clin Psychopharmacol 2001; 16 (05) 279-284
• 28 DeSalvo KB, Fisher WP, Tran K, Bloser N, Merrill W, Peabody J. Assessing measurement properties of two single-item general health measures. Qual Life Res 2006; 15 (02) 191-201
• 29 Graham JM, Unterschute MS. A reliability generalization meta-analysis of self report measures of adult attachment. J Pers Assess 2014; 25: 1-11
• 30 Ravitz P, Maunder R, Hunter J, Sthankiya B, Lancee W. Adult attachment measures: a 25-year review. J Psychosom Res 2010; 69 (04) 419-432
• 31 Shevlin M, Boyda D, Elklit A, Murphy S. Adult attachment styles and the psychological response to infant bereavement. Eur J Psychotraumatol 2014; 5: 23295
• 32 Suttle M, Hall MW, Pollack MM. et al. Therapeutic alliance between bereaved parents and physicians in the pediatric intensive care unit. Pediatr Crit Care Med 2020; 22 (04) e243-e252
• 33 Institute of Medicine. When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families. Washington, DC: The National Academies Press; 2003: 73-76
• 34 Kersting A, Brähler E, Glaesmer H, Wagner B. Prevalence of complicated grief in a representative population-based sample. J Affect Disord 2011; 131 (1-3): 339-343
• 35 Pohlkamp L, Kreicbergs U, Sveen J. Factors during a child's illness are associated with levels of prolonged grief symptoms in bereaved mothers and fathers. J Clin Oncol 2020; 38 (02) 137-144
• 36 Slade A, Holmes J. Attachment and psychotherapy. Curr Opin Psychol 2019; 25: 152-156
• 37 McWilliams LA, Bailey SJ. Associations between adult attachment ratings and health conditions: evidence from the National Comorbidity Survey Replication. Health Psychol 2010; 29 (04) 446-453
• 38 U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health. National Survey on Drug Use and Health. 2017 (NSDUH) (HHS Publication No. SMA 18–5068 2018) Accessed February 6, 2021 at: https://www.nimh.nih.gov/health/statistics/major-depression.shtml#part_155033
• 39 Kreicbergs U, Valdimarsdóttir U, Onelöv E, Henter JI, Steineck G. Anxiety and depression in parents 4-9 years after the loss of a child owing to a malignancy: a population-based follow-up. Psychol Med 2004; 34 (08) 1431-1441
• 40 Sirki K, Saarinen-Pihkala UM, Hovi L. Coping of parents and siblings with the death of a child with cancer: death after terminal care compared with death during active anticancer therapy. Acta Paediatr 2000; 89 (06) 717-721
• 41 Harvard Medical School. National Comorbidity Survey (NCS). Data Table 2: 12-month prevalence DSM-IV/WMH-CIDI disorders by sex and cohort. August 21, 2017. Accessed February 6, 2021 at: https://www.hcp.med.harvard.edu/ncs/index.php
• 42 Dückers MLA, Alisic E, Brewin CR. A vulnerability paradox in the cross-national prevalence of post-traumatic stress disorder. Br J Psychiatry 2016; 209 (04) 300-305
• 43 Murphy SA, Johnson LC, Chung IJ, Beaton RD. The prevalence of PTSD following the violent death of a child and predictors of change 5 years later. J Trauma Stress 2003; 16 (01) 17-25
• 44 Logan EL, Thornton JA, Breen LJ. What determines supportive behaviors following bereavement? A systematic review and call to action. Death Stud 2018; 42 (02) 104-114