Hydrogen sulfide : Metabolic mediator or toxic gas ? *

Effective communication with parents has become a significant concern in pediatric critical care, particularly in the context of end-of-life care. A growing body of research evidence has highlighted communication problems between parents and healthcare professionals. In a study of pediatric end-of-life care, a group of bereaved parents reported that they were dissatisfied with their interactions with staff (1). This was largely attributable to confusing, inadequate, or uncaring communications regarding treatment or prognosis. A related study conducted a needs assessment of staff and families in pediatric palliative care. Healthcare professionals reported feeling inexperienced in communicating with patients and families about end-of-life issues, while families reported distress caused by uncaring delivery of bad news and upsetting careless remarks made by staff (2). In an examination of end-of-life care and communication in the pediatric intensive care unit (PICU), priority needs identified by parents included honest and complete information, ready access to healthcare professionals, communication and care coordination, and emotional expression and support from healthcare professionals (3). In a study of parental perceptions of PICU quality of care for their dying child, parents reporting a low level of quality of care felt they were uninformed about the child’s condition and unable to understand the cause of death (4). These parents also perceived healthcare professionals as less sympathetic than did parents who were more satisfied with care. An examination of autopsy discussions in the PICU reported parental dissatisfaction with the manner in which physicians’ own opinions were implied in the process—where physicians presented parents with what appeared to be a foregone conclusion that an autopsy was not needed (5). A study of bereaved parents whose children died in the PICU highlighted that the actions of healthcare professionals involve more than the transmission of information. Some healthcare professionals communicated in a manner that also conveyed kindness, which significantly comforted parental grief (6). A randomized trial in adult critical care has demonstrated that implementation of a structured proactive communication program decreased posttraumatic stress, anxiety, and depression among family members (7). Dr. Meert and colleagues (8) offer an important contribution to this emerging body of literature in this issue of Pediatric Critical Care Medicine. This multisite (six PICUs) qualitative study involved a secondary analysis of data collected from 56 parents through semistructured telephone interviews. Forty of these parents indicated that they wished to report on PICU physician communication about their child’s terminal illness and death. The most cited communication issues related to physicians’ availability and attentiveness to parents’ informational needs. Other issues referred to honesty and comprehensiveness of information, affect with which information was provided, withholding of information, provision of false hope, complexity of vocabulary, pace of providing information, contradictory information, and physicians’ body language. These findings enrich our understanding of the complexity of parental needs that communication must attend to. Particularly striking was parents’ apparently contradictory wish to want information fully disclosed yet paced according to their ability to receive it. Also, time urgencies and prognostic uncertainties that are characteristic of the PICU setting seem to inherently compromise communication with parents. The study’s limitations (largely acknowledged by the authors) need to be reviewed to establish directions for future research on communication in this setting. Most important, this study was not originally designed to examine communication. This phenomenon was analyzed secondarily through data that emerged spontaneously. We do not know about the experiences of parents in the initial study who did not choose to speak about communication. Further studies are needed that are specifically designed to examine communication with tailored parent recruitment and data collection procedures. It is noteworthy that the rate of disclosure among parents varied widely across sites, raising questions about potential cross-site inconsistencies in data collection methods. This study examined a highly complex and sensitive domain through telephone interviews. Face-to-face interviews may have fostered even richer disclosures. Only a small proportion of parents were fathers or nonwhite. Thus, findings may not adequately reflect their perspectives. Communication issues related to cultural or linguistic diversity need to be specifically examined. This study examined the experiences of bereaved parents only. It would be important to also seek the perspectives of parents whose children survived (9). When possible, the communication experiences of critically ill children themselves should also be researched (10). Communication needs to be understood broadly, not only in the context of bad news; parents have communication needs throughout their PICU stay. Also, further research should employ the term end of life cautiously because it may imply a healthcare professionals’ bias that the child should be at the end of life. In the PICU, resuscitative measures render the end of life obscure. Many instances emerge in which healthcare professionals believe that life-sustaining therapies should be limited while parents seek to have life prolonged despite the challenges. In short, the work of Dr. Meert and colleagues (8) strengthens our understanding of communication in the PICU *See also p. 2.