Therapeutic Alliance Between Bereaved Parents and Physicians in the PICU

Abstract

Therapeutic alliance is the collaborative bond that develops between patients/families and healthcare providers. Our objective is to determine the extent of therapeutic alliance bereaved parents perceive to have occurred with their child's physicians during their child's PICU stay, and associated factors. DESIGN:Multicenter observational study. SETTING: Eight children's hospitals affiliated with the Collaborative Pediatric Critical Care Research Network.PATIENTS: Parents greater than or equal to 18 years old whose child died in a PICU (including cardiac ICU). INTERVENTIONS:Bereaved parents completed the Human Connection Scale, a 16-item measure of therapeutic alliance, 6 months after their child's death. Human Connection Scale scores range from 16 to 64 with higher scores indicating greater alliance. Parents provided sociodemographic data, and medical records were reviewed for the child's clinical characteristics. MEASUREMENTS AND MAIN RESULTS:Two-hundred and thirty-three parents of 157 deceased children responded to the Human Connection Scale with greater than or equal to 80% item completion. Among parents, 146 (62.7%) were female, 155 (66.5%) were White and 46 (19.7%) were Black, 175 (75.1%) were married, and 209 (89.7%) had at least a high-school education. Among children, median age at the time of death was 5.9 years (interquartile range, 0.64-13.9 yr) and 114 (72.6%) died after limitation or withdrawal of life support. Mean Human Connection Scale score was 51.4 ± 11.1 for all parents, 52.6 ± 9.0 for White parents, and 47.0 ± 13.7 for Black parents. In multivariable modeling predicting Human Connection Scale scores, race was the only parent or child characteristic in the final model. Human Connection Scale scores were significantly different (-4.56; 95% CI, -8.53 to -0.6; p = 0.025) between the Black and White parents with items about trust, care, and honest communication showing the greatest mean difference. CONCLUSIONS: Among parents bereaved in the PICU, therapeutic alliance with physicians is moderately high. Future research should identify strategies to strengthen therapeutic alliance with Black parents and examine the role of alliance on bereaved parents' health outcomes.

Exploring trust development in families of children towards surgical and emergency care providers: A scoping review of the literature

“…Some studies also noted a positive association of trust with reliability, availability, and security [24,25]. However, several papers noted that dependability trust can be undermined by perceived issues with racial and ethnic fairness [15][16][17]19], and physician's unmet expectations to effectively signal trustworthiness during clinical encounters [24,26].…”

“…Most of the studies noted that developing compassionate interactions (based on empathy for the family's situation, offering encouragement and support, etc.) and providing family-centered care were significantly correlated with the parents' confidence in the physician's caring and with parental satisfaction of the quality of services in pediatric healthcare settings [15][16][17][19][20][21][22][23][24][25]. On the other hand, some articles specified that inaccurate comprehension of multicultural parents' backgrounds and inadequate care of their specific needs and concerns were significant predictors of parental distrust or mistrust in caring, especially within racial and ethnic minorities [15][16][17].…”

“…Among the demographic factors associated with lower physician trust reported by parents from minority groups, three studies demonstrated high correlation with race and ethnicity [16,17,19], while two publications reported that no significant difference was seen in trust scores for these specific characteristics [15,26]. Racial and ethnics barriers, such as beliefs and suspicions, fears of judgement and past experienced discrimination [15][16][17], along with literacy/education and language barriers [15,18] were identified as factors limiting parents' confidence in physician competency and dependability [15,16,19], and significantly and negatively correlated with trust in communication and caring [15][16][17]. Research has demonstrated that parental trust in emergency surgery is a construct with specific dimensions that can be reliably measured.…”

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

“…Cronbach's α has been reported as 0.9 and validity demonstrated by positive association with emotional acceptance of death 16 For this study, the HCS was adapted to evaluate the relationship between parents and their child's PICU physicians. 32 Each adapted item specifically referred to PICU physicians, for example, “How much did you trust your child's doctor(s) in the ICU?” The complete adapted scale is shown in Supplementary Tables 1 – 4 (available in the online version only). Scores range from 16 to 64; higher scores indicate greater therapeutic alliance.…”

How to Make Communication Among Oncologists, Children With Cancer, and Their Caregivers Therapeutic

“…Third, even transparency and truth telling are culturally nuanced; pediatric patients and their families have discrete preferences about what, when, and how information is delivered, and to whom it is relayed . Fourth, there are well-documented race-based disparities in patient-reported perception of therapeutic alliance; bereaved Black parents report significantly lower therapeutic alliance than White parents . Finally, this analysis included only the perceptions of clinicians, not the perceptions of families.…”