Journal of Pediatric Oncology

Nursing
http://jpo.sagepub.com/

A Memorial Service for Families of Children who Died From Cancer and Blood Disorders
Sue P. Heiney, Linda Wells and Julian Ruffin
Journal of Pediatric Oncology Nursing 1996 13: 72
DOI: 10.1177/104345429601300204
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A Memorial Service for Families of Children

Who Died From Cancer and Blood Disorders
Sue P. Heiney, RN, MN, CS, Linda Wells, RN, MA, CNA,
and Julian

Ruffin, PhD

The grief of staff who work with dying children and the grief of family members
after the death of a child has been widely documented. Interventions to facilitate
grieving have been extensively developed for parents but less so for siblings and
staff. This article describes one approach, a memorial service, for families and
staff that has wide applicability for providing support after a death. The
memorial service provides families and staff with a healing ritual of remembrance, a source of closure after the death, and a recognition of the relationships
established between families and staff. The service particularly legitimizes the
staffs grief experience. The organization, implementation, and evaluation of
such a program is discussed.
© 1996 by Association of Pediatric Oncology Nurses.

STAFF of the Childrens Center for

Cancer and Blood Disorders wanted to
develop a bereavement program for patients
and families. When families were informally
surveyed using a simple feedback form regarding their bereavement needs, their major
concern identified was the sense of being
abandoned by the treatment team who had
cared for their child for many years. The
relationships that developed were an important source of support for the families during
the treatment process, and they expected
similar support after the death. Treatment
team members were viewed as extended
family. Similarly, staff needed a way to have
closure on the intensely personal relationships they had formed. Yet such a closure
was difficult when staff were daily confronting the need to care for new patients. In
response to this need, the staff planned and
implemented a bereavement group for par-

THE
i.

From the Center for Cancer Treatment and Research

and Childrens Center for Cancer and Blood Disorders,
Richland Memorial Hospital, Columbia, SC.
Address reprint requests to Sue P. Heiney, RN, MN, CS,
Center for Cancer Treatment and Research, Richland
Memorial Hospital, Seven Richland Medical Park, Colum-

bia, SC29203.
1996 by Association of Pediatric Oncology Nurses.
1043-4542/96/1302-0002$3.00/0

©

ents, extended families, and siblings in 1986

that met biweekly for eight sessions. 1,2 However, several logistical difficulties, such as
distance from treatment center and small
number of children who died each month,
precluded the establishment of an ongoing
group. Therefore, the staff developed a follow-up bereavement program to ease the
transition for the bereaved family from the
staff to the natural support systems within
the home community.3 In 1987, as a part of
this program, the staff initiated an annual
memorial service with a twofold purpose: to
convey to the family that the child was still
remembered and to provide the staff with a
designated time for closure. Since that time,
eight services have been held. This article
reviews the literature on grief in staff and
families and the use of ritual in mourning,

and describes the

planning, implementation,

and evaluation of the program.

Literature Review
To
well

develop a memorial service that was

grounded in an understanding of the

grief process, the literature related to staff

and family grief was explored. Information on
ritual as a way of resolving grief was also
obtained.

72

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73

Staff Stress and Grief

stressed when a child has died. The

literature reports that the death of a child is
considered the ultimate tragedy.15 Each family member reacts to the childs death in his
or her own way. Coping with the loss and the
feelings that arise differs from person to
more

The stress experienced by oncology staff

and the potential for burnout, especially
among nurses, has been extensively documented. The stress may be caused by the
influence of the job on interpersonal relationships, reservations about developing relationships with patients, emotional involvement,
finding value in ones work, and difficult
patients.1.4-6 Sources of stress for caregivers
may include the decline of a patient with
whom staff had strong attachments, hope for
a cure, and a sense of responsibility for the
death.7 Myriad emotional and troublesome
symptoms are both sources of and reactions
to stress.8-9 These symptoms include being
drained and emotionally used up, guilt, selfdoubt, confusion, anger, helplessness, and
depression. Because staff develops intimate
relationships with the patient and family,2 the
severing of these relationships at the death of
the patient is a major source of grief for staff.
Pediatric oncology nurses continually face
this kind of stress and may grieve repeatedly.
Their grief needs to be addressed during the
actual caregiving time and after the death of
the patient. Paradoxically, these staff members may find themselves in the role of
providing bereavement care to the family
while needing support and comfort for themselves. 1,1 Therefore, staff need support strategies that focus on resolving their grief in a
positive manner. Research suggests that recognition of the role and significance of staff
stress with dying patients is important in
planning approaches for supporting the care-

giver.12
Family Reactions to Loss
In working with grieving families, a critically important framework for developing
interventions is the family system.13 Families
function as a system composed of individuals with unique personalities. Each member
has his or her own identity and role within the
family system. When a member dies, the
system becomes disrupted. The surviving
members experience a void and an emptiness. Often the stability of the family system
may be threatened.14 The family is even

person.16
Parents. Parental grief is filled with intense
emotions. Parents may have a desperate
need to remember their child and to talk to
someone who truly understands the circumstances of the childs death.2,1?,18 The parents may become so preoccupied with their
own grief that other family members, even

their surviving children, may be closed out or

forgotten.
Siblings. The death of a brother or sister
during childhood can be traumatic. The surviving child often hides his or her grief in an
effort to protect the fragile parents from
further distress. In Rosens9 work, she found
that a central theme in sibling loss is a
prohibition against mourning. Often the surviving child is encouraged to be strong and
silent instead of being allowed to remember
the deceased or express feelings. In this
environment, the grieving sibling cannot access interventions needed to help cope with
the loss of a sibling.2 Therefore, ,a critical
need is that grieving siblings be provided with
ways to accomplish the tasks of mourning.
Activities that promote acknowledging and
accepting the loss, and facing and bearing
the pain are helpful in grief resolution.21
Extended family. The extended family of a
deceased child is often left to deal with their
grief alone. The term &dquo;forgotten grievers&dquo;22
has been used to describe those family members, but little work has been directed toward
helping them cope.18 Grandparents have reported the death of a grandchild as a double
grief experience. They feel grief for both their
own child who is undergoing this ordeal and
for their beloved grandchild. The grieving
process may be intensified for grandparents
and other extended family members because
they do not have the same bereavement
follow-up opportunities provided parents and
siblings. Therefore, health care professionals need to reach out and assist the extended

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74

feelings of grief into a revitalof caring, and transform the loss

of a child to death into an embrace of a
childs life.24
Memorial service. A memorial service is
one type of funeral. The distinguishing characteristics of a memorial service are the
absence of the body and the focus on life as
opposed to death.23 There has been some
concern expressed that funeral rituals occur
too soon after death. Consequently, the survivors may still be in a state of shock and not
able to benefit from the service. This concern
suggests the value of providing continued
rituals throughout the mourning process, such
as the Roman Catholic anniversary mass and
the Jewish unveiling, which occur a year
after the death.23 A memorial service allows
families, friends, and health care providers to
experience a sense of healing and connection to their community during times of be-

family members as they try to cope with their

to thaw frozen

grief.

ized

Rituals for

healing

All societies practice rituals, and these

activities have been traced back some 60,000
years to the time of Neanderthals.23 Historically, rituals have been used to acknowledge
significant moments of development including death.24 Rituals are behaviors or activities
that provide a symbolic expression to
thoughts and feelings. Such activities can be
one-time occurrences or repetitive behaviors. Rituals have numerous benefits for the
participants. They provide a sense of order
and comfort during times of instability, turmoil, and grief.25,26 Rituals have the magical
quality of both announcing and creating
change.27 Also, they reflect changes that
always involve both beginnings and endings
as well as joy and pain concurrently.28 Participating in a ritual provides a strong healing
experience that symbolizes transition, healing, and continuity.z~ The curative power of
rituals is that they connect people with a
sense of forgiveness, compassion, and an
awareness

that

people

are more

alike than

different.28
Use of ritual in grief and bereavement. Rituals provide one method of grief resolution.
Two types of rituals are typically associated
with death: the funeral and the memorial
service. These rituals seem to meet certain
universal human needs, such as confirming
the reality of death, assisting in the expression of feelings, stimulating memories of the
deceased, and providing support to the family and friends of the deceased.23 Both of
these rituals support grief resolution by initiating tasks of grieving including providing a
symbolic acknowledgment of the severing of
the relationship and support for readjustment
to the environment in which the deceased is

missing.113
Funeral. Burial ceremonies or funerals
have been practiced since the earliest times
as a means of honoring the dead and helping
survivors.z~,3o The major function of a funeral
is as a rite of passage.8 The funeral has the
power to transform isolation into community,

sense

reavement. 28,31
The literature on staff stress and grief,
family grief, and rituals served as a framework for developing a memorial service for
families and staff. This information was used
in the planning and implementation of the
program. The memorial service encompasses both families and caregivers and
serves a dual purpose of supporting both the
family and the staff, and connecting them
through a healing ritual. The service provides
staff with a concrete way to minister to the
families and helps minimize feelings of failure related to the death.

Planning
Preparation for the memorial service involved establishing the goals and objectives
for the service as well as setting up a timeline
and implementing the organizational steps
necessary for a smooth program. Although
one staff member serves as logistical coordinator, the entire staff (nurses, social worker,
physicians, clerical staff, and child life specialist) of the Childrens Center for Cancer
and Blood Disorders is involved in developing and implementing the service.

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75

Philosophy and Goals of Service

TABLE 1.

Timeline

The fabric of the service was woven from

several principles and goals that reflected the
overall philosophy of the service. The idea of
&dquo;a joy shared is multiplied and a grief shared
is divided&dquo; was a guiding principle in developing the service. The service was visualized as
a time that would give families a legitimate
reason for returning to the treatment center, a
ritual of remembrance and closure, and a
public recognition of the bonds that had been
established between families and staff. Also,
the service provided similar benefits to staff
to aid them in grieving children who had died.
The staff wanted a service that did not seem
to be a funeral but instead was uplifting,
reflective, and healing. The purpose was not
to prevent feelings of sadness and grief but to
give them a new avenue of expression. A
nonsectarian service was desired so that
everyone would feel comfortable attending
regardless of religious affiliation or ethnic

background.
Logistical Details/Timeline
Many logistical details must be attended to
in

planning a memorial service. Some of the

were determined by convenience or

details

necessity. Others were determined to support the attainment of goals. The date chosen

Sunday closest to National Arbor

Day
keeping with the garden, life-cycle
theme. Two major details, site selection and
graphic design/printing, are discussed later

was

the
in

to aid others who may be planning a similar

program. A timeline is also given in Table 1
to provide planning information and details.
Many bereaved families find it difficult to
return to the treatment center. However, the
staff decided to have the service in the main

auditorium of the hospital. This central location was familiar to the families but was not
located in the same building as the treatment
center. Another reason for selecting the hospital was to integrate the planting into the
service and provide a garden location where
family members could return as they desired.
The staff wanted the service to include the
planting of a flowering tree or shrub to symbolize hope and rebirth.

Graphic design and program printing are

another important element involved in program implementation. The invitation and program were designed to enhance the meaning
of the service, provide remembrances, and
reflect the goals of the service. Therefore,
much thought and time were invested in the
graphic design, layout, and wording of the
two pieces. The artwork on the invitation and
program use similar graphic features. For
several years, a photograph of a bloom from
the planting was used. More recently, the
design has featured children flying a kite. The
kite is used as a symbol of hope (Fig 1 ).
Purple, a traditional color of mourning, is
used as an ink color.
Mailing lists for the invitations included
parents of honored children, parents of children previously honored, hospital and cancer center staff, appropriate community
members, and special friends. Parents of the

children

being

honored receive

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letter and

76

FIGURE 1.
Invitation. (Reprinted with permission from the Center for Cancer Treatment and Research, Richland Memorial

Hospital, Columbia, SC)

enclosure of five invitations. These invitations are to be given by the parents to

extended family members and friends. Families may request more than five invitations
but are asked to have all guests respond if
they plan to attend.

Description of Seroice
To achieve the established goals, the staff
determined that the service should include

music,

an

uplifting meditation,

an

opportu-

vice. The music is

provided by a vocalist who

accompanies himself on a guitar. A variety of

songs has been used over the years of the
service. The criteria for choosing the songs
are that they are largely nonsectarian and
reflect the purpose of the service. Examples
of songs used include &dquo;Celebrate the Times,&dquo;
&dquo;Thats What Love Is For,&dquo; &dquo;Eulogy,&dquo; &dquo;I Will

Always Remember You,&dquo; and &dquo;Aloha.&dquo;

TABLE 2.
Order of Service

nity to reflect on memories of the deceased

children, a memorial planting, and a child
recognition. Also, the staff wanted to give
each family a special memento to remind
them that their child was special to the staff
and that the staff still cared about the family.
An example of the order of service is shown
in Table 2. One aspect of the service that is
integrated throughout is the use of music.
Music is used initially to create a hopeful and

soothing environment, and later to reinforce

the various components of the order of ser-

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____

77

A reflective mood is set by using, quiet,

meditative music accompanied by a slide
show that features nature scenes of the four
seasons that begins about 15 minutes before
the service. Greetings are extended by the
medical director and the administrative manager of the center. The greetings emphasize
both the pain of grief and the joy of shared
memories. They stress the value, uniqueness, and contribution of each child and
family in the continuing battle against cancer
and blood disorders.
The memorial meditation is generally delivered by a staff member or a volunteer who
has a close connection with the children and
their families. The purpose of the meditation
is to honor the memory of the children and to
focus on hope for the families. As our families come from many religious backgrounds,
the meditation does not espouse a particular

administration who agreed that a planting

could be done if the plants met the approval
of the groundskeeping staff. For the first
seven services, a tree or shrub was purchased before the service, and the groundskeeping staff prepared the site. At the latest
service, the families were given a flowering
plant like the flower bed of annuals at a
designated site in the garden. The staff member who is coordinating this part of the service discusses the meaning of the planting
and the garden, and reads a short meditation. Siblings are especially invited to shovel
dirt into the prepared site around the tree or
shrub; others participate if they desire.
The responsive reading acknowledges and
assures the families that the memories of the
children and their contributions will continue
to live. The reading of this by all the gathered
participants focuses on the guiding principle
of &dquo;a joy shared is multiplied and a grief
shared is divided.&dquo; The reading was adapted
from a closing response, &dquo;We Remember

theological perspective.
After the meditation, the participants are
led in an activity to help them focus on a
specific memory of the child they came to
honor. Each person present at the memorial
service is encouraged to write a special
memory on a card with a picture of children
flying kites. This part of the service offers the
participants a new avenue for expressing
their feelings. These cards may remain private or be shared with others, and may be left
for placement in the memory book: The
memory book contains pictures, poems, articles, and other items pertaining to the children that families have contributed. As families from past services still attend this service,
all of our memory books are available before
and after the service for families, staff, and
guests to peruse.
After a benediction, the service moves into
the garden area. A memorial planting, responsive reading, child recognition, balloon
release, and song conclude the program.
During an informal evaluation session after
the first support group, staff brainstormed
ways to acknowledge both the close ties that
families felt with the staff and the hospital,
and that the life of the child was remembered.
An idea was born to establish a garden in
which a planting could be done during the
service. A proposal was made to hospital

Them.&dquo;32
The child

identifies each child

name is read, and a
forward
member
comes
to receive a
family
memento and a balloon from the staff. Also,
in some years, special friends or supporters
for the center who died in the p,ast year are
recognized. The memento generally is related to the symbol for the center, a kite. The
balloon release takes place during the closing song and is a symbolic way for the
families to publicly say good-bye to their
children. Although the balloon release is
emotionally difficult, it is considered a therapeutic step in the healing process.

individually.

recognition

Each childs

Follow-Up
After the service, the coordinator sends a
letter to each family who was unable to
attend the service in which their child was
honored. In addition to the letter, staff encloses remembrances of the service. These
remembrances include a copy of the program, inserts, and the take-home remembrance.

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78

Clinical Evaluation
Because of the nature of this service, staff
has been reluctant to conduct a formal written evaluation of the program. Staff has felt
that this type of evaluation was not appropriate and would detract from the purpose of the
service. However, staff remains aware of the
importance of obtaining feedback about the
program, and the need to critique the program and monitor its quality. The program
was initiated to acknowledge formally the
emotional bonds that had developed between staff and families. Therefore, staff
wants to continue to assess if the specified

bereavement needs of the families

are

being

met through the service.

Staff has conducted eight services. Several

approaches have been used to evaluate the
program informally. These include debriefing
with staff, obtaining informal feedback from
families, and conducting an informal process
evaluation. The first service was particularly
difficult as 99 children were honored. Staff
had decided to honor all children who had
died since the beginning of the pediatric
oncology program. Staff felt overwhelmed
just looking at the list and thinking about the
many children whom they had cared for who
had died. Therefore, the coordinator informally encouraged staff to share feelings about
the service and explore the meaning of the
service to them personally as well as to the
families. These discussions allowed the coordinator to assess staffs opinions about the
value of the service to them and solicit
evaluation comments. Staff acknowledged
the painfulness of the service and the emotional intensity, but were strongly supportive
of its value and wanted to continue next year.
A second method of clinical evaluation
was to solicit family evaluations informally.
At the end of the service, staff informally
interacts with families. Most families spontaneously share the value of the service and its
meaningfulness to them, which suggests an
immediate positive reaction. Also, staff has
noted that some families return year after
year. Their return is to connect with staff and
show support to other grieving families. Some

families write letters of thanks after the

vice. Comments included the following:

ser-

planning the memorial service is

but
rewarding for all of you.&dquo;
painful
&dquo;The memorial service was sweet, moving
&dquo;I know

and

so

meaningful.&dquo;

touched by a wife who constantly

reached over and touched her husband
throughout the service. He cried openly. I
wondered if their loss was recent; their
emotion was so deep and yet after almost
five years there are times when I feel the
loss just happened.&dquo;
&dquo;We are looking forward to the memorial
service. The first one was so sweet and
unforgettable; this one will be just as meaningful to those parents who have lost a
child recently.&dquo;
&dquo;I

was

Finally, staff continuously assesses and

evaluates the role of the service throughout
the year during bereavement follow-up and
support groups. Through the bereavement
follow-up program, staff has continued to
receive positive comments about the service
from families.
A third method of evaluation is to look at
the process and changes within the service
over the years. Positive trends have been
noted. Staff meets after the service to debrief
and discuss changes that may be instituted
at the next service. Staff evaluations of the
personal value of the service are obtained
through staff meetings and planning sessions. Staff strongly supports the service and
its value by including it as a repeat program
when planning the next years psychosocial
programs.
As the staff members have grown and
matured, they are more involved in planning
of the service. Initially, staffs involvement
was passive (eg, they might suggest a song
to be used or a speaker). The early involvement was more cognitive, making decisions
about the service. Over time, they have
become more actively involved in participating and planning. Initially, staff was reluctant
to be involved in the more public tasks of the
service. However, over time their comfort
with an active role in the actual service has
increased. The most difficult part of the

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79

service to present is the meditation; during

the past four services, staff members have
presented it. Their increased participation
seems to provide them emotional healing
and an opportunity to comfort families.
The service also provides an opportunity
for others connected to the children to experience a healing ritual, and say good-bye and
remember the child. Childrens hospital staff,

Ronald McDonald staff and volunteers, Camp

Kemo volunteers, Lasting Impression volunteers, and other community and hospital
staff attend. Their attendance also provides
an indication to the parents of how many
people their childs life has touched. This
message gives meaning to the childs life and
shows that the child made a contribution to
the lives of many people.

References
1. Heiney S, Wells L, Gunn G: Effects of group therapy
bereaved extended family of children with cancer. J
Ped One Nurs 10:99-104, 1993
2. Heiney S, Goon-Johnson K, Ruffin J: The effects of
a support group on selected psychosocial outcomes of
bereaved parents whose child died from cancer. J Ped
Onc Nurs 1994
3. Heiney S, Hasan L, Price K: Developing and implementing a bereavement program for a childrens hospital. J Pediatr Nurs 8:385-391, 1993
4. Koocher G: Adjustment and coping strategies
among the caretakers of cancer patients. Social Work in
Health Care 5:145-150, 1979
5. Hinds P, Fairclough D, Dobos C, et al: Development and testing of the stressor scale for pediatric
oncology nurses. Cancer Nurs 13:354-360, 1990
6. Herschbach P: Work-related stress specific to physicians and nurses working with cancer patients. J
on

Psychosoc Oncol 10:79-98, 1992

7. Vachon M: Staff stress in care of the terminally ill.
Quarterly Review Bulletin 5:13-17, 1979
8. Small M, Engler A, Rushton C: Saying goodbye in
the intensive care unit: Helping caregivers grieve. Pediatr Nurs 17:103-105, 1991
9. Johnson S: After a Child Dies: Counseling Be-

reaved Families. New York, NY, Springer, 1987

10. Shubin S: Burnout: The professional hazard you
face in nursing. Nurs78 8:22-27, 1978
11. McElroy A: Burnout: A review of the literature
with

application to cancer nursing.

217, 1982

Cancer Nurs 5 :211-

12. Moser D, Krikorian D: Satisfaction and stress

incidents reported by hospice nurses: A pilot study. Nurs
Leadership 5:9-17, 1982
13. Heiney S: Assessing and intervening with dysfunctional families. Oncol Nurs Forum 15:585-590, 1988
14. Sanders CM: Grief: The mourning after. New York,

NY, Wiley, 1989

15. Schiff HS: The Bereaved Parent. New York, NY,
1985
16. Miles MS: The Grief of Parents When a Child Dies.
Chicago, IL, The Compassionate Friends, 1980
17. Knapp D: Beyond Endurance: When a Child Dies.
New York, NY, Stockton, 1986
18. Rando T: The unique issues and impact of the

Penguin,

death of a child, in Rando T (ed): Parental Loss of a

Child. Champaign, IL, Research Press, 1986, pp 5-44
19. Rosen H: Prohibitions against mourning in childhood sibling loss. Omega 15:307-316, 1984-1986
20. Heiney SP: Sibling grief: A case report. Arch
Psychiatr Nurs 5:121-127, 1991
21. Baker JE, Sedney MA, Gross E: Psychological
tasks for bereaved, children. Am J Orthopsychiatry

62:105-116, 1992
22.

Gyulay

J: The

forgotten grievers.

Am J Nurs

75:1476-1479, 1975
23. Rando T: Funerals and funerary rituals, in Grief,
Dying, and Death: Clinical Interventions for Caregivers.
Champaign, IL, Research Press, 1984, pp 173-197
24. Armstrong L: Afterward: Remembrance from a
psychiatric clinical nurse specialists perspective. MCN

17:313, 1992
25. Adams D, Deveau E: After death: How families
survive through grief and mourning, in Coping with
Childhood Cancer: Where Do We Go From Here? Reston, VA, Reston, 1984, pp 199-239
26. Rando T: Therapeutic interventions with grievers,
in Grief, Dying, and Death: Clinical lntgrventions for
Caregivers. Champaign, IL, Research Press, 1984, pp
75-117
27. Imber-Black E, Roberts J: How rituals work for us,
in Rituals for Our Times. New York, NY, Harper Peren-

nial, 1993, pp 25-56

28. Imber-Black E, Roberts J: Life-cycle rituals, in
Rituals for Our Times. New York, NY, Harper Perennial,
1993, pp 267-290
29. Siblette K, Flagg M: Old and new funeral rituals, in
Final Celebrations: A Guide for Personal and Family
Funeral Planning. Ventura, CA, Pathfinder Publishing of
California, 1992, pp 79-102
30. Hollingsworth C, Pasnau R: Mans attitudes toward death: Funerals and rituals, in Hollingsworth C,
Pasnau R (eds): The Family in Mourning: A Guide for
Health Professionals. Philadelphia, PA, Grune & Stratton, 1977, pp 133-139
31. Hammer M, Nichols J, Armstrong L: A ritual of
remembrance. MCN 17:310-313, 1992
32. Connelly C: Given in Love. Omaha, NE, Centering Corporation, 1990

Downloaded from jpo.sagepub.com at US DEPT OF VETERAN AFFAIRS on April 9, 2013