Table 3.

Protective and risk factors

	Protective factors	Risk factors
Innate Ring	Presence of spiritual support, guidance and counsel [81–85]	Perceptions of guilt, anger, desperation and Divine punishment [89, 99, 100]
	Strong spiritual beliefs [151]
	Belief in reunion with child in the afterlife [86, 93]
Individual Ring	Viewing death as positive outcome Relief from suffering [92, 105] Greater purpose [107] Reduced fear of death [106] Appreciation of own mortality [108, 109]	Anger, fear and guilt to changes in the child’s condition [96, 106, 117, 118, 134, 163, 171]
	Well symptomatically cared for [114–120]	Protracted dying process [111, 120] Poor symptom management [10, 108, 143, 146, 151, 152]
	Frequent personalised and timely updates on child’s prognosis and condition [131, 132]	Being unaware of prognosis [112] Ineffectual preparation by healthcare professionals [92, 100, 113, 116, 131, 150, 163] Unrealistic prognostication [10, 113, 129, 132, 135, 138, 165, 166],
	Personalised communication [113]	poor communication [10, 82, 116, 117, 129, 131, 132, 135, 143, 148, 165–167]
	Being present at the death [98, 126, 140, 143–145]	Not involved in end-of-life decision [84] Separated from the child [131, 148] Lack of a conducive environment to say goodbye [148, 164]
	Respect for advanced care plan [111] Effective end of life care [121–124]	Inadequate social [82, 88, 120, 148, 154, 161, 165, 175] Inadequate spiritual [82, 88, 98, 176, 177] Inadequate bereavement support [82, 83, 89, 92, 108, 109, 127, 141, 143, 148, 150, 152, 154, 163, 178]
	Positive means of coping including: Remembering the child [87, 89, 90, 106, 109, 132] (memory boxes, commemorating anniversaries) [82, 89, 92, 95, 96, 115, 116, 127, 138, 156–158] Greater self-care [152, 155] Giving back to society [106, 109, 134, 149, 152] Donating organs [87, 90, 92, 109, 127, 138, 155] Re-dedicating their lives [107, 109, 134]	Anxiety, depression, post-traumatic stress symptoms [89, 158, 163, 168, 172, 173] Insomnia [89] Permanently damaged parental self-concept [168] Role confusion [171] Poor social function [10, 89, 99] Functional impairment such as phobias, or somatic problems [81, 92, 155, 163, 174] Suicidal ideation and prolonged grief [10, 89]
Relational Ring	Spousal support [89, 90]	Spousal disagreements, stress, grief [39, 92, 112, 134]
	Support from family and friends [88, 137, 140, 154, 155, 176]	No family/friends to support [83] Insensitivity from family/friends [85, 90, 167]
	Support from remaining children [92, 109]	Previous neglect of other children [82, 83, 95, 143, 148, 150, 155]
Societal Ring	Continued support from healthcare professionals who knew family and the child [81, 83, 88, 108, 114, 135, 138, 140, 146, 147]	Feeling ‘abandoned’ by the hospital staff [82, 85, 114, 120, 127, 176, 183] Reporting feeling of having suffered a ‘double loss’[109] or ‘multiple losses’ [111] following poor bereavement support [184]
	Trusting relationship with healthcare professionals [114–119, 147]
	Able to share feelings [127, 128] Receive guidance [116, 117, 119, 127, 129, 130] Receive culturally appropriate care [87, 117, 128, 135, 136] Receive compassionate care [90, 111, 115, 118, 119, 134]	Lack of professional support [84, 125] Poor transition of care [114, 127, 129, 140, 143, 148] Role conflict [167–169] Loss of parental role [113, 160] Lack of cultural sensitivity [170]