Bereavement in adult intensive care units (ICUs) is often sudden and unexpected, with death frequently following unpredictable and rapid trajectories 1. This leaves families with little opportunity for emotional preparation. The highly medicalised, invasive and technologically mediated environment further shapes the dying process, creating a markedly different experience from that of other end-of-life care settings where emotion-focussed support is more deliberately integrated into bereavement support strategies 2. This unique context contributes to a heightened psychological burden for bereaved ICU families, with studies linking ICU bereavement to increased rates of anxiety, depression and post-traumatic stress 3. Notably, over half of ICU-bereaved families meet the diagnostic criteria for prolonged grief disorder, compared to fewer than 10% in the general population 4. Against this backdrop, there is growing recognition of the significant psychological burden that ICU bereavement places on families, prompting calls for more compassionate, family-centred models of care 5. Yet, when applied to bereavement support, the concept of family-centred care in the ICU often remains narrow in scope. The needs of children, who are frequently central to the family and equally affected by the loss, are often overlooked 6. Notably, current UK and European clinical guidelines for ICU bereavement support contain no specific recommendations for involving or supporting children when someone close to them is dying in an adult ICU 7-9. Furthermore, research examining the experiences of ICU-bereaved families rarely considers children's perspectives or needs. This omission risks marginalising children as passive bystanders rather than recognising them as active grievers and participants in the end-of-life experience. More critically, it fails to account for the profound psychological impact that ICU-based bereavement can have on children, particularly when they are not provided with timely, honest and developmentally appropriate information 6. In the absence of clear guidance or robust child-focussed research, ICU staff are often left to rely on instinct. As a result, practices vary widely between, sometimes even within, units 6, and insights from broader clinical settings show that healthcare professionals report feeling uncertain, ill-equipped and uncomfortable supporting children through the bereavement process 10, 11. This discomfort is understandable. The ICU is a high-stakes, fast-paced environment in which clinical priorities often take precedence. Discussing death is inherently challenging; doing so with children can feel especially daunting for bedside clinical staff, particularly without adequate time, training or psychological support 11. Yet, the consequence of this discomfort and uncertainty amongst clinical staff is that children are often excluded from ICU visits, provided with limited or unclear information and left to make sense of their loss without guidance from those best placed to support them. Adults, both parents, caregivers and healthcare professionals may act as gatekeepers, avoiding direct conversations in an effort to shield children from distress 6. Importantly, children themselves rarely avoid the topic. They are often naturally curious and responsive to emotionally honest communication. The challenge lies not in children's capacity to engage, but in adults' preparedness, and confidence, to include them. The exclusion of children from ICU bereavement processes is far from benign. Children who experience the death of a significant adult face elevated risks of psychological and behavioural difficulties, including depression, anxiety, post-traumatic stress symptoms and school disengagement 12. These risks are exacerbated when children are unsupported, misinformed or prevented from participating in the death and mourning process. Shielding children from these realities can increase anxiety and confusion. Those who are excluded from seeing a dying relative, or given only partial information, may construct their own narratives - ones that often involve self-blame or distorted perceptions of what occurred 8, 13, 14. Children who are included during bereavement and offered a meaningful role report feeling valued, important and connected to their loved one 14. Inclusion can help reduce anxiety and confusion by bridging the gap between imagination and reality, especially when children are supported to ask questions, and participate in rituals or small acts of care 6, 13. These experiences have been shown to foster healthier grief responses, promote emotional resilience and strengthen family bonds during a profoundly difficult time 13, 14. When supported appropriately, children are not only capable of engaging with death and dying, they often find comfort and meaning in doing so 14. Crucially, the ICU may represent the only opportunity to involve children in a meaningful way. It presents a critical window in which healthcare professionals can support healthy grief adaptation by proactively seeking out children likely to be affected by the death of an important adult, advocating for child presence, modelling honest communication, facilitating parent–child dialogue and helping families prepare the child for what they might see and experience 6. Current models of family-centred care in ICU often fall short of their own promise. If family-centred ICU care is to be more than aspirational rhetoric, it must fully include children. This means recognising children as integral members of the family system, addressing their unique needs and equipping ICU healthcare professionals with guidance on how to communicate with them effectively. Family-centred care must consider not only those at the bedside, but also those just beyond it. ICU staff can act as advocates for children when an important adult is dying, ensuring they are not overlooked. By proactively identifying children likely to be affected, staff can initiate timely and compassionate support at a critical moment. Children may not always ask to be included, but they will notice when they are not. As illustrated in Figure 1 from our recently published narrative review 6, a proactive framework for recognising and supporting bereaved children in ICU families offers a practical starting point. Centred on the principles of identifying, empowering, advocating and supporting, this model invites ICU professionals to gently enquire about children connected to the patient, offer families developmentally appropriate guidance for talking with children and encourage inclusion where possible. Simple prompts and evidence-informed messages can go a long way in reducing distress and promoting healthy coping 6. Many families may not think to ask whether their child can visit or may assume it is not appropriate. ICU professionals can play a crucial role in offering informed choice, making it clear that visiting is possible, and helping families consider the potential benefits of inclusion. To fully realise a child-inclusive model of bereavement support in the ICU, further research and targeted investment are essential. Future studies should explore the lived experiences of bereaved children and their caregivers in the adult ICU context to better understand their needs, preferences and the barriers to meaningful involvement. This includes examining how children of different ages and developmental stages experience ICU bereavement, and how tailored interventions can support them effectively. Epidemiological research is also needed to quantify the prevalence and long-term consequences of childhood bereavement in ICU settings; data that are currently lacking but critical for informing policy. In parallel, caregiver-focussed research should investigate how best to support parents and relatives in involving children in end-of-life care, including how cultural, familial and individual factors shape these decisions. Understanding these dynamics is vital for developing sensitive, flexible approaches that meet diverse family needs. For healthcare professionals, there is a need for targeted training that builds confidence and competence in supporting children. This includes communication skills, developmental understanding and practical strategies for involving children in ICU visits and rituals around death and dying. Clinical guidelines should be revised to include specific, evidence-based recommendations for child-inclusive bereavement care in adult ICUs, supported by co-produced tools and resources. Institutional commitment is key. Hospitals and healthcare systems must prioritise bereaved children as part of routine ICU family care, not as an afterthought, but as vital members of the grieving family. Without explicit attention to children's needs, family-centred care in the intensive care unit remains both conceptually flawed and practically incomplete. When we fail to recognise and respond to the needs of bereaved children in families, we risk delivering care that is neither fully compassionate nor truly inclusive. The solution is not to ask ICU professionals to do more, but to support them to do differently, through training, guidance and institutional support. Enabling families to make informed decisions about involving children in ICU bereavement care is not simply good practice; it is a fundamental act of compassion and should be embedded as a core element of family-centred care principles. If we truly believe in family-centred care, we must ask ourselves: Who do we mean when we say ‘family’? This commentary coincides with the early phase of The POSIE Study, and appreciation is extended to the study's steering committee and public contributors for their ongoing commitment to improving child-inclusive ICU bereavement care. The author has no conflicts of interest to declare. This commentary is published alongside the launch of the POSIE-1 Study (endorsed by the European Society for Intensive Care Medicine). The data that support the findings of this study are available from the corresponding author upon reasonable request.
Annelies Rowland (Mon,) studied this question.