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Jordan M, Keefer PM, Lee YLA, Meade K, Snaman JM, Wolfe J, Kamal A, Rosenberg A. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Children. J Palliat Med 2018; 21:1783-1789. [PMID: 30289325 DOI: 10.1089/jpm.2018.0482] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Given the limited number of pediatric-specific palliative care programs, palliative care providers of all disciplines may be called on to care for infants, children, and adolescents with serious illness. This article provides a review of the unique components of pediatric palliative care, including key roles within an interdisciplinary team, pediatric developmental considerations, use of medical technology and complexities of symptom management in children with serious illness, hospice utilization, as well as pointers for discussions with families regarding a patient's quality of life and goals of care.
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Affiliation(s)
- Megan Jordan
- 1 Duke Palliative Care, Departments of Medicine and Pediatrics, Duke University, Durham, North Carolina
| | - Patricia M Keefer
- 2 Pediatric Palliative Care Program, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, Ann Arbor, Michigan
- 3 Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Yu-Lin Amy Lee
- 4 Duke Internal Medicine-Pediatrics Primary Care, Departments of Medicine and Pediatrics, Duke University, Durham, North Carolina
| | - Kristin Meade
- 5 Duke Palliative Care, Department of Medicine, Duke University, Durham, North Carolina
| | - Jennifer M Snaman
- 6 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joanne Wolfe
- 6 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- 7 Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- 8 Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Arif Kamal
- 9 Duke Cancer Institute, Duke Fuqua School of Business, Durham, North Carolina
| | - Abby Rosenberg
- 10 Division of Hematology/Oncology, Department of Pediatrics, Seattle Children's Research Institute, Center for Clinical and Translational Research, University of Washington, Seattle, Washington
- 11 Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington, Seattle, Washington
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Short SR, Thienprayoon R. Pediatric palliative care in the intensive care unit and questions of quality: a review of the determinants and mechanisms of high-quality palliative care in the pediatric intensive care unit (PICU). Transl Pediatr 2018; 7:326-343. [PMID: 30460185 PMCID: PMC6212394 DOI: 10.21037/tp.2018.09.11] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
This article reviews the state and practice of pediatric palliative care (PC) within the pediatric intensive care unit (PICU) with specific consideration of quality issues. This includes defining PC and end of life (EOL) care. We will also describe PC as it pertains to alleviating children's suffering through the provision of "concurrent care" in the ICU environment. Modes of care, and attendant strengths, of both the consultant and integrated models will be presented. We will review salient issues related to the provision of PC in the PICU, barriers to optimal practice, parental, and staff perceptions. Opportunity areas for quality improvement and the role of initiatives and measures such as education, family-based initiatives, staff needs, symptom recognition, grief, and communication follow. To conclude, we will look to the literature for PC resources for pediatric intensivists and future directions of study.
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Birchley G. The Harm Principle and the Best Interests Standard: Are Aspirational or Minimal Standards the Key? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:32-34. [PMID: 30133389 DOI: 10.1080/15265161.2018.1485772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Abstract
OBJECTIVES To describe practical considerations and approaches to best practices for end-of-life care for critically ill children and families in the PICU. DATA SOURCES Literature review, personal experience, and expert opinion. STUDY SELECTION A sampling of the foundational and current evidence related to the withdrawal of life-sustaining therapies in the context of childhood critical illness and injury was accessed. DATA EXTRACTION Moderated by the authors and supported by lived experience. DATA SYNTHESIS Narrative review and experiential reflection. CONCLUSIONS Consequences of childhood death in the PICU extend beyond the events of dying and death. In the context of withdrawal of life-sustaining therapies, achieving a quality death is impactful both in the immediate and in the longer term for family and for the team. An individualized approach to withdrawal of life-sustaining therapies that is informed by empiric and practical knowledge will ensure best care of the child and support the emotional well-being of child, family, and the team. Adherence to the principles of holistic and compassionate end-of-life care and an ongoing commitment to provide the best possible experience for withdrawal of life-sustaining therapies can achieve optimal end-of-life care in the most challenging of circumstances.
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Quality of Living and Dying: Pediatric Palliative Care and End-of-Life Decisions in the Netherlands. Camb Q Healthc Ethics 2018; 27:376-384. [PMID: 29845907 DOI: 10.1017/s0963180117000767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In 2002, The Netherlands continued its leadership in developing rules and jurisdiction regarding euthanasia and end-of-life decisions by implementing the Euthanasia Act, which allows euthanasia for patients 12 years of age and older. Subsequently, in 2005, the regulation on active ending of life for newborns was issued. However, more and more physicians and parents have stated that the age gap between these two regulations-children between 1 and 12 years old-is undesirable. These children should have the same right to end their suffering as adults and newborn infants. An extended debate on pediatric euthanasia ensued, and currently the debate is ongoing as to whether legislation should be altered in order to allow pediatric euthanasia. An emerging major question regards the active ending of life in the context of palliative care: How does a request for active ending of life relate to the care that is given to children in the palliative phase? Until now, the distinction between palliative care and end-of-life decisions continues to remain unclear, making any discussion about their mutual in- and exclusiveness hazardous at best. In this report, therefore, we aim to provide insight into the relationship between pediatric palliative care and end-of-life decisions, as understood in the Netherlands. We do so by first providing an overview of the (legal) rules and regulations regarding euthanasia and active ending of life, followed by an analysis of the relationship between these two, using the Dutch National Guidelines for Palliative Care for Children. The results of this analysis revealed two major and related features of palliative care and end-of-life decisions for children: (1) palliative care and end-of-life decisions are part of the same process, one that focuses both on quality of living and quality of dying, and (2) although physicians are seen as ultimately responsible for making end-of-life decisions, the involvement of parents and children in this decision is of the utmost importance and should be regarded as such.
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Marsac ML, Kindler C, Weiss D, Ragsdale L. Let's Talk About It: Supporting Family Communication during End-of-Life Care of Pediatric Patients. J Palliat Med 2018; 21:862-878. [PMID: 29775556 DOI: 10.1089/jpm.2017.0307] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Communication is key in optimizing medical care when a child is approaching end of life (EOL). Research is yet to establish best practices for how medical teams can guide intrafamily communication (including surviving siblings) when EOL care is underway or anticipated for a pediatric patient. While recommendations regarding how medical teams can facilitate communication between the medical team and the family exist, various barriers may prevent the implementation of these recommendations. OBJECTIVE This review aims to provide a summary of research-to-date on family and medical provider perceptions of communication during pediatric EOL care. DESIGN Systematic review. RESULTS Findings from a review of 65 studies suggest that when a child enters EOL care, many parents try to protect their child and/or themselves by avoiding discussions about death. Despite current recommendations, medical teams often refrain from discussing EOL care with pediatric patients until death is imminent for a variety of reasons (e.g., family factors and discomfort with EOL conversations). Parents consistently report a need for honest complete information, delivered with sensitivity. Pediatric patients often report a preference to be informed of their prognosis, and siblings express a desire to be involved in EOL discussions. CONCLUSIONS Families may benefit from enhanced communication around EOL planning, both within the family and between the family and medical team. Future research should investigate a potential role for medical teams in supporting intrafamily communication about EOL challenges and should examine how communication between medical teams and families can be facilitated as EOL approaches.
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Affiliation(s)
- Meghan L Marsac
- 1 Department of Pediatrics, Kentucky Children's Hospital , Lexington, Kentucky.,2 College of Medicine, University of Kentucky , Lexington, Kentucky
| | - Christine Kindler
- 1 Department of Pediatrics, Kentucky Children's Hospital , Lexington, Kentucky
| | - Danielle Weiss
- 3 Department of Pediatrics, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Lindsay Ragsdale
- 1 Department of Pediatrics, Kentucky Children's Hospital , Lexington, Kentucky.,2 College of Medicine, University of Kentucky , Lexington, Kentucky
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Ekberg S, Bradford NK, Herbert A, Danby S, Yates P. Healthcare Users' Experiences of Communicating with Healthcare Professionals About Children Who Have Life-Limiting Conditions: A Qualitative Systematic Review. J Palliat Med 2018; 21:1518-1528. [PMID: 29762072 DOI: 10.1089/jpm.2017.0422] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Globally, an estimated eight million children could benefit from palliative care each year. Effective communication about children with life-limiting conditions is well recognized as a critical component of high-quality pediatric palliative care. OBJECTIVE To synthesize existing qualitative research exploring healthcare users' experiences of communicating with healthcare professionals about children with life-limiting conditions. DESIGN The results of a systematic literature search were screened independently by two reviewers. Raw data and analytic claims were extracted from included studies and were synthesized using thematic analysis methods for systematic reviews. DATA SOURCES MEDLINE, PubMed, CINAHL, Embase, PsycINFO, Scopus, Web of Science, ProQuest, and ScienceDirect were searched for articles published in English between 1990 and May 2017. RESULTS This review included 29 studies conducted across 11 countries and involving at least 979 healthcare users (adults [n = 914], patients [n = 25], and siblings [n = 40]). The four domains of communication experience identified through thematic synthesis are: Information, Emotion, Collaboration, and Relationship. Although included studies were from a range of settings and diverse populations, further research is needed to explore whether and how domains of communication experience differ across settings and populations. In particular, further research about children's palliative care experiences is needed. CONCLUSIONS Healthcare users typically value communication with healthcare professionals: that (1) is open and honest, (2) acknowledges emotion, (3) actively involves healthcare users, and (4) occurs within established and trusting relationships.
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Affiliation(s)
- Stuart Ekberg
- 1 Institute of Health and Biomedical Innovation , Queensland University of Technology, Brisbane, Queensland, Australia .,2 School of Psychology and Counselling, Queensland University of Technology , Queensland, Australia, Brisbane, Queensland, Australia
| | - Natalie K Bradford
- 3 Children's Health Queensland Hospital and Health Service , Brisbane, Queensland, Australia
| | - Anthony Herbert
- 3 Children's Health Queensland Hospital and Health Service , Brisbane, Queensland, Australia .,4 Children's Health Queensland Clinical Unit, Faculty of Medicine, University of Queensland , Brisbane, Queensland, Australia
| | - Susan Danby
- 5 School of Early Childhood and Inclusive Education , Queensland University of Technology, Brisbane, Queensland, Australia
| | - Patsy Yates
- 1 Institute of Health and Biomedical Innovation , Queensland University of Technology, Brisbane, Queensland, Australia .,6 School of Nursing, Queensland University of Technology , Brisbane, Queensland, Australia
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Hoell JI, Weber HL, Balzer S, Danneberg M, Gagnon G, Trocan L, Borkhardt A, Janßen G, Kuhlen M. Advance care planning and outcome in pediatric palliative home care. Oncotarget 2018; 9:17867-17875. [PMID: 29707152 PMCID: PMC5915160 DOI: 10.18632/oncotarget.24929] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 03/08/2018] [Indexed: 11/25/2022] Open
Abstract
Pediatric advance care planning seeks to ensure end-of-life care conforming to the patients/their families' preferences. To expand our knowledge of advance care planning and "medical orders for life-sustaining treatment" (MOLST) in pediatric palliative home care, we determined the number of patients with MOLST, compared MOLST between the four "Together for Short Lives" (TfSL) groups and analyzed, whether there was a relationship between the content of the MOLST and the patients' places of death. The study was conducted as a single-center retrospective analysis of all patients of a large specialized pediatric palliative home care team (01/2013-09/2016). MOLST were available in 179/198 children (90.4%). Most parents decided fast on MOLST, 99 (55.3%) at initiation of pediatric palliative home care, 150 (83.4%) within the first 100 days. MOLST were only changed in 7.8%. Eighty/179 (44.7%) patients decided on a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) order, 58 (32.4%) on treatment limitations of some kind and 41 (22.9%) wished for the entire spectrum of life-sustaining measures (Full Code). Most TfSL group 1 families wanted DNACPR and most TfSL group 3/4 parents Full Code. The majority (84.9%) of all DNACPR patients died at home/hospice. Conversely, all Full Code patients died in hospital (80% in an intensive care setting). The circumstances of the childrens' deaths can therefore be predicted considering the content of the MOLST. Regular advance care planning discussions are thus a very important aspect of pediatric palliative home care.
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Affiliation(s)
- Jessica I. Hoell
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Hannah L. Weber
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Stefan Balzer
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Mareike Danneberg
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Gabriele Gagnon
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Laura Trocan
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Arndt Borkhardt
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Gisela Janßen
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Michaela Kuhlen
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
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Richards CA, Starks H, O’Connor MR, Bourget E, Hays RM, Doorenbos AZ. Physicians Perceptions of Shared Decision-Making in Neonatal and Pediatric Critical Care. Am J Hosp Palliat Care 2018; 35:669-676. [PMID: 28990396 PMCID: PMC5673589 DOI: 10.1177/1049909117734843] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Most children die in neonatal and pediatric intensive care units after decisions are made to withhold or withdraw life-sustaining treatments. These decisions can be challenging when there are different views about the child's best interest and when there is a lack of clarity about how best to also consider the interests of the family. OBJECTIVE To understand how neonatal and pediatric critical care physicians balance and integrate the interests of the child and family in decisions about life-sustaining treatments. METHODS Semistructured interviews were conducted with 22 physicians from neonatal, pediatric, and cardiothoracic intensive care units in a single quaternary care pediatric hospital. Transcribed interviews were analyzed using content and thematic analysis. RESULTS We identified 3 main themes: (1) beliefs about child and family interests; (2) disagreement about the child's best interest; and (3) decision-making strategies, including limiting options, being directive, staying neutral, and allowing parents to come to their own conclusions. Physicians described challenges to implementing shared decision-making including unequal power and authority, clinical uncertainty, and complexity of balancing child and family interests. They acknowledged determining the level of engagement in shared decision-making with parents (vs routine engagement) based on their perceptions of the best interests of the child and parent. CONCLUSIONS Due to power imbalances, families' values and preferences may not be integrated in decisions or families may be excluded from discussions about goals of care. We suggest that a systematic approach to identify parental preferences and needs for decisional roles and information may reduce variability in parental involvement.
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Affiliation(s)
- Claire A. Richards
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Helene Starks
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - M. Rebecca O’Connor
- Department of Family and Child Nursing, School of Nursing, University of Washington, Seattle, WA, USA
| | - Erica Bourget
- Department of Immunology, Fred Hutchinson’s Cancer Research Center, Seattle, WA, USA
| | - Ross M. Hays
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
- Department of Rehabilitative Medicine, School of Medicine, University of Washington, Seattle, WA, USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA
- Palliative Care Program, Seattle Children’s Hospital, Seattle, WA, USA
- The Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA
| | - Ardith Z. Doorenbos
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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Zaal-Schuller IH, Willems DI, Ewals F, van Goudoever JB, de Vos MA. Involvement of nurses in end-of-life discussions for severely disabled children. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2018; 62:330-338. [PMID: 29388276 DOI: 10.1111/jir.12473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 12/08/2017] [Accepted: 12/21/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND In children with profound intellectual and multiple disabilities (PIMD), discussions about end-of-life decisions (EoLDs) are comparatively common. Nurses play a crucial role in the care for these children, yet their involvement in EoLD discussions is largely unknown. The objective of this research was to investigate the involvement in the hospital of nurses in discussions with parents and physicians about EoLDs for children with PIMD. METHOD In a retrospective, qualitative study, we conducted semi-structured interviews with the nurses of 12 children with PIMD for whom an EoLD was made within the past 2 years. RESULTS Parents primarily discuss EoLDs with nurses before and after the meeting with the physician. Nurses who were involved in EoL discussions with parents and physicians assisted them by giving factual information about the child and by providing emotional support. Some nurses, especially nurses from ID-care services, were not involved in EoL discussions, even if they had cared for the child for a long period of time. Some of the nurses had moral or religious objections to carrying out the decisions. CONCLUSION Most nurses were not involved in EoL discussions with parents and physicians in the hospital. Excluding nurses from EoL discussions can cause them moral distress. The involvement of nurses in EoL discussions for children with PIMD should be improved, especially by involving nurses from ID-care services. Because these nurses are usually familiar with the child, they can be valuable sources of information about the child's quality of life.
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Affiliation(s)
- I H Zaal-Schuller
- Section of Medial Ethics, Department of General Practice, University of Amsterdam, Amsterdam, the Netherlands
| | - D I Willems
- Section of Medial Ethics, Department of General Practice, University of Amsterdam, Amsterdam, the Netherlands
| | - F Ewals
- Intellectual Disability Medicine, Department of Medical Practice, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - J B van Goudoever
- Department of Pediatrics, VU Medisch Centrum, Amsterdam, the Netherlands
- Academic Medical Centre, Emma's Children's Hospital, Department of Paediatrics, Amsterdam, The Netherlands
| | - M A de Vos
- Section of Medial Ethics, Department of General Practice, University of Amsterdam, Amsterdam, the Netherlands
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The Importance of Parental Connectedness and Relationships With Healthcare Professionals in End-of-Life Care in the PICU. Pediatr Crit Care Med 2018; 19:e157-e163. [PMID: 29329163 DOI: 10.1097/pcc.0000000000001440] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Support from healthcare professionals in a PICU is highly valuable for parents of dying children. The way they care for the patients and their families affects the parents' initial mourning process. This study explores what interaction with hospital staff is meaningful to parents in existential distress when their child is dying in the PICU. DESIGN Qualitative interview study. SETTING Level 3 PICU in the Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, and the Netherlands. SUBJECTS Thirty-six parents of 20 children who had died in this unit 5 years previously. INTERVENTIONS Parents participated in audio-recorded interviews in their own homes. The interviews were transcribed and analyzed using qualitative methods. MEASUREMENTS AND MAIN RESULTS Parents' narratives of their child's end-of-life stage in the PICU bespeak experiences of estrangement, emotional distancing, and loneliness. Significant moments shared with hospital staff that remained valuable even after 5 years primarily involved personal connectedness, reflected in frequent informational updates, personal commitment of professionals, and interpersonal contact with doctors and nurses. CONCLUSIONS Parents whose children died in the PICU value personal connectedness to doctors and nurses when coping with existential distress. Medical and nursing training programs should raise awareness of parents' need for contact in all interactions but especially in times of crisis and apprehension.
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Palliative Care. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00092-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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63
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Sisk BA, Mack JW, Ashworth R, DuBois J. Communication in pediatric oncology: State of the field and research agenda. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26727. [PMID: 28748597 PMCID: PMC6902431 DOI: 10.1002/pbc.26727] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/19/2017] [Accepted: 06/20/2017] [Indexed: 12/12/2022]
Abstract
From the time of diagnosis through either survivorship or end of life, communication between healthcare providers and patients or parents can serve several core functions, including fostering healing relationships, exchanging information, responding to emotions, managing uncertainty, making decisions, and enabling patient/family self-management. We systematically reviewed all studies that focused on communication between clinicians and patients or parents in pediatric oncology, categorizing studies based on which core functions of communication they addressed. After identifying gaps in the literature, we propose a research agenda to further the field.
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Affiliation(s)
- Bryan A. Sisk
- Department of Pediatrics, St. Louis Children’s, Hospital, St. Louis, Missouri
| | - Jennifer W. Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts,Department of Medicine, Boston Children’s, Hospital, Boston, Massachusetts
| | - Rachel Ashworth
- Department of Pediatrics, Washington, University School of Medicine, St. Louis, Missouri
| | - James DuBois
- Department of Medicine, Washington, University School of Medicine, St. Louis, Missouri
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Hebert LM, Watson AC, Madrigal V, October TW. Discussing Benefits and Risks of Tracheostomy: What Physicians Actually Say. Pediatr Crit Care Med 2017; 18:e592-e597. [PMID: 28938289 PMCID: PMC5716895 DOI: 10.1097/pcc.0000000000001341] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES When contemplating tracheostomy placement in a pediatric patient, a family-physician conference is often the setting for the disclosure of risks and benefits of the procedure. Our objective was to compare benefits and risks of tracheostomy presented during family-physician conferences to an expert panel's recommendations for what should be presented. DESIGN We conducted a retrospective review of 19 transcripts of audio-recorded family-physician conferences regarding tracheostomy placement in children. A multicenter, multidisciplinary expert panel of clinicians was surveyed to generate a list of recommended benefits and risks for comparison. Primary analysis of statements by clinicians was qualitative. SETTING Single-center PICU of a tertiary medical center. SUBJECTS Family members who participated in family-physician conferences regarding tracheostomy placement for a critically ill child from April 2012 to August 2014. MEASUREMENTS AND MAIN RESULTS We identified 300 physician statements describing benefits and risks of tracheostomy. Physicians were more likely to discuss benefits than risks (72% vs 28%). Three broad categories of benefits were identified: 1) tracheostomy would limit the impact of being in the PICU (46%); 2) perceived obstacles of tracheostomy can be overcome (34%); and 3) tracheostomy optimizes respiratory health (20%). Risks fell into two categories: tracheostomy involves a big commitment (71%), and it has complications (29%). The expert panel's recommendations were similar to risks and benefits discussed during family conferences; however, they suggested physicians present an equal balance of discussion of risks and benefits. CONCLUSIONS When discussing tracheostomy placement, physicians emphasized benefits that are shared by physicians and families while minimizing the risks. The expert panel recommended a balanced approach by equally weighing risks and benefits. To facilitate educated decision making, physicians should present a more extensive range of risks and benefits to families making this critical decision.
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Affiliation(s)
- Lauren M. Hebert
- Children’s Hospital at Memorial University Medical Center, Savannah, Georgia
- Mercer University School of Medicine Department of Pediatrics, Savannah, Georgia
| | - Anne C. Watson
- Children’s National Health Systems, Washington, District of Columbia
| | - Vanessa Madrigal
- Children’s National Health Systems, Washington, District of Columbia
- The George Washington University School of Medicine and Health Sciences Department of Pediatrics, Washington, District of Columbia
| | - Tessie W. October
- Children’s National Health Systems, Washington, District of Columbia
- The George Washington University School of Medicine and Health Sciences Department of Pediatrics, Washington, District of Columbia
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Mooney-Doyle K, Deatrick JA, Ulrich CM, Meghani SH, Feudtner C. Parenting in Childhood Life-Threatening Illness: A Mixed-Methods Study. J Palliat Med 2017; 21:208-215. [PMID: 28972873 DOI: 10.1089/jpm.2017.0054] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Parenting children with life-threatening illness (LTI) and their healthy siblings requires parents to consider their various needs. OBJECTIVE AND METHODS We conducted a concurrent, cross-sectional mixed-methods study to describe challenges parents face prioritizing tasks and goals for each child with qualitative data, compare parents' tasks and goals for children with LTI and healthy siblings with quantitative data, and describe parenting in terms of the process of prioritizing tasks and goals for all children in the family. RESULTS Participants included 31 parents of children with LTI who have healthy siblings and were admitted to a children's hospital. Qualitative interviews revealed how parents managed children's needs and their perceptions of the toll it takes. Quantitative data revealed that parents prioritized "making sure my child feels loved" highest for ill and healthy children. Other goals for healthy siblings focused on maintaining emotional connection and regularity within the family and for ill children focused on illness management. Mixed-methods analysis revealed that parents engaged in a process decision making and traded-off competing demands by considering needs which ultimately transformed the meaning of parenting. DISCUSSION Future research can further examine trade-offs and associated effects, how to support parent problem-solving and decision-making around trade-offs, and how to best offer social services alongside illness-directed care.
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Affiliation(s)
- Kim Mooney-Doyle
- 1 Department of Family and Community Health, School of Nursing, University of Maryland , Baltimore, Maryland
| | - Janet A Deatrick
- 2 Department of Family and Community Health, School of Nursing, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Connie M Ulrich
- 3 Department of Biobehavioral Health Sciences, School of Nursing, Center for Medical Ethics, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Salimah H Meghani
- 4 Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Chris Feudtner
- 5 Department of General Pediatrics and Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
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Suttle ML, Jenkins TL, Tamburro RF. End-of-Life and Bereavement Care in Pediatric Intensive Care Units. Pediatr Clin North Am 2017; 64:1167-1183. [PMID: 28941542 PMCID: PMC5747301 DOI: 10.1016/j.pcl.2017.06.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Most childhood deaths in the United States occur in hospitals. Pediatric intensive care clinicians must anticipate and effectively treat dying children's pain and suffering and support the psychosocial and spiritual needs of families. These actions may help family members adjust to their loss, particularly bereaved parents who often experience reduced mental and physical health. Candid and compassionate communication is paramount to successful end-of-life (EOL) care as is creating an environment that fosters meaningful family interaction. EOL care in the pediatric intensive care unit is associated with challenging ethical issues, of which clinicians must maintain a sound and working understanding.
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Affiliation(s)
- Markita L. Suttle
- Department of Critical Care Medicine, Nationwide Children's Hospital
| | - Tammara L. Jenkins
- Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | - Robert F. Tamburro
- Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
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Birchley G, Gooberman-Hill R, Deans Z, Fraser J, Huxtable R. 'Best interests' in paediatric intensive care: an empirical ethics study. Arch Dis Child 2017; 102:930-935. [PMID: 28408466 PMCID: PMC5739819 DOI: 10.1136/archdischild-2016-312076] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/30/2017] [Accepted: 03/08/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In English paediatric practice, English law requires that parents and clinicians agree the 'best interests' of children and, if this is not possible, that the courts decide. Court intervention is rare and the concept of best interests is ambiguous. We report qualitative research exploring how the best interests standard operates in practice, particularly with decisions related to planned non-treatment. We discuss results in the light of accounts of best interests in the medical ethics literature. DESIGN We conducted 39 qualitative interviews, exploring decision making in the paediatric intensive care unit, with doctors, nurses, clinical ethics committee members and parents whose children had a range of health outcomes. Interviews were audio-recorded and analysed thematically. RESULTS Parents and clinicians indicated differences in their approaches to deciding the child's best interests. These were reconciled when parents responded positively to clinicians' efforts to help parents agree with the clinicians' view of the child's best interests. Notably, protracted disagreements about a child's best interests in non-treatment decisions were resolved when parents' views were affected by witnessing their child's physical deterioration. Negotiation was the norm and clinicians believed avoiding the courts was desirable. CONCLUSIONS Sensitivity to the long-term interests of parents of children with life-limiting conditions is defensible but must be exercised proportionately. Current approaches emphasise negotiation but offer few alternatives when decisions are at an impasse. In such situations, the instrumental role played by a child's deterioration and avoidance of the courts risks giving insufficient weight to the child's interests. New approaches to decision making are needed.
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Affiliation(s)
- Giles Birchley
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | | | - Zuzana Deans
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - James Fraser
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
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Lotz JD, Daxer M, Jox RJ, Borasio GD, Führer M. "Hope for the best, prepare for the worst": A qualitative interview study on parents' needs and fears in pediatric advance care planning. Palliat Med 2017; 31:764-771. [PMID: 27881828 PMCID: PMC5557107 DOI: 10.1177/0269216316679913] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pediatric advance care planning is advocated by healthcare providers because it may increase the chance that patient and/or parent wishes are respected and thus improve end-of-life care. However, since end-of-life decisions for children are particularly difficult and charged with emotions, physicians are often afraid of addressing pediatric advance care planning. AIM We aimed to investigate parents' views and needs regarding pediatric advance care planning. DESIGN We performed a qualitative interview study with parents of children who had died from a severe illness. The interviews were analyzed by descriptive and evaluation coding according to Saldaña. SETTING/PARTICIPANTS We conducted semi-structured interviews with 11 parents of 9 children. Maximum variation was sought regarding the child's illness, age at death, care setting, and parent gender. RESULTS Parents find it difficult to engage in pediatric advance care planning but consider it important. They argue for a sensitive, individualized, and gradual approach. Hope and quality of life issues are primary. Parents have many non-medical concerns that they want to discuss. Written advance directives are considered less important, but medical emergency plans are viewed as necessary in particular cases. Continuity of care and information should be improved through regular pediatric advance care planning meetings with the various care providers. Parents emphasize the importance of a continuous contact person to facilitate pediatric advance care planning. CONCLUSION Despite a need for pediatric advance care planning, it is perceived as challenging. Needs-adjusted content and process and continuity of communication should be a main focus in pediatric advance care planning. Future research should focus on strategies that facilitate parent engagement in pediatric advance care planning to increase the benefit for the families.
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Affiliation(s)
- Julia Desiree Lotz
- 1 Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Marion Daxer
- 1 Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Ralf J Jox
- 2 Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University of Munich, Munich, Germany.,3 Geriatric Palliative Care, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Gian Domenico Borasio
- 4 Palliative Care Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Monika Führer
- 1 Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
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69
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End-of-Life Decision Making for Parents of Extremely Preterm Infants. J Obstet Gynecol Neonatal Nurs 2017; 46:727-736. [DOI: 10.1016/j.jogn.2017.06.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 11/23/2022] Open
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Gelbart B. Challenges of paediatric organ donation. J Paediatr Child Health 2017; 53:534-539. [PMID: 28398658 DOI: 10.1111/jpc.13541] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 01/20/2017] [Accepted: 01/20/2017] [Indexed: 11/29/2022]
Abstract
Paediatric organ donation represents a small fraction of overall organ donation in Australia and New Zealand and indeed world-wide. Many factors contribute to low donation rates including low paediatric intensive care mortality, consent rates and medical suitability relating to disease, age and size. In the past decade, the re-emergence of donation after circulatory death has changed the landscape for the paediatric population. This article reviews the current status and challenges of organ donation for the paediatric population.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Murdoch Children's Research Institute, DonateLife, Victoria, Melbourne, Victoria, Australia
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71
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Elements of Family-Centered Care in the Pediatric Intensive Care Unit: An Integrative Review. J Hosp Palliat Nurs 2017; 19:238-246. [PMID: 28496382 DOI: 10.1097/njh.0000000000000335] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This paper reports result from a systematic search and thematic analysis of qualitative literature to identify key issues related to family-centered care, behaviors, and communication skills that support the parental role and improve patient and family outcomes in the PICU. Five themes were identified: 1) sharing information; 2) hearing parental voices; 3) making decisions for or with parents; 4) negotiating roles; and 5) individualizing communication. These themes highlight several gaps between how parents want to be involved and perceive clinicians engage them in the care of their child. Parental preferences for involvement differ in the domains of information sharing, decision making, and power-sharing across a spectrum of parental roles from parents as care provider to care recipient. The PICU setting may place clinicians in a double bind trying to both engage families and protect them from distress. Asking families of critically ill children about their preferences for participation across these domains may improve clinician-family relationships.
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Haward MF, Gaucher N, Payot A, Robson K, Janvier A. Personalized Decision Making: Practical Recommendations for Antenatal Counseling for Fragile Neonates. Clin Perinatol 2017; 44:429-445. [PMID: 28477670 DOI: 10.1016/j.clp.2017.01.006] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Emphasis has been placed on engaging parents in processes of shared decision making for delivery room management decisions of critically ill neonates whose outcomes are uncertain and unpredictable. The goal of antenatal consultation should rather be to adapt to parental needs and empower them through a personalized decision-making process. This can be done by acknowledging individuality and diversity while respecting the best interests of neonates. The goal is for parents to feel like they have agency and ability and are good parents, before birth, at birth, and after, either in the NICU or until the death of their child.
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Affiliation(s)
- Marlyse F Haward
- Department of Pediatrics, Albert Einstein College of Medicine, The Children's Hospital at Montefiore, New York, NY 10467, USA
| | - Nathalie Gaucher
- Department of Pediatrics, CHU Sainte-Justine Research Center, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T 1J4, Canada; Clinical Ethics Unit, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T-1C5, Canada
| | - Antoine Payot
- Department of Pediatrics, CHU Sainte-Justine Research Center, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T 1J4, Canada; Clinical Ethics Unit, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T-1C5, Canada; Palliative Care Unit, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada; Unité d'Éthique Clinique et de Partenariat Famille, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada
| | - Kate Robson
- Canadian Premature Babies Foundation, Toronto, Ontario M4N 3M5, Canada
| | - Annie Janvier
- Department of Pediatrics, CHU Sainte-Justine Research Center, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T 1J4, Canada; Clinical Ethics Unit, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T-1C5, Canada; Palliative Care Unit, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada; Unité d'Éthique Clinique et de Partenariat Famille, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada; Department of Pediatrics and Clinical Ethics, Sainte-Justine Hospital, University of Montreal, 3175 Chemin Côte-Sainte-Catherine, Montreal, Quebec H3T 1C5, Canada.
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Hendriks MJ, Klein SD, Bucher HU, Baumann-Hölzle R, Streuli JC, Fauchère JC. Attitudes towards decisions about extremely premature infants differed between Swiss linguistic regions in population-based study. Acta Paediatr 2017; 106:423-429. [PMID: 27880025 DOI: 10.1111/apa.13680] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 11/11/2016] [Accepted: 11/21/2016] [Indexed: 11/29/2022]
Abstract
AIM Studies have provided insights into the different attitudes and values of healthcare professionals and parents towards extreme prematurity. This study explored societal attitudes and values in Switzerland with regard to this patient group. METHODS A nationwide trilingual telephone survey was conducted in the French-, German- and Italian-speaking regions of Switzerland to explore the general population's attitudes and values with regard to extreme prematurity. Swiss residents of 18 years or older were recruited from the official telephone registry using quota sampling and a logistic regression model assessed the influence of socio-demographic factors on end-of-life decision-making. RESULTS Of the 5112 people contacted, 1210 (23.7%) participated. Of these 5% were the parents of a premature infant and 26% knew parents with a premature infant. Most participants (77.8%) highlighted their strong preference for shared decision-making, and 64.6% said that if there was dissent then the parents should have the final word. Overall, our logistic regression model showed that regional differences were the most significant factors influencing decision-making. CONCLUSION The majority of the Swiss population clearly favoured shared decision-making. The context of sociocultural demographics, especially the linguistic region in which the decision-making took place, strongly influenced attitudes towards extreme prematurity and decision-making.
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Affiliation(s)
- Manya J. Hendriks
- Department of Neonatology; Perinatal Centre; University Hospital Zurich; University of Zurich; Zurich Switzerland
- Institute of Biomedical Ethics and History of Medicine; University of Zurich; Zurich Switzerland
| | - Sabine D. Klein
- Department of Neonatology; Perinatal Centre; University Hospital Zurich; University of Zurich; Zurich Switzerland
| | - Hans Ulrich Bucher
- Department of Neonatology; Perinatal Centre; University Hospital Zurich; University of Zurich; Zurich Switzerland
| | - Ruth Baumann-Hölzle
- Dialogue Ethics Foundation; Interdisciplinary Institute for Ethics in Healthcare; Zurich Switzerland
| | - Jürg C. Streuli
- Institute of Biomedical Ethics and History of Medicine; University of Zurich; Zurich Switzerland
| | - Jean-Claude Fauchère
- Department of Neonatology; Perinatal Centre; University Hospital Zurich; University of Zurich; Zurich Switzerland
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Davies B, Steele R, Krueger G, Albersheim S, Baird J, Bifirie M, Cadell S, Doane G, Garga D, Siden H, Strahlendorf C, Zhao Y. Best Practice in Provider/Parent Interaction. QUALITATIVE HEALTH RESEARCH 2017; 27:406-420. [PMID: 27557925 DOI: 10.1177/1049732316664712] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
In this 3-year prospective grounded theory study in three pediatric settings, we aimed to develop a conceptualization of best practice health care providers (BPHCPs) in interaction with parents of children with complex, chronic, life-threatening conditions. Analysis of semistructured interviews with 34 parents and 80 health care professionals (HCPs) and 88 observation periods of HCP/parent interactions indicated that BPHCPs shared a broad worldview; values of equity, family-centered care, and integrity; and a commitment to authentic engagement. BPHCPs engaged in direct care activities, in connecting behaviors, and in exquisitely attuning to particularities of the situation in the moment, resulting in positive outcomes for parents and HCPs. By focusing on what HCPs do well, findings showed that not only is it possible for HCPs to practice in this way, but those who do so are also recognized as being the best at what they do. We provide recommendations for practice and initial and ongoing professional education.
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Affiliation(s)
- Betty Davies
- 1 University of Victoria, Victoria, British Columbia, Canada
| | | | - Guenther Krueger
- 3 Retired NVivo Computer Software Consultant, Burnaby, British Columbia, Canada
| | - Susan Albersheim
- 4 Children's & Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | | | - Michelle Bifirie
- 6 University of British Columbia, Vancouver, British Columbia, Canada
| | - Susan Cadell
- 7 University of Waterloo, Waterloo, Ontario, Canada
| | - Gweneth Doane
- 1 University of Victoria, Victoria, British Columbia, Canada
| | - Deepshikha Garga
- 4 Children's & Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Harold Siden
- 4 Children's & Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Caron Strahlendorf
- 4 Children's & Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Yuan Zhao
- 3 Retired NVivo Computer Software Consultant, Burnaby, British Columbia, Canada
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Verberne LM, Kars MC, Schouten-van Meeteren AYN, Bosman DK, Colenbrander DA, Grootenhuis MA, van Delden JJM. Aims and tasks in parental caregiving for children receiving palliative care at home: a qualitative study. Eur J Pediatr 2017; 176:343-354. [PMID: 28078429 PMCID: PMC5321698 DOI: 10.1007/s00431-016-2842-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 12/06/2016] [Accepted: 12/23/2016] [Indexed: 11/18/2022]
Abstract
UNLABELLED In paediatric palliative care (PPC), parents are confronted with increasing caregiving demands. More children are cared for at home, and the need for PPC of children is lengthened due to technical and medical improvements. Therefore, a clear understanding of the content of parental caregiving in PPC becomes increasingly important. The objective is to gain insight into parental caregiving based on the lived experience of parents with a child with a life-limiting disease. An interpretative qualitative study using thematic analysis was performed. Single or repeated interviews were undertaken with 42 parents of 24 children with a malignant or non-malignant disease, receiving PPC. Based on their ambition to be a 'good parent', parents caring for a child with a life-limiting disease strived for three aims: controlled symptoms and controlled disease, a life worth living for their ill child and family balance. These aims resulted in four tasks that parents performed: providing basic and complex care, organising good quality care and treatment, making sound decisions while managing risks and organising a good family life. CONCLUSION Parents need early explanation from professionals about balancing between their aims and the related tasks to get a grip on their situation and to prevent becoming overburdened. What is Known: • In paediatric palliative care, parents are confronted with increasing caregiving demands. • Parenting is often approached from the perspective of stress. What is New: • Parents strive for three aims: controlled symptoms and controlled disease, a life worth living for their child and family balance. • Parents perform four tasks: providing basic and complex care, organising good quality care, making decisions while managing risks and organising a good family life. • Professionals need insight into the parents' aims and tasks from the parental perspective to strengthen parents' resilience.
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Affiliation(s)
- Lisa M. Verberne
- 0000000090126352grid.7692.aDepartment of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - Marijke C. Kars
- 0000000090126352grid.7692.aDepartment of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - Antoinette Y. N. Schouten-van Meeteren
- 0000000404654431grid.5650.6Department of Pediatric Oncology, Emma Children’s Hospital, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Diederik K. Bosman
- 0000000404654431grid.5650.6Department of Pediatrics, Emma Children’s Hospital, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Derk A. Colenbrander
- 0000000404654431grid.5650.6Department of Pediatrics, Emma Children’s Hospital, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Martha A. Grootenhuis
- 0000000404654431grid.5650.6Psychosocial Department, Emma Children’s Hospital, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands ,Princess Máxima Center for Pediatric Oncology, Lundlaan 6, 3584 AE Utrecht, The Netherlands
| | - Johannes J. M. van Delden
- 0000000090126352grid.7692.aDepartment of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
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Dallas RH, Kimmel A, Wilkins ML, Rana S, Garcia A, Cheng YI, Wang J, Lyon ME. Acceptability of Family-Centered Advanced Care Planning for Adolescents With HIV. Pediatrics 2016; 138:peds.2016-1854. [PMID: 27940700 PMCID: PMC5127070 DOI: 10.1542/peds.2016-1854] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Small pilot studies support the appropriateness of engaging adolescents with chronic or life-limiting illnesses in pediatric advance care planning (pACP). We do not yet know if pACP is acceptable, feasible, and worthwhile, even if emotionally intense, in a fully powered randomized controlled trial. METHODS We conducted a prospective 2-arm randomized controlled trial at 6 US urban hospitals. Adolescent/family member dyads were randomized to receive the 1-session-a-week 3-session FAmily-CEntered Advance Care Planning (FACE) pACP intervention (1, ACP Survey; 2, Goals of Care Conversation/Treatment Preferences; 3, Completion of Advance Directive) or active comparator (1, Developmental History; 2, Safety Tips; 3, Nutrition/Exercise). The Satisfaction Questionnaire was administered to participants independently after each session by a blinded research assistant. RESULTS We enrolled 53% of eligible participants and intervened with 97 adolescent/family dyads. Adolescents ranged in age from 14 to 21 years; 54% were male individuals; 93% African American; and 73% perinatally infected. Attendance was 99% for all 3 sessions in each arm. At session 3, FACE adolescents and family dyad members, respectively, found the session useful (98%, 98%) and helpful (98%, 100%), despite feelings of sadness (25%, 17%). FACE adolescents' improvement in the total subscale A score (useful, helpful, like a load off my mind, satisfied, something I needed to do, courageous, worthwhile) was better than control adolescents at session 3 (β = 1.16, P = .02). There were no adverse events. CONCLUSIONS FACE enabled worthwhile conversations, while simultaneously eliciting intense emotions. No participants withdrew, 99% of those enrolled completed each session, and there were no adverse events, evidence of pACP's feasibility, acceptability, and safety.
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Affiliation(s)
- Ronald H. Dallas
- Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Allison Kimmel
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia
| | - Megan L. Wilkins
- Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Sohail Rana
- Howard University College of Medicine, Washington, District of Columbia
| | - Ana Garcia
- The University of Miami Miller School of Medicine, Miami, Florida; and
| | - Yao I. Cheng
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia
| | - Jichuan Wang
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia;,The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Maureen E. Lyon
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia;,The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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Zaal-Schuller IH, Willems DL, Ewals FVPM, van Goudoever JB, de Vos MA. How parents and physicians experience end-of-life decision-making for children with profound intellectual and multiple disabilities. RESEARCH IN DEVELOPMENTAL DISABILITIES 2016; 59:283-293. [PMID: 27665411 DOI: 10.1016/j.ridd.2016.09.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/28/2016] [Accepted: 09/15/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND End-of-life decisions (EoLD) often concern children with profound intellectual and multiple disabilities (PIMD). Yet, little is known about how parents and physicians discuss and make these decisions. AIMS The objective of this research was to investigate the experiences of the parents and the involved physician during the end-of-life decision-making (EoLDM) process for children with PIMD. METHODS In a retrospective, qualitative study, we conducted semi-structured interviews with the physicians and parents of 14 children with PIMD for whom an EoLD was made within the past two years. RESULTS A long-lasting relationship appeared to facilitate the EoLDM process, although previous negative healthcare encounters could also lead to distrust. Parents and physicians encountered disagreements during the EoLDM process, but these disagreements could also improve the decision-making process. Most parents, as well as most physicians, considered the parents to be the experts on their child. In making an EoLD, both parents and physicians preferred a shared decision-making approach, although they differed in what they actually meant by this concept. CONCLUSION The EoLDM process for children with PIMD can be improved if physicians are more aware of the specific situation and of the roles and expectations of the parents of children with PIMD.
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Affiliation(s)
- I H Zaal-Schuller
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - D L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - F V P M Ewals
- Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre Rotterdam, The Netherlands.
| | - J B van Goudoever
- Department of Paediatrics, Emma Children's Hospital - Academic Medical Centre, Amsterdam & Department of Paediatrics, VU University Medical Centre, Amsterdam, The Netherlands.
| | - M A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Shaw C, Stokoe E, Gallagher K, Aladangady N, Marlow N. Parental involvement in neonatal critical care decision-making. SOCIOLOGY OF HEALTH & ILLNESS 2016; 38:1217-1242. [PMID: 27666147 DOI: 10.1111/1467-9566.12455] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The article analyses the decision-making process between doctors and parents of babies in neonatal intensive care. In particular, it focuses on cases in which the decision concerns the redirection of care from full intensive care to palliative care at the end of life. Thirty one families were recruited from a neonatal intensive care unit in England and their formal interactions with the doctor recorded. The conversations were transcribed and analysed using conversation analysis. Analysis focused on sequences in which decisions about the redirection of care were initiated and progressed. Two distinct communicative approaches to decision-making were used by doctors: 'making recommendations' and 'providing options'. Different trajectories for parental involvement in decision-making were afforded by each design, as well as differences in terms of the alignments, or conflicts, between doctors and parents. 'Making recommendations' led to misalignment and reduced opportunities for questions and collaboration; 'providing options' led to an aligned approach with opportunities for questions and fuller participation in the decision-making process. The findings are discussed in the context of clinical uncertainty, moral responsibility and the implications for medical communication training and guidance. A Virtual Abstract of this paper can be accessed at: https://www.youtube.com/watch?v=MyuymxDNupk&feature=youtu.be.
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Affiliation(s)
- Chloe Shaw
- Department of Neonatology, University College London, UK.
| | | | | | - Narendra Aladangady
- Department of Neonatology, Homerton University Hospital, London, UK
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, QMUL
| | - Neil Marlow
- Department of Neonatology, University College London, UK
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Watson AC, October TW. Clinical Nurse Participation at Family Conferences in the Pediatric Intensive Care Unit. Am J Crit Care 2016; 25:489-497. [PMID: 27802949 PMCID: PMC5751701 DOI: 10.4037/ajcc2016817] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Clinical nurses attend family conferences in the intensive care unit, but their role during these meetings is not yet fully understood. OBJECTIVES To assess perceived and observed contributions of the clinical nurse during family conferences. METHODS Prospective cross-sectional survey and review of 40 audio-recorded family conferences conducted in the 44-bed pediatric intensive care unit of an urban pediatric hospital. RESULTS Survey responses from 47 nurses were examined. Most nurses thought it important to attend family conferences, but identified workload as a barrier to attendance. They perceived their roles as gaining firsthand knowledge of the discussion and providing a unique perspective regarding patient care, emotional support, and advocacy. Audio recordings revealed that bedside nurses attended 20 (50%) of 40 family conferences and spoke in 5 (25%) of the 20. Nurses verbally contributed 4.6% to the overall speech at the family conference, mostly providing information on patient care. CONCLUSIONS The clinical nurse is often absent or silent during family conferences in the intensive care unit, despite the important roles they want to play in these settings. Strategies to improve both the physical and verbal participation of clinical nurses during the family conference are suggested, especially in the context of previous research demonstrating the need for more attention in family conferences to social-emotional support and patient advocacy.
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Affiliation(s)
- Anne C Watson
- Anne C. Watson is the research nurse coordinator for critical care medicine, Children's National Health Systems, Washington, DC. Tessie W. October is an attending physician in the pediatric intensive care unit at Children's National Health Systems, Washington, DC, and an assistant professor in the Department of Pediatrics, George Washington University, Washington, DC.
| | - Tessie W October
- Anne C. Watson is the research nurse coordinator for critical care medicine, Children's National Health Systems, Washington, DC. Tessie W. October is an attending physician in the pediatric intensive care unit at Children's National Health Systems, Washington, DC, and an assistant professor in the Department of Pediatrics, George Washington University, Washington, DC
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October TW, Hinds PS, Wang J, Dizon ZB, Cheng YI, Roter DL. Parent Satisfaction With Communication Is Associated With Physician's Patient-Centered Communication Patterns During Family Conferences. Pediatr Crit Care Med 2016; 17:490-7. [PMID: 27058750 PMCID: PMC4893980 DOI: 10.1097/pcc.0000000000000719] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the association between physician's patient-centered communication patterns and parental satisfaction during decision-making family conferences in the PICU. DESIGN Single-site, cross-sectional study. SETTING Forty-four-bed PICUs in a free-standing children's hospital. PARTICIPANTS Sixty-seven English-speaking parents of 39 children who participated in an audiorecorded family conference with 11 critical care attending physicians. MEASUREMENTS AND MAIN RESULTS Thirty-nine family conferences were audiorecorded. Sixty-seven of 77 (92%) eligible parents were enrolled. The conference recordings were coded using the Roter Interaction Analysis System and a Roter Interaction Analysis System-based patient-centeredness score, which quantitatively evaluates the conversations for physician verbal dominance and discussion of psychosocial elements, such as a family's goals and preferences. Higher patient-centeredness scores reflect higher proportionate dialogue focused on psychosocial, lifestyle, and socioemotional topics relative to medically focused talk. Parents completed satisfaction surveys within 24 hours of the conference. Conferences averaged 45 minutes in length (SD, 19 min), during which the medical team contributed 73% of the dialogue compared with parental contribution of 27%. Physicians dominated the medical team, contributing 89% of the team contribution to the dialogue. The majority of physician speech was medically focused (79%). A patient-centeredness score more than 0.75 predicted parental satisfaction (β = 12.05; p < 0.0001), controlling for the length of conference, child severity of illness, parent race, and socioeconomic status. Parent satisfaction was negatively influenced by severity of illness of the patient (β = -4.34; p = 0.0003), controlling for previously mentioned factors in the model. CONCLUSIONS Parent-physician interactions with more patient-centered elements, such as increased proportions of empathetic statements, question asking, and emotional talk, positively influence parent satisfaction despite the child's severity of illness.
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Affiliation(s)
- Tessie W October
- 1Department of Critical Care Medicine, Children's National Health Systems, Washington, DC. 2Department of Pediatrics, George Washington University School of Medicine, Washington, DC. 3Department of Nursing Research and Quality Outcomes, Children's National Health Systems, Washington, DC. 4Center for Translational Science, Department of Pediatrics, Children's National Health Systems, Washington, DC. 5Department of Epidemiology and Biostatistics, George Washington University School of Medicine, Washington, DC. 6Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Clément de Cléty S, Friedel M, Verhagen AAE, Lantos JD, Carter BS. Please Do Whatever It Takes to End Our Daughter's Suffering! Pediatrics 2016; 137:peds.2015-3812. [PMID: 26644491 DOI: 10.1542/peds.2015-3812] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2015] [Indexed: 11/24/2022] Open
Abstract
What is the best way to care for a child with severe neurologic impairment who seems to be dying and is in intractable pain? Can we give sedation as we remove life support? Is it ethically permissible to hasten death? In the United States, 5 states have legalized assisted suicide (although only for competent adults). In Belgium and the Netherlands, euthanasia is legal for children under some circumstances. We present a case in which parents and doctors face difficult decisions about palliative care. Experts from Belgium, the Netherlands, and the United States then discuss how they would respond to such a case.
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Affiliation(s)
| | - Marie Friedel
- Haute Ecole Vinci and Université catholique de Louvain, Brussels, Belgium
| | - A A Eduard Verhagen
- Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; and
| | - John D Lantos
- Children's Mercy Hospital and University of Missouri, Kansas City, Missouri
| | - Brian S Carter
- Children's Mercy Hospital and University of Missouri, Kansas City, Missouri
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Bateman LB, Tofil NM, White ML, Dure LS, Clair JM, Needham BL. Physician Communication in Pediatric End-of-Life Care: A Simulation Study. Am J Hosp Palliat Care 2015; 33:935-941. [PMID: 26169522 DOI: 10.1177/1049909115595022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The objective of this exploratory study is to describe communication between physicians and the actor parent of a standardized 8-year-old patient in respiratory distress who was nearing the end of life. METHODS Thirteen pediatric emergency medicine and pediatric critical care fellows and attendings participated in a high-fidelity simulation to assess physician communication with an actor-parent. RESULTS Fifteen percent of the participants decided not to initiate life-sustaining technology (intubation), and 23% of participants offered alternatives to life-sustaining care, such as comfort measures. Although 92% of the participants initiated an end-of-life conversation, the quality of that discussion varied widely. CONCLUSION Findings indicate that effective physician-parent communication may not consistently occur in cases involving the treatment of pediatric patients at the end of life in emergency and critical care units. PRACTICE IMPLICATIONS The findings in this study, particularly that physician-parent end-of-life communication is often unclear and that alternatives to life-sustaining technology are often not offered, suggest that physicians need more training in both communication and end-of-life care.
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Affiliation(s)
- Lori Brand Bateman
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nancy M Tofil
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marjorie Lee White
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Leon S Dure
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Belinda L Needham
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Madden K, Wolfe J, Collura C. Pediatric Palliative Care in the Intensive Care Unit. Crit Care Nurs Clin North Am 2015; 27:341-54. [PMID: 26333755 DOI: 10.1016/j.cnc.2015.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The chronicity of illness that afflicts children in Pediatric Palliative Care and the medical technology that has improved their lifespan and quality of life make prognostication extremely difficult. The uncertainty of prognostication and the available medical technologies make both the neonatal intensive care unit and the pediatric intensive care unit locations where many children will receive Pediatric Palliative Care. Health care providers in the neonatal intensive care unit and pediatric intensive care unit should integrate fundamental Pediatric Palliative Care principles into their everyday practice.
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Affiliation(s)
- Kevin Madden
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1414, Houston, TX 77030, USA.
| | - Joanne Wolfe
- Pediatric Palliative Care, Pediatric Palliative Care Service, Department of Psychosocial Oncology and Palliative Care, Children's Hospital Boston, Dana-Farber Cancer Institute, Harvard Medical School, DA2-012, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Christopher Collura
- Division of Neonatal Medicine, Department of Pediatric & Adolescent Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55902, USA
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