J Pediatr Intensive Care 2023; 12(01): 003-011
DOI: 10.1055/s-0041-1727179
Original Article

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

Markita Suttle
1   Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, United States
Mark W. Hall
1   Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, United States
Murray M. Pollack
2   Department of Pediatrics, Children's National Hospital, Washington, United States
Robert A. Berg
3   Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Pennsylvania, United States
Patrick S. McQuillen
4   Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California, United States
Peter M. Mourani
5   Department of Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, Colorado, United States
Anil Sapru
6   Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, California, United States
Joseph A. Carcillo
7   Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pennsylvania, United States
Emily Startup
8   Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
Richard Holubkov
8   Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
Jonathan Michael Dean
8   Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
Daniel A. Notterman
9   Department of Molecular Biology, Princeton University, New Jersey, United States
Kathleen L. Meert
10   Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, Central Michigan University, Mt. Pleasant, Michigan, United States
› Author Affiliations
Funding This study was supported in part, by the following cooperative agreements from the Eunice Kennedy Shriver National Institute of Child Health and Human Development: UG1HD083170, UG1HD049981, UG1HD63108, UG1HD083166, UG1HD083171, UG1HD049983, U01HD049934, UG1HD050096.


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.

Supplementary Material

Publication History

Received: 14 December 2020

Accepted: 20 February 2021

Article published online:
17 May 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

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