In the present study, a grounded theory approach was employed with the purpose of developing a substantive theoretical model to identify and illustrate changes in sibling relationships after pediatric bone marrow transplantation (BMT). Further investigation of the impact of sibling relationship quality on children's adaptation following this life-threatening medical procedure was examined. Two families, each consisting of a sibling dyad that included a child who received a BMT and a well sibling that ranged in age from 10-14 and a parent, participated in the study. Siblings were interviewed individually, and in the dyad, to capture an insider's view of the sibling relationship after BMT and factors that impact child adaptation to pediatric BMT. Child observational and parent survey data provided a multiple-informant and multiple-method approach which helped to foster a more complete picture of the broader family context. Findings suggest that children's sibling relationships improved after BMT, as evidenced by their building a close relationship, establishing intimacy and gaining trust, and learning to get along and settle differences better. Positive coping strategies included identifying and utilizing supports and resources, praying/prayer, making life easier for the sibling, and redefining what is important in life. Children's individual adaptation outcomes included accepting the illness, recognizing the longevity of the relationship, reducing worry/stress, and moving beyond the illness. Analyses that were grounded in the data from the present study suggest four theoretical propositions. First,children's sibling relationships have the potential for positive change after BMT. Second, close sibling relationships can serve as a buffer, or protective factor, to the adverse conditions and extremely stressful situations encountered after BMT. Third, positive changes in children's sibling relationships after BMT can positively influence children's coping strategies which may have a direct influence on children's adaptation to BMT. The fourth, and primary hypothesis, suggests that positive changes in children's sibling relationships after BMT potentiate new coping strategies in the dyad that are more facilitative to child adaptation than managing stress on one's own. Findings add to the general knowledge on sibling relationships and shed light on the complexities of children's sibling relationships when one child is severely ill.

Blood and marrow transplantation (BMT) has become an increasingly acceptable treatment for children with life threatening malignant diseases. Survival rates for transplant recipients vary from 23% to 63%. Children with complications from BMT, typically die in the hospital after a prolonged stay. The parental decision to allow a child to die a natural death is typically made in an aura of emotional duress and bewilderment at the complexity and volume of new information that must be assimilated.The purpose of this study was to describe the process of parental decision making for Do Not Resuscitate (DNR) or to withdraw life support in pediatric BMT.The framework for this study was developed from the author's epistemology that blends neo-modernism (recognition of individual uniqueness yet acknowledgment that certain underlying universal principals exist) with the idea that the nature of all things may be viewed as an ongoing, self-constructing process.Grounded theory methodology was used. The sample (determined through theoretical sampling) consisted of seven parents of children who died following BMT and for whom the parent made an end-of-life decision. Data was analyzed using constant comparative analysis, a method that combines both substantive and theoretical coding of data with a qualitative style of theory development.The realization of parental knowing was the process that parents used to navigate the human problem of having to make the end-of-life decision for their children who were dying following blood and marrow transplantation. This process consisted of four categories: Developing Trust, Committed to Seeing It Through, Facing My Worst Fear, and Acceptance of Self.The knowledge gained from this study will inform nurses who care for children who are dying following pediatric BMT. Strategies may be developed that will assist nurses to support the development of parental trust, to help sustain the commitment of parents as they move through the BMT treatment journey, and to assist parents as they face their worst fear. As a result, parents should be better able to achieve an acceptance for themselves that will facilitate a more satisfying experience of the ever changing process occurring in their own lives.