Dr Katharine Weetman, Assistant Professor in Clinical Communication [1], Professor Cara Bailey, Professor in end of life care [1][2], Dr Christine Mott, Consultant in Paediatric Palliative Medicine [3][4].

1. College of Medicine and Health, University of Birmingham.
2. St Giles Hospices, Lichfield, Staffordshire.
3. Birmingham Women’s and Children’s NHS Trust.
4. Acorns Children’s Hospice, Selly Oak, Birmingham.

The moral and ethical dilemma of whether healthcare staff should pay their respects and attend the funeral of a patient is longstanding [1-4]. Research studies [2,3,5] as well as opinion pieces [4,6] have pondered whether it is the appropriate and professional thing to do [1]. Nonetheless, healthcare staff often have the human response of seeking closure and time to grieve the death of a patient [6,7]; a funeral provides a formal context and potential space for this important processing of emotions and memories. Attending a funeral creates a connection to the patient’s family as it may be the last time the care team sees them, and it also provides healthcare staff with the opportunity to check in on the family response to the death (e.g. to identify further support/signposting that may be needed). Without such grieving rituals and opportunities [4], healthcare staff may be left with unresolved bereavement narratives [7] that could have a long lasting negative impact on their wellbeing. 

A systematic review by Kim et al. (2019) [5] on medical practitioner attendance at patient’s funerals found that clinician attendance and attitudes may be affected by characteristics such as experience/role, gender and age [5]. However, it is notable that much of the research to date specifically looks at adult patient funerals and that of babies, children, and young people are often excluded or unstated. Nonetheless, healthcare professionals may experience intense grief after a child patient death [8]. Of the limited research available [7,9], professionals seem to think that they should attend the funerals of their paediatric patients and that they can benefit from this experience [1]. Attendance at these funerals may be more complex and ambiguous; the patient themselves may not have been able to express their views on how they feel about their clinician going to their funeral. Moreover, there are the preferences of the parents and families to consider; this arguably increases the sensitivity of navigating the situation appropriately. Funeral attendance may be seen as blurring the boundaries between personal and professional lives [1,2] but equally expressing condolences may be an expectation of parents; they may feel disappointed or let down if the caring healthcare professional is absent [5]. Perspectives may vary depending on the religious and cultural norms of the family [1], which need to be respected [8]. Is the presence of a doctor or nurse at the funeral of a child viewed as a compassionate response to death or is it a professional over-step or invasion of privacy?

Paediatric palliative care in the UK may differ from adult palliative care services in that babies, children, and young people may be referred to this specialist service before or from birth. It is not uncommon for these patients to be under paediatric palliative care services for years rather than weeks or months, and the clinical care input may span their whole life. Healthcare staff may get to know these babies, children, and young people very well and feel compelled to attend their funeral. Nonetheless, in the experience of the authors, guidance and policies may be non-existent, deliberately vague, or considered a grey area. This can leave the decision up to the individual healthcare staff or service, causing confusion, stress, uncertainty and internalised moral and ethical conflict. Within the last 20 or so years, a few UK organisations have attempted to resolve this through more directed policies such as prohibiting attendance either entirely or during work hours or otherwise having a single named administrative/managerial representative from the healthcare organisation attend on behalf of all staff. Some organisations stipulate a set amount of representatives from a service/site who may attend a patient funeral so that there is no sense to families of favouritism. Other organisations may steer away from clear policies and so healthcare staff may attend on personal/unpaid time, annual leave or in plain clothes as a member of the public, so as not to represent their place of work. Some may feel pressured to either attend the child’s funeral as an obligation or to decline invitations for fear of professional rebuttal or complaints. Reference to the limited guidance/research available, suggests funeral attendance should be supported within working hours [8], although this may place pressure on service resources with knock-on impacts for the staff. 

Although the answer may not be straightforward, avoiding the question will not help to resolve this issue or dilemma, which continues to pervade paediatric settings nationally.

Summary (take home messages):

1. The authors here suggest that more support is needed to help healthcare staff manage the grief and conflicted feelings of going to the funerals of their paediatric patients. Although decision-making may require review on a case-by-case basis, clearer guidance and standards are required to reduce the burden falling on individual staff to know what is best for themselves and families and ultimately “do the right thing”. 
2. We call for more evidence in this area of the margins of grief within paediatric palliative care settings; such research must consider the potentially differing perspectives of organisations, healthcare staff, child patients and their families alongside the inherent risks and benefits of attending funerals. 
3. Further research should particularly explore the patient/family perspectives. 

References:

1.Schoenbine D., Gerhart J., McLean K.A., et al. Attending Patient Funerals as a Follow-Up Practice of Pediatric Oncologists. Illness, Crisis & Loss. 2023;31(1):168-74. Available from: https://journals.sagepub.com/doi/abs/10.1177/10541373211047305.

2.Zambrano S.C., Chur-Hansen A., Crawford G.B. Beyond Right or Wrong: Attitudes and Practices of Physicians, Nurses, Psychologists, and Social Workers Regarding Attendance at Patient Funerals. Journal of Palliative Medicine. 2018;22(4):400-7. Available from: https://doi.org/10.1089/jpm.2018.0234.

3.Zambrano S.C., Chur-Hansen A., Crawford G.B. Attending patient funerals: Practices and attitudes of Australian medical practitioners. Death Studies. 2017;41(2):78-86. Available from: https://doi.org/10.1080/07481187.2016.1214631.

4.McCartney M. Margaret McCartney: Should doctors go to patients’ funerals? BMJ. 2018;362:k2865. Available from: https://www.bmj.com/content/bmj/362/bmj.k2865.full.pdf.

5.Kim K., Churilov L., Huang A., et al. Bereavement practices employed by hospitals and medical practitioners toward attending funeral of patients: A systematic review. Medicine. 2019;98(36):e16692. Available from: https://journals.lww.com/md-journal/fulltext/2019/09060/bereavement_practices_employed_by_hospitals_and.3.aspx.

6.Barber K., Weinberg L. Not Always Curing but Always Caring: An Anesthesiologist’s Perspective of Attending a Patient’s Funeral. Anesthesia & Analgesia. 2017;125(6). Available from: https://journals.lww.com/anesthesia-analgesia/fulltext/2017/12000/not_always_curing_but_always_caring__an.46.aspx.

7.McConnell T., Scott D., Porter S. Healthcare staff ’s experience in providing end-of-life care to children: A mixed-method review. Palliative Medicine. 2016;30(10):905-19. Available from: https://journals.sagepub.com/doi/abs/10.1177/0269216316647611.

8.Finlay F., MacCallam J. Supporting Best Practice for Attending a Child’s Funeral as Part of Our Professional Role: Guidelines for Developing Service Policy. Journal of Palliative Medicine. 2017;20(8):801-. Available from: https://journals.sagepub.com/doi/abs/10.1089/jpm.2017.0173.

9.James K., Hawley B., McCoy C.R., et al. Challenges and Opportunities of Providing Pediatric Funeral Services: A National Survey of Funeral Professionals. American Journal of Hospice and Palliative Medicine®. 2022;39(3):289-94. Available from: https://journals.sagepub.com/doi/abs/10.1177/10499091211019298.

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Declaration of interests:

We have read and understood the BMJ Group policy on declaration of interests and declare no competing interests.