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Jalmsell L, Forslund M, Hansson MG, Henter JI, Kreicbergs U, Frost BM. Transition to noncurative end-of-life care in paediatric oncology--a nationwide follow-up in Sweden. Acta Paediatr 2013; 102:744-8. [PMID: 23557514 DOI: 10.1111/apa.12242] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 02/18/2013] [Accepted: 03/14/2013] [Indexed: 11/28/2022]
Abstract
AIM To estimate whether and when children dying from a malignancy are recognized as being beyond cure and to study patterns of care the last weeks of life. METHODS A nationwide retrospective medical record review was conducted. Medical records of 95 children (60% of eligible children) who died from a malignancy 2007-2009 in Sweden were studied. RESULTS Eighty-three children (87%) were treated without curative intent at the time of death. Children with haematological malignancies were less likely to be recognized as being beyond cure than children with brain tumours [relative risks (RR) 0.7; 95% confidence interval (CI) 0.6-0.9] or solid tumours (RR 0.8; 0.6-1.0). The transition to noncurative care varied from the last day of life to over four years prior to death (median 60 days). Children with haematological malignancies were treated with a curative intent closer to death and were also given chemotherapy (RR 5.5; 1.3-22.9), transfusions (RR 2.0; 1.0-4.0) and antibiotics (RR 5.3; 1.8-15.5) more frequently than children with brain tumours the last weeks of life. CONCLUSION The majority of children dying from a malignancy were treated with noncurative intent at the time of death. The timing of a transition in care varied with the diagnoses, being closer to death in children with haematological malignancies.
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Affiliation(s)
| | - Martin Forslund
- Department of Pediatrics; Uppsala University Hospital; Uppsala; Sweden
| | - Mats G Hansson
- Centre for Research Ethics & Bioethics; Uppsala University; Uppsala; Sweden
| | - Jan-Inge Henter
- Department of Women's and Children's Health; Childhood Cancer Research Unit, Karolinska Institutet; Karolinska University Hospital; Stockholm; Sweden
| | | | - Britt-Marie Frost
- Department of Pediatrics; Uppsala University Hospital; Uppsala; Sweden
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Rallison LB, Raffin-Bouchal S. Living in the in-between: families caring for a child with a progressive neurodegenerative illness. QUALITATIVE HEALTH RESEARCH 2013; 23:194-206. [PMID: 23175537 DOI: 10.1177/1049732312467232] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Medical advances in recent years have led to an increased life span for children with progressive, neurodegenerative illnesses. The purpose of this hermeneutic inquiry was to explore the experience of families caring for their child at home. In-depth, audiorecorded interviews with six families (13 interviews) living in western Canada were transcribed and analyzed. The illness journey was revealed to be complex and unpredictable. We discovered many metaphors that spoke to the child's/family's life and explored the paradox of duality, such as holding both joy and sorrow, and containing both suffering and love. We outline implications for policy development within the area of respite care and coordination of services for families. The voices of families must be a vital component to influence and guide education and service development within the emerging specialty of pediatric palliative care.
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Affiliation(s)
- Lillian B Rallison
- Faculty of Nursing, University of Calgary, 2500 University Dr. NW, Calgary, Alberta T2N 1N4, Canada.
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Yang SC. Assessment and Quantification of Taiwanese Children's Views of a Good Death. OMEGA-JOURNAL OF DEATH AND DYING 2013; 66:17-37. [DOI: 10.2190/om.66.1.b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The concept of a “good death” reflects an individual's positive perceptions of and expectations about death. What constitutes a good death varies based on factors such as sociocultural norms, time, space, and even individual characteristics such as age, culture, and health status. Kehl (2006) maintained that this definitional ambiguity has impeded the implementation of measures intended to appropriately assist the dying because it has been difficult to determine what clinical evaluations and caregiving practices should be used to provide patients with more than “a good death” as it is medically defined. Thus, a more comprehensive and systematic conceptual understanding of this concept is urgently necessary.
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Garvie PA, He J, Wang J, D'Angelo LJ, Lyon ME. An exploratory survey of end-of-life attitudes, beliefs, and experiences of adolescents with HIV/AIDS and their families. J Pain Symptom Manage 2012; 44:373-85.e29. [PMID: 22771129 PMCID: PMC3432673 DOI: 10.1016/j.jpainsymman.2011.09.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 09/06/2011] [Accepted: 09/15/2011] [Indexed: 11/17/2022]
Abstract
CONTEXT For youths with life-limiting conditions, little is known regarding families' understanding of their adolescent's wishes for end-of-life (EOL) care. OBJECTIVES To examine congruence in HIV positive adolescents and their families' thoughts about death and dying. METHODS The Lyon Advance Care Planning Survey-Adolescent and Surrogate versions were administered within a randomized controlled trial. Participants (n=48) were medically stable adolescents aged 14-21 years with HIV/AIDS and their families. Congruence was measured by intraclass correlation coefficients (ICCs) for continuous variables and by kappa for ordinal or dichotomous responses. RESULTS Adolescent participants were as follows: mean age 16.6 years (range 14-21); 37.5% males; 92% African American; 38% CD4 count <200; and viral load mean=32,079 copies/mL (range <400-91,863 copies/mL). Adolescent/family dyads agreed that it is important to complete an advance directive to let loved ones know their wishes (21/24 dyads), yet no dyads agreed an advance directive had been completed. Dyads endorsed incongruent thoughts about the adolescent being afraid of dying in pain (64%; congruent afraid=8 dyads, kappa=-0.0769) and being off life support machines (congruent important=9 dyads, ICC=-0.133, 95% confidence interval = -0.540, 0.302, P=0.721). Families' knowledge of teens' preferences for the timing of EOL conversations (early vs. late in course of illness) was poor (kappa=-0.1186). Adolescents (90%) wanted to talk about EOL issues before they entered the dying phase. CONCLUSION Although important areas of congruence emerged, equally important areas, such as the timing of these conversations and adolescents' EOL needs and wishes, are not known by their families. Families need help initiating conversations to assure that their adolescents' EOL wishes are known to them.
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Cook KA, Mott S, Lawrence P, Jablonski J, Grady MR, Norton D, Liner KP, Cioffi J, Hickey P, Reidy S, Connor JA. Coping while caring for the dying child: nurses' experiences in an acute care setting. J Pediatr Nurs 2012; 27:e11-21. [PMID: 22703689 DOI: 10.1016/j.pedn.2011.05.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Revised: 05/17/2011] [Accepted: 05/24/2011] [Indexed: 11/17/2022]
Abstract
The aim of this study was to describe and understand behavior and coping strategies used by pediatric nurses caring for dying children on an inpatient acute care cardiology unit. Qualitative descriptive methods consisting of semistructured questions were presented to acute care nurses participating in focus groups. The nurses who participated in the focus groups had cared for an acutely ill child who died. Conventional content analysis was used to analyze data and organize results. The categories that emerged included the following: boundaries, memories, disconnecting, and labeling. Colleague support, institutional resources, and nurses' experience level were critical to the process of coping. Coping and grieving are facilitated by colleague and unit resources. Studies exploring job dissatisfaction, stress, and burnout from an inadequate grieving process are required.
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Affiliation(s)
- Katherine A Cook
- Nursing/Patient Services, Children's Hospital Boston, Boston, MA, USA.
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Abstract
Pediatric palliative care at the end-of-life is focused on ensuring the best possible quality of life for patients with life-threatening illness and their families. To achieve this goal, important needs include: engaging with patients and families; improving communication and relationships; relieving pain and other symptoms, whether physical, psychosocial, or spiritual; establishing continuity and consistency of care across different settings; considering patients and families in the decision-making process about services and treatment choices to the fullest possible and desired degree; being sensitive to culturally diverse beliefs and values about death and dying; and responding to suffering, bereavement, and providing staff support. Any effort to improve quality of palliative and end-of-life care in pediatric oncology must be accompanied by an educational strategy to enhance the level of competence among health care professionals with regard to palliative care and end-of-life management skills as well as understanding of individualized care planning and coordination processes.
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Yang SC, Lai SY. Validation of a new measure of the concept of good death among Taiwanese children. DEATH STUDIES 2012; 36:228-252. [PMID: 24567980 DOI: 10.1080/07481187.2011.573178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The purpose of this study was to develop and validate an instrument to measure dimensions of the concept of a good death held by Taiwanese children. The sample consisted of 1,698 Taiwanese children, approximately 12-14 years of age. Participants completed the self-administered Good Death Concept Scale (GDCS), which consists of 30 statements describing potentially important contributors to a good death that had been identified in the relevant literature. Findings indicated that the GDCS is reliable and valid, as evidenced by the acceptable reliability, the consistent item-total correlations, the successful confirmatory factor analysis modeling, and the significant associations between the scale measuring concepts of a good death and 2 standardized scales (the Multidimensional Fear of Death Scale and the Death Attitude Profile-Revised). The results of this study suggest that GDCS measures 8 distinct domains, each reflecting a different aspect of good death: physical/biological, psychological, social, cognitive, altruistic, spiritual, affective, and rational.
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Affiliation(s)
- Shu Ching Yang
- Graduate Institute of Education, National Sun Yat-sen University, Kaohsiung, Taiwan, ROC.
| | - Sih-Yi Lai
- Graduate Institute of Education, National Sun Yat-sen University, Kaohsiung, Taiwan, ROC
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Parents' dilemma: decisions concerning end-of-life care for their child. J Pediatr Health Care 2012; 26:57-61. [PMID: 22153144 DOI: 10.1016/j.pedhc.2011.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 07/11/2011] [Accepted: 07/16/2011] [Indexed: 11/23/2022]
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Martin AK, Baertschi B. In favor of PGD: the moral duty to avoid harm argument. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2012; 12:12-13. [PMID: 22452464 DOI: 10.1080/15265161.2012.656808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Angela K Martin
- Institute for Biomedical Ethics, Geneva University Medical School, CMU/1, rue Michel Servet, Geneva, Switzerland.
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Doorenbos A, Lindhorst T, Starks H, Aisenberg E, Curtis JR, Hays R. Palliative care in the pediatric ICU: challenges and opportunities for family-centered practice. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2012; 8:297-315. [PMID: 23194167 PMCID: PMC3647033 DOI: 10.1080/15524256.2012.732461] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
The culture of pediatric intensive care units (PICUs) is focused on curative or life-prolonging treatments for seriously ill children. We present empirically-based approaches to family-centered palliative care that can be applied in PICUs. Palliative care in these settings is framed by larger issues related to the context of care in PICUs, the stressors experienced by families, and challenges to palliative care philosophy within this environment. Innovations from research on family-centered communication practices in adult ICU settings provide a framework for development of palliative care in PICUs and suggest avenues for social work support of critically ill children and their families.
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Affiliation(s)
- Ardith Doorenbos
- Department of Biobehavioral Nursing & Health Systems, School of Nursing, University of Washington, Seattle, Washington, USA.
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62
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Quinn C, Bailey ME. Caring for children and families in the community: experiences of Irish palliative care clinical nurse specialists. Int J Palliat Nurs 2011; 17:561-7. [DOI: 10.12968/ijpn.2011.17.11.561] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Claire Quinn
- School of Nursing & Midwifery, Aras Moyola, National University of Ireland, Galway, ROI, and Milford Care Centre, Limerick, ROI
| | - Maria E Bailey
- Department of Nursing & Midwifery, Health Science Building North Bank Campus, University of Limerick, Castletroy, Limerick, ROI
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Saad R, Huijer HAS, Noureddine S, Muwakkit S, Saab R, Abboud MR. Bereaved parental evaluation of the quality of a palliative care program in Lebanon. Pediatr Blood Cancer 2011; 57:310-6. [PMID: 21394892 DOI: 10.1002/pbc.23082] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Accepted: 01/20/2011] [Indexed: 11/07/2022]
Abstract
BACKGROUND Palliative care (PC) is important in Pediatric Oncology as more than 20% of children with cancer still die despite modern treatment. As a significant number of children reside in countries with limited resources; more research in PC is needed there. This study aimed at evaluating the quality of care provided to children with cancer at the Children's Cancer Center of Lebanon (CCCL) during their last month of life as perceived by the bereaved parents. PROCEDURE Between 2002 and 2007, 76 children with cancer treated at CCCL succumbed to their disease. Twenty-nine of the bereaved parents were interviewed at home about the symptoms and suffering experienced by their children during the last month of life, communication with the healthcare team, quality of care delivered, and recommendations for improving care. RESULTS Fatigue, anorexia, and pain were the most prevalent symptoms and edema was the most distressing. The overall communication with the healthcare team and the overall quality of care delivered was rated as "very good" to "excellent" by 86.2% and 93.1% of the participants, respectively. Parents suggested improving the organization of care, the communication, and the availability of human and material resources. CONCLUSIONS This study is the first conducted in Lebanon to evaluate the quality of pediatric palliative care (PPC). The parents' experiences in our country were similar to those described in other countries, religions, and cultures. Significant strengths and weaknesses in the management of the dying children, from the parents' perspective, were uncovered and recommendations for improving practice were made.
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Affiliation(s)
- Rima Saad
- Children's Cancer Center of Lebanon, American University of Beirut Medical Center, Beirut, Lebanon.
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64
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Conducting research with end-of-life populations: overcoming recruitment challenges when working with clinical agencies. Appl Nurs Res 2011; 25:258-63. [PMID: 21700424 DOI: 10.1016/j.apnr.2011.04.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 04/13/2011] [Accepted: 04/22/2011] [Indexed: 11/20/2022]
Abstract
Conducting end-of-life (EOL) research can present numerous challenges associated with recruitment and retention of research subjects. Such issues may result from working with a variety of clinical settings or the uniqueness of the patient population. The purposes of this article were to describe recruitment challenges in EOL research when collaborating with different types of clinical agencies and to discuss strategies that are being used to overcome these recruitment issues.
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65
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Fitchett G, Lyndes KA, Cadge W, Berlinger N, Flanagan E, Misasi J. The Role of Professional Chaplains on Pediatric Palliative Care Teams: Perspectives from Physicians and Chaplains. J Palliat Med 2011; 14:704-7. [DOI: 10.1089/jpm.2010.0523] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Wendy Cadge
- Department of Sociology, Brandeis University, Waltham, Massachusetts
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Lago PM, Nilson C, Piva JP, Halal MG, Carvalho Abib GMD, Garcia PCR, Vieira AC. Nurses’ participation in the end-of-life — process in two paediatric intensive care units in Brazil. Int J Palliat Nurs 2011; 17:264, 267-70. [DOI: 10.12968/ijpn.2011.17.6.264] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Patrícia M Lago
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - Cristine Nilson
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - Jefferson Pedro Piva
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - Michel Georges Halal
- Fellow, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | | | - Pedro Celiny R Garcia
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - Ana Cláudia Vieira
- Hospital São Lucas, Pontificia Universidade Catolica do Rio Grande do Sul, Brazil
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Baker JN, Kane JR, Rai S, Howard SC, Hinds PS. Changes in medical care at a pediatric oncology referral center after placement of a do-not-resuscitate order. J Palliat Med 2010; 13:1349-52. [PMID: 21034279 DOI: 10.1089/jpm.2010.0177] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Parents may fear that a do-not-resuscitate (DNR) order will result in reduction of the level, quality, and priority of their child's medical care. We therefore assessed medical care that was continued, added, and discontinued after a DNR order was placed in the medical record. PATIENTS/METHODS Retrospective review of the charts of 200 pediatric oncology patients at St. Jude Children's Research Hospital who died between July 1, 2001 and February 28, 2005, were younger than 22 years old at death, and had a documented DNR order. Medical interventions that were added (between the DNR order and death), continued (not discontinued between 24 hours before and 72 hours after DNR), and discontinued (within 72 hours after DNR) were identified and compared by using binomial proportions. RESULTS With the exception of chemotherapy, the studied medical interventions that patients were receiving at the time of the DNR order were continued in 66.7% to 99.3% of cases. Chemotherapy was continued in 33.3%. The most frequently added interventions were oxygen, steroids, and pain medicine. The most frequently discontinued interventions were laboratory draws, chemotherapy, antibiotics, and parenteral nutrition. CONCLUSIONS In this cohort of pediatric oncology patients, the medical interventions being received were continued with a high frequency after placement of a DNR order. Chemotherapy was continued only in a minority of patients, possibly signifying a shift in goals. These findings may help to reassure families that a DNR order need not result in a change in any of their child's medical therapies which appropriately advance the defined goals of care.
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Affiliation(s)
- Justin N Baker
- Department of Pediatric Medicine, Division of Palliative and End-of-Life Care, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.
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68
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Helping Parents Make and Survive End of Life Decisions for Their Seriously Ill Child. Nurs Clin North Am 2010; 45:465-74. [DOI: 10.1016/j.cnur.2010.03.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Parental mortality rates in a western country after the death of a child: assessment of the role of the child's sex. ACTA ACUST UNITED AC 2010; 7:39-46. [PMID: 20189153 DOI: 10.1016/j.genm.2010.02.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND Loss of a child has been associated with elevated mortality rates in parents. Studies that focus on the influence of the child's sex on parental mortality are sparse. OBJECTIVE The main objective of the present study was to reevaluate the combined impact of the parents' and child's sex within a larger sample and focus on adverse health effects as an objective measure of possible long-term effects of maladaptive grief reactions. METHODS For the time period between 1980 and 1996, all children in Denmark who died before 18 years of age were identified. Parents who had lost a child were identified as the bereaved (exposed) group. Mortality rates of parents within the same-sex parent-child dyad were compared with mortality rates of parents within the opposite-sex parent-child dyad. Separate analyses were performed for bereaved fathers and for bereaved mothers, and additional analyses were conducted to examine the sole effect of the child's sex, irrespective of parental gender. A Cox proportional hazards regression model was used to estimate the hazard ratios (HRs) with 95% CIs. RESULTS The study population consisted of 21,062 parents (mean age at entry, 32 years; 11,221 mothers, 9841 fathers). Bereaved parents who had lost a child of the same sex had similar overall mortality as bereaved parents who had lost a child of the opposite sex (HR = 1.02; 95% CI, 0.85-1.22). Similar findings were observed for mortality due to natural death (HR = 0.96; 95% CI, 0.78-1.18) or mortality due to unnatural death (HR = 1.22; 95% CI, 0.84-1.77). Bereaved fathers who had lost a son had similar mortality as those bereaved by the death of a daughter (HR = 1.10; 95% CI, 0.86-1.40). Bereaved mothers who had lost a daughter had similar mortality as those bereaved by the death of a son (HR = 0.93; 95% CI, 0.70-1.22). Bereaved parents who had lost a son had mortality rates similar to those who had lost a daughter (HR = 1.09; 95% CI, 0.91-1.31). The interactions between grouping variable and sex of parents were not significant, indicating that the differential effect of losing a child based on sex of the child was not greater for fathers than for mothers. CONCLUSIONS The results of this study revealed no significant effect of sex of the deceased child on mortality in these bereaved parents. The results might differ if this study was replicated in a population with a different grief culture and, more importantly, different gender schemas.
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Rishel CJ. Conceptual framework for the study of parental end-of-life decision making in pediatric blood and marrow transplantation. Oncol Nurs Forum 2010; 37:184-90. [PMID: 20189923 DOI: 10.1188/10.onf.184-190] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVES To describe a conceptual framework that will facilitate research and practice concerning parental end-of-life decision making in pediatric blood and marrow transplantation (BMT). DATA SOURCES A review of relevant literature from Ovid, CINAHL, EBSCO, MEDLINE, PsycINFO, and various sociology and theology databases was combined with experiential knowledge. DATA SYNTHESIS The method of concept and theory synthesis and derivation as described by Walker and Avant was used in the development of this framework. CONCLUSIONS Use of the proposed conceptual framework is expected to provide the organization necessary for thinking, observation, and interpretation of parental end-of-life decision making in pediatric BMT. IMPLICATIONS FOR NURSING The ability to describe the process of parental end-of-life decision making in pediatric BMT will help nurses to provide appropriate counseling, education, and support for these children and their families at the end of life. In addition, the process will help nurses to promote the well-being of the children's families after end of life.
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Lyon ME, Garvie PA, Briggs L, He J, Malow R, D'Angelo LJ, McCarter R. Is it safe? Talking to teens with HIV/AIDS about death and dying: a 3-month evaluation of Family Centered Advance Care (FACE) planning - anxiety, depression, quality of life. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2010; 2:27-37. [PMID: 22096382 PMCID: PMC3218704 DOI: 10.2147/hiv.s7507] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose To determine the safety of engaging HIV-positive (HIV+) adolescents in a Family Centered Advance Care (FACE) planning intervention. Patients and methods We conducted a 2-armed, randomized controlled clinical trial in 2 hospital-based outpatient clinics from 2006–2008 with HIV+ adolescents and their surrogates (n = 76). Three 60–90 minutes sessions were conducted weekly. FACE intervention groups received: Lyon FCACP Survey©, the Respecting Choices® interview, and completion of The Five Wishes©. The Healthy Living Control (HLC) received: Developmental History, Healthy Tips, Future Planning (vocational, school or vocational rehabilitation). Three-month post-intervention outcomes were: completion of advance directive (Five Wishes©); psychological adjustment (Beck Depression, Anxiety Inventories); quality of life (PedsQL™); and HIV symptoms (General Health Self-Assessment). Results Adolescents had a mean age, 16 years; 40% male; 92% African-American; 68% with perinatally acquired HIV, 29% had AIDS diagnosis. FACE participants completed advance directives more than controls, using time matched comparison (P < 0.001). Neither anxiety, nor depression, increased at clinically or statistically significant levels post-intervention. FACE adolescents maintained quality of life. FACE families perceived their adolescents as worsening in their school (P = 0.018) and emotional (P = 0.029) quality of life at 3 months, compared with controls. Conclusions Participating in advance care planning did not unduly distress HIV+ adolescents.
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Affiliation(s)
- Maureen E Lyon
- Children's National Medical Center and George Washington School of Medicine and Health Sciences, Washington, District of Columbia
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Heath JA, Clarke NE, McCarthy M, Donath SM, Anderson VA, Wolfe J. Quality of care at the end of life in children with cancer. J Paediatr Child Health 2009; 45:656-9. [PMID: 19903251 DOI: 10.1111/j.1440-1754.2009.01590.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM Current Australian guidelines for the provision of paediatric palliative care highlight the importance of services being focused on the needs of the child and family. We aimed to establish parents' level of satisfaction with the quality of care currently being provided to children dying of cancer. METHODS We interviewed 96 parents of children who died of cancer in Melbourne, Australia between 1996 and 2004 to ascertain how they rated the care provided to their child during the end-of-life period. RESULTS A majority of parents were satisfied with the care provided by their primary oncologist, local doctors, palliative care services and home-care nurses. Most parents felt that discussions about key medical and treatment decisions were appropriate and clearly understood. Parents were generally satisfied with the leadership roles undertaken in decision-making in the end-of-life period; however, parents who were not satisfied indicated that they would like additional involvement of their primary oncologist. CONCLUSIONS Current approaches to end-of-life care in children with cancer appear to be satisfactory. The main focus should continue to be on open and honest communication.
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Affiliation(s)
- John A Heath
- Children's Cancer Centre, Royal Children's Hospital, University of Melbourne, Melbourne, Victoria 3052, Australia.
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73
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Klein SM. Moral distress in pediatric palliative care: a case study. J Pain Symptom Manage 2009; 38:157-60. [PMID: 19615637 DOI: 10.1016/j.jpainsymman.2009.04.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Accepted: 04/06/2009] [Indexed: 11/19/2022]
Abstract
End-of-life decisions for children can be complicated by disagreements between families and health care teams. These conflicts can lead to moral distress in providers. In addition, difficulties in prognostication aggravate the problem. How teams and institutions address potential staff distress is essential to providing effective palliative care for children. Through a case study of a child with a severe life-limiting syndrome, an analysis of both the ethical and legal implications of parental and team conflict are discussed. An ethics team can help provide guidance for teams and help mediate goals of care discussions with families. Palliative care consultation can also be useful, especially in providing support for both the parent and the child.
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Affiliation(s)
- Scott M Klein
- Clinical Services and Pediatric Critical Care Medicine, Maimonides Infants and Children's Hospital of Brooklyn, Brooklyn, New York 11219, USA.
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74
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Lyon ME, Garvie PA, Briggs L, He J, McCarter R, D'Angelo LJ. Development, feasibility, and acceptability of the Family/Adolescent-Centered (FACE) Advance Care Planning intervention for adolescents with HIV. J Palliat Med 2009; 12:363-72. [PMID: 19327074 PMCID: PMC2991180 DOI: 10.1089/jpm.2008.0261] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To develop, adapt, and ensure feasibility, acceptability, and safety of the Family/Adolescent-Centered (FACE) Advance Care Planning intervention. PATIENTS AND METHODS Two-group, randomized, controlled trial in two hospital-based outpatient clinics in Washington, D.C. and Memphis, Tennessee, from 2006 to 2008 was conducted. Participants (n = 38 dyads) included medically stable adolescents aged 14 to 21 years with HIV/AIDS and surrogates/families over age 20. Three 60- to 90-minute sessions were conducted via a semistructured family interview with a trained/certified interviewer. Intervention received: (1) Lyon Advance Care Planning Survey; (2) Respecting Choices interview; and (3) Five Wishes. Control received (1) Developmental History, (2) Health Tips, and (3) Future Plans. Feasibility was measured by percent enrollment, attendance, retention, and completeness of data. Acceptability and safety were measured by Satisfaction Questionnaire, using longitudinal regression analysis. RESULTS Adolescents' mean age was 16 years; 40% were males; 92% were black; HIV transmission rate was 68% perinatal and 32% sexually acquired; 42% were asymptomatic; 29% were symptomatic; and 29% had a diagnosis of AIDS. Intervention adolescents were more likely to rate sessions positively (p = 0.002) and less likely to rate sessions negatively (p = 0.011) than controls. Guardians/surrogates were more likely to rate the sessions positively (p = 0.041) and demonstrated no difference in rating sessions negatively (p = 0.779) than controls. CONCLUSIONS Existing advance care planning models can be adapted for age, disease, and culture. Adolescents with HIV/AIDS were satisfied with an advance care planning approach that facilitated discussion about their end-of-life wishes with their families. Families acknowledged a life-threatening condition and were willing to initiate end-of-life conversations when their adolescents were medically stable.
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Affiliation(s)
- Maureen E Lyon
- Department of Adolescent and Young Adult Medicine, Children's National Medical Center, Washington, D.C. 20010-2970, USA.
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75
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Abstract
O estudo teve por objetivo descrever os antecedentes, atributos e conseqüências do conceito de morte digna da criança. Utilizou-se a estratégia de análise de conceito para avaliar os 40 artigos, tendo como foco publicações nas áreas médica e de enfermagem, que estudaram ou focalizaram a morte digna da criança. Os atributos do conceito de morte digna da criança incluem: qualidade de vida, cuidado centrado na criança e na família, conhecimento específico sobre cuidados paliativos, decisão compartilhada, alívio do sofrimento da criança, comunicação clara, relacionamento de ajuda e ambiente acolhedor. Poucos artigos trazem a definição de morte digna da criança e, quando isso ocorre, essa definição é vaga e, muitas vezes, ambígua entre os vários autores. Esse aspecto indica que o conceito ainda não é consistentemente definido, demandando estudos de sua manifestação na prática clínica, contribuindo com os cuidados no final da vida em pediatria.
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76
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Lee KJ, Dupree CY. Staff Experiences with End-of-Life Care in the Pediatric Intensive Care Unit. J Palliat Med 2008; 11:986-90. [DOI: 10.1089/jpm.2007.0283] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- K. Jane Lee
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Claretta Y. Dupree
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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77
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Pritchard M, Burghen E, Srivastava DK, Okuma J, Anderson L, Powell B, Furman WL, Hinds PS. Cancer-related symptoms most concerning to parents during the last week and last day of their child's life. Pediatrics 2008; 121:e1301-9. [PMID: 18450873 DOI: 10.1542/peds.2007-2681] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Studies of symptoms in children dying a cancer-related death typically rely on medical chart reviews or parental responses to symptom checklists. However, the mere presence of a symptom does not necessarily correspond with the distress it can cause the child's parents. The purpose of this study was to identify the cancer-related symptoms that most concerned parents during the last days of their child's life and the strategies parents identified as helpful with their child's care. METHODS Sixty-five parents of 52 children who had died a cancer-related death within the previous 6 to 10 months participated in telephone interviews. Eligibility criteria included being the parent or guardian of a child aged 0 to 21 years who had died within the previous 6 to 10 months after being treated at a pediatric cancer center, having been with their child during the last week of the child's life, speaking English, being willing to participate, and having access to a telephone. RESULTS Eighteen symptoms of concern were identified as occurring during their child's final week and final day of life. The most frequently reported symptoms at both times included changes in behavior, changes in appearance, pain, weakness and fatigue, and breathing changes. The proportion of reported symptoms did not differ according to patient gender, disease, or location of death (intensive care, elsewhere in the hospital, or home). The most helpful strategies used by health care professionals to assist the child or parents included giving pain and anxiety medications, spending time with the child or family, providing competent care, and giving advice. CONCLUSIONS This knowledge can guide professionals in preparing parents for the symptoms that a child imminently dying of cancer is likely to experience and in providing care that will be helpful to parents.
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Affiliation(s)
- Michele Pritchard
- Department of Oncology, St Jude Children's Research Hospital, 332 N Lauderdale, Memphis, TN 38105-2794, USA
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78
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Lyon ME, Williams PL, Woods ER, Hutton N, Butler AM, Sibinga E, Brady MT, Oleske JM. Do-not-resuscitate orders and/or hospice care, psychological health, and quality of life among children/adolescents with acquired immune deficiency syndrome. J Palliat Med 2008; 11:459-69. [PMID: 18363489 PMCID: PMC2782484 DOI: 10.1089/jpm.2007.0148] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The frequency of do-not-resuscitate (DNR) orders and hospice enrollment in children/adolescents living with acquired immune deficiency syndrome (AIDS) and followed in Pediatric AIDS Clinical Trials Group (PACTG) Study 219C was examined, and evaluated for any association with racial disparities or enhanced quality of life (QOL), particularly psychological adjustment. METHODS A cross-sectional analysis of children with AIDS enrolled in this prospective multicenter observational study between 2000 and 2005 was conducted to evaluate the incidence of DNR/hospice overall and by calendar time. Linear regression models were used to compare caregivers' reported QOL scores within 6 domains between those with and without DNR/hospice care, adjusting for confounders. RESULTS Seven hundred twenty-six (726) children with AIDS had a mean age of 12.9 years (standard deviation [SD]=4.5), 51% were male, 60% black, 25% Hispanic. Twenty-one (2.9%) had either a DNR order (n=16), hospice enrollment (n=7), or both (n=2). Of 41 children who died, 80% had no DNR/hospice care. Increased odds of DNR/hospice were observed for those with CD4% less than 15%, no current antiretroviral use, and prior hospitalization. No differences by race were detected. Adjusted mean QOL scores were significantly lower for those with DNR/hospice enrollment than those without across all domains except for psychological status and health care utilization. Poorer psychological status correlated with higher symptom distress, but not with DNR/hospice enrollment after adjusting for symptoms. CONCLUSIONS Children who died of AIDS rarely had DNR/hospice enrollment. National guidelines recommend that quality palliative care be integrated routinely with HIV care. Further research is needed to explore the barriers to palliative care and advance care planning in this population.
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Affiliation(s)
- Maureen E Lyon
- Department of Adolescent and Young Adult Medicine, Children's National Medical Center, Washington, DC 20010-2970, USA.
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79
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Hendrickson K, McCorkle R. A Dimensional Analysis of the Concept: Good Death of a Child With Cancer. J Pediatr Oncol Nurs 2008; 25:127-38. [DOI: 10.1177/1043454208317237] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The death of a child is painful to all witnesses, but the experience varies among individuals, and differing perspectives lead to a variety of definitions for a good death. This analysis is undertaken to clarify the dimensions involved in a good death of a child with cancer and to examine them from 3 perspectives: the dying child, the child's family, and the health care providers.
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Affiliation(s)
| | - Ruth McCorkle
- Center for Chronic Illness Care, Yale School of Nursing
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80
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Abstract
Paediatric palliative care is an emerging subspecialty that focuses on achieving the best possible quality of life for children with life-threatening conditions and their families. To achieve this goal, the individuals working in this field need to: clearly define the population served; better understand the needs of children with life-threatening conditions and their families; develop an approach that will be appropriate across different communities; provide care that responds adequately to suffering; advance strategies that support caregivers and health-care providers; and promote needed change by cultivating educational programmes. Despite these challenges, advances in paediatric palliative care have been achieved in a short period of time; we expect far greater progress as the field becomes more formalised and research networks are established.
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Affiliation(s)
- Stephen Liben
- The Montreal Children's Hospital of the McGill University Health Center, Montreal, Quebec, Canada
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81
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Baker JN, Hinds PS, Spunt SL, Barfield RC, Allen C, Powell BC, Anderson LH, Kane JR. Integration of palliative care practices into the ongoing care of children with cancer: individualized care planning and coordination. Pediatr Clin North Am 2008; 55:223-50, xii. [PMID: 18242323 PMCID: PMC2577813 DOI: 10.1016/j.pcl.2007.10.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Most parents of children with cancer have dual primary goals: a primary cancer-directed goal of cure and a primary comfort-related goal of lessening suffering. Early introduction of palliative care principles and practices into their child's treatment is respectful and supportive of these goals. The Individualized Care Planning and Coordination Model is designed to integrate palliative care principles and practices into the ongoing care of children with cancer. Application of the model helps clinicians to generate a comprehensive individualized care plan that is implemented through Individualized Care Coordination processes as detailed here. Clinicians' strong desire to provide compassionate, competent, and sensitive care to the seriously ill child and the child's family can be effectively translated into clinical practice through these processes.
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Affiliation(s)
- Justin N Baker
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN 38105-2794, USA
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82
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Abstract
A significant component of palliative care is the prompt diagnosis and management of distress, anxiety, and depression. This article reviews the symptoms and treatment of anxiety and depressive disorders in children at the end of life. Distinguishing between symptoms and disorders, the importance of open communication, consideration of the child's understanding of death, diagnostic challenges in chronically ill children, and suicidality are discussed. Because treatment options are available, it is imperative that symptoms are recognized and addressed. Understanding the issues involved in screening and diagnosis and the risks and benefits of available treatments can lead to an informed approach to the management of these disorders in the palliative care setting.
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Affiliation(s)
- Leslie S Kersun
- Division of Oncology, The Children's Hospital of Philadelphia, 4th Floor Wood Building, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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83
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Browning DM, Solomon MZ. Relational learning in pediatric palliative care: transformative education and the culture of medicine. Child Adolesc Psychiatr Clin N Am 2006; 15:795-815. [PMID: 16797450 DOI: 10.1016/j.chc.2006.03.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The discrepancy between what is taught in formal educational settings and what is learned by practitioners in the informal flow of everyday practice has been called the hidden curriculum. In this article, the authors apply a well-documented range of concerns about the hidden curriculum and the erosion of professionalism to the arena of pediatric palliative care education. The authors propose that educational initiatives must always be grounded in the charged existential space of relationships among children, families,and practitioners, because the learning that matters most occurs within these relationships. The authors present an educational approach, which they call relational learning, and offer some preliminary strategies educators may wish to foster this kind of learning in their own health care organizations.
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Affiliation(s)
- David M Browning
- Center for Applied Ethics and Professional Practice, Education Development Center, Inc., 55 Chapel Street, Newton, MA 02458, USA.
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