title: Death, bereavement and randomised controlled trials (BRACELET): a methodological study of policy and practice in neonatal and paediatric intensive care trials.
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.
  
  
  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.
  
  
  BACKGROUND
  Funding for this study was provided by the Health Technology Assessment programme of the National Institute for Health Research.
authors.affiliation: Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Claire
authors.initials: C
authors.lastname: Snowdon
authors.affiliation: Institute for Women's Health, University College London, London, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Brocklehurst
authors.affiliation: Departments of Neurology, and Anaesthesia (Pediatrics), Harvard Medical School and Boston Children's Hospital, Boston, MA, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Tasker
authors.affiliation: Newcastle Neonatal Service, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: Ward Platt
authors.affiliation: Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Sheila
authors.initials: S
authors.lastname: Harvey
authors.affiliation: Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Diana
authors.initials: D
authors.lastname: Elbourne
mesh_terms: D000328:Adult; D001601:Bereavement; D002675:Child, Preschool; D003643:Death; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D015278:Intensive Care Units, Pediatric; D008297:Male; D008875:Middle Aged; D016134:Organizational Policy; D010290:Parents / Q000523:psychology*; D036301:Qualitative Research; D016032:Randomized Controlled Trials as Topic; D012944:Social Support; D011795:Surveys and Questionnaires; D006113:United Kingdom