Pediatric palliative care

Knowledge and utilization of palliative radiotherapy by pediatric oncologists

Background and Purpose

Palliative radiotherapy (prt) is a routine part of oncology care in adult patients, but it is used much less frequently among children with incurable cancer. We surveyed Canadian pediatric oncologists to learn about their knowledge and use of prt and to identify potential barriers to referral.

Methods

A 13-item questionnaire assessing prt knowledge and utilization was sent to 80 Canadian pediatric oncologists.

Results

The survey completion rate was 80%, with most respondents being providers of palliative care for children and making referrals for prt. Although 62% had received training in radiation oncology, only 28% had received formal palliative care training. Respondents with palliative care training were found to be significantly more knowledgeable about prt and were more likely to refer children for prt (p < 0.01). Only 59% of respondents thought that they had adequate knowledge about the indications for prt. A positive correlation was found between knowledge about the indications for prt and referral for treatment (p < 0.01). Among survey respondents, 51% believed that prt was underutilized, and the perceived barriers to prt referral included patient or family reluctance, distance to the cancer centre, belief that prt has little impact on quality of life, and concerns about toxicity.

Conclusions

Palliative radiotherapy is considered to be underutilized among children. This situation appears to be related, in part, to inadequate knowledge and training among pediatric oncologists, suggesting that more emphasis needs to be placed on pediatric palliative care education.

Advance care planning for paediatric patients

Medical and technological advances have increased survival rates and enhanced the quality of life for infants, children and youths with chronic life-threatening conditions. Advance care planning includes the process of discussing life-sustaining treatments and establishing long-term care goals. Paediatric health care practitioners have an ethical obligation to educate themselves about this aspect of medical care. The present statement aims to assist health care practitioners to discuss advance care planning for paediatric patients in varied settings. Advance care planning requires effective communication to clarify the goals of care and establish agreement on what treatments may or may not be appropriate to achieve these goals, including resuscitative and palliative measures.

Barriers to hospice for children as perceived by hospice organizations in North Carolina

Despite improving organization of hospice for children with life-limiting illnesses, services may be underutilized. We asked representatives of all 76 existing North Carolina hospice organizations about barriers to serving children. Representatives of 61 agencies responded (80%). Hospices serving children differed from hospices not serving children on perception of barriers: 1) Lack of pediatric trained staff (8% vs 42%, p = 0.01); 2) lack of pediatrician consultation (23% vs 50%, p = 0.03); 3) lack of pediatric pharmacy (4% vs 32%, p = 0.006), and inconsistent plan of care between pediatrician and hospice (12% vs 47%, p = 0.01). Lack of pediatric referrals (78%) and families wanting to continue curative therapies while receiving hospice care (77%) were felt to be the most important barriers overall. Enhanced training of pediatric providers and a model of care which blends disease-specific treatment with hospice may improve access to hospice services for children.

Pediatric palliative care patients: a prospective multicenter cohort study

OBJECTIVE

To describe demographic and clinical characteristics and outcomes of patients who received hospital-based pediatric palliative care (PPC) consultations.

DESIGN, SETTING, AND PATIENTS

Prospective observational cohort study of all patients served by 6 hospital-based PPC teams in the United States and Canada from January to March 2008.

RESULTS

There were 515 new (35.7%) or established (64.3%) patients who received care from the 6 programs during the 3-month enrollment interval. Of these, 54.0% were male, and 69.5% were identified as white and 8.1% as Hispanic. Patient age ranged from less than one month (4.7%) to 19 years or older (15.5%). Of the patients, 60.4% lived with both parents, and 72.6% had siblings. The predominant primary clinical conditions were genetic/congenital (40.8%), neuromuscular (39.2%), cancer (19.8%), respiratory (12.8%), and gastrointestinal (10.7%). Most patients had chronic use of some form of medical technology, with gastrostomy tubes (48.5%) being the most common. At the time of consultation, 47.2% of the patients had cognitive impairment; 30.9% of the cohort experienced pain. Patients were receiving many medications (mean: 9.1). During the 12-month follow-up, 30.3% of the cohort died; the median time from consult to death was 107 days. Patients who died within 30 days of cohort entry were more likely to be infants and have cancer or cardiovascular conditions.

CONCLUSIONS

PPC teams currently serve a diverse cohort of children and young adults with life-threatening conditions. In contrast to the reported experience of adult-oriented palliative care teams, most PPC patients are alive for more than a year after initiating PPC.

Palliative care and pediatric surgery

Pediatric surgeons can play an important role in offering procedures that may improve the quality of life for terminally ill children. As with all palliative interventions, surgical therapies should be evaluated in the context of explicitly defined treatment goals while weighing the risks and benefits of procedures in the context of a shortened life span. It is essential that pediatric surgeons become active members in the multidisciplinary team that provides palliative care.

How parents of children receiving pediatric palliative care use religion, spirituality, or life philosophy in tough times

BACKGROUND

How parents of children with life threatening conditions draw upon religion, spirituality, or life philosophy is not empirically well described.

METHODS

Participants were parents of children who had enrolled in a prospective cohort study on parental decision-making for children receiving pediatric palliative care. Sixty-four (88%) of the 73 parents interviewed were asked an open-ended question on how religion, spirituality, or life philosophy (RSLP) was helpful in difficult times. Responses were coded and thematically organized utilizing qualitative data analysis methods. Any discrepancies amongst coders regarding codes or themes were resolved through discussion that reached consensus.

RESULTS

Most parents of children receiving palliative care felt that RSLP was important in helping them deal with tough times, and most parents reported either participation in formal religious communities, or a sense of personal spirituality. A minority of parents, however, did not wish to discuss the topic at all. For those who described their RSLP, their beliefs and practices were associated with qualities of their overall outlook on life, questions of goodness and human capacity, or that "everything happens for a reason." RSLP was also important in defining the child's value and beliefs about the child's afterlife. Prayer and reading the bible were important spiritual practices in this population, and parents felt that these practices influenced their perspectives on the medical circumstances and decision-making, and their locus of control. From religious participation and practices, parents felt they received support from both their spiritual communities and from God, peace and comfort, and moral guidance. Some parents, however, also reported questioning their faith, feelings of anger and blame towards God, and rejecting religious beliefs or communities.

CONCLUSIONS

RSLP play a diverse and important role in the lives of most, but not all, parents whose children are receiving pediatric palliative care.

Palliative care consultation in pediatric oncology

PURPOSE

Pediatric oncology patients benefit from the involvement of palliative care. This study examined the timing of palliative care consultation.

METHODS

A retrospective chart review was performed on all children from the Children's Hospital of Eastern Ontario with a diagnosis of malignancy.

RESULTS

Since 2006, 50 children with cancer were referred to palliative care. The mean time of referral after diagnosis was 461 days, with 8(16%) referred within 30 days of diagnosis, 13(26%) before a relapse occurred, 20(40%) after the first relapse, and 9(18%) after ≥2 relapses. Of the 40 patients referred to palliative care who died, 28% died at home, 30% in hospital, and 43% in hospice. Of the 49 oncology patients who died during the study period, 88% received a palliative care consult prior to death.

CONCLUSIONS

The majority of children in this study who died from cancer were referred to palliative care. Oncologists should strive to refer patients early in their disease.

Care goals and decisions for children referred to a pediatric palliative care program

OBJECTIVE

To describe goals of care for children with complex, life-limiting conditions and to assess the variables that may influence these goals.

METHODS

Goals of care were elicited from the parents and children with complex, life-limiting conditions during initial palliative care consultation. Data abstracted included: diagnoses, demographics, time from diagnosis until initial palliative care consult, spirituality status, resuscitative status, and disposition at discharge. Goals of care were categorized into one of four quality-of-life domains: 1) physical health and independence, 2) psychological and spiritual, 3) social, and 4) environment. Summary statistics were prepared and comparisons were made between the four categories of goals. Descriptive statistics were utilized to explore potential associations with a decision to pursue full medical support.

RESULTS

One hundred and forty goals of care were obtained from 50 patients/parents. The median patient age was 4.6 years. Thirty-seven patients had significant cognitive delay/impairment. Neuromuscular disorders accounted for more than half of the diagnoses. Forty-nine patients identified at least one goal pertaining to physical health and independence. This was significantly more than any other category (p < 0.0001). Thirty-three of the 50 patients (66%) opted for full medical support at the time of initial consult.

CONCLUSIONS

Children with complex, life-limiting conditions and their families referred to a palliative care service commonly verbalize goals related to health maintenance and independence. Anticipating this expectation may foster communication and improve patient care.

Health Care Reform and Concurrent Curative Care for Terminally Ill Children: A Policy Analysis

Within the Patient Protection and Affordable Care Act of 2010 or health care reform, is a relatively small provision about concurrent curative care that significantly affects terminally ill children. Effective on March 23, 2010, terminally ill children, who are enrolled in a Medicaid or state Children's Health Insurance Plans (CHIP) hospice benefit, may concurrently receive curative care related to their terminal health condition. The purpose of this article was to conduct a policy analysis of the concurrent curative care legislation by examining the intended goals of the policy to improve access to care and enhance quality of end of life care for terminally ill children. In addition, the policy analysis explored the political feasibility of implementing concurrent curative care at the state-level. Based on this policy analysis, the federal policy of concurrent curative care for children would generally achieve its intended goals. However, important policy omissions focus attention on the need for further federal end of life care legislation for children. These findings have implications nurses.

Quality of Life Measurement for Children with Life-Threatening Conditions: Limitations and a New Framework

About 500,000 children are coping with life-threatening conditions (LTC) in the United States every year. Different service programs such as an integrated pediatric palliative care program may benefit health-related quality of life (HRQOL) which is a great concern of this children population and their families. However, evidence is limited about the appropriate HRQOL instruments for use. This study aims to validate psychometric properties of a generic HRQOL instrument, the Pediatric Quality of Life (PedsQL) 4.0, for children with LTC. The parent proxy-report was used. We conducted a telephone interview to collect data of 257 parents whose children had LTC and were enrolled in Medicaid. We used standard psychometric methods to validate the PedsQL: scale reliability, item-domain convergent/discriminant validity, and known-groups validity. We also conducted Rasch analysis to assess construct validity. Results suggest that the PedsQL did not demonstrate valid psychometric properties for measuring HRQOL in this population. Rasch analysis suggests that the contents of the items in all domains did not appropriately cover the latent HRQOL of children with LTC. We document several methodological challenges in using a generic instrument to measuring HRQOL and propose a new framework to improve HRQOL measures for children with LTC. The strategies include revising the content of existing items, designing new items, adding important themes (e.g., financial challenge), and applying computerized adaptive test to better select appropriate items for individual children with LTC.

Prevalence of life-threatening conditions in children

OBJECTIVE

We estimated the prevalence of children with life-threatening conditions (LTC) cared for in the military health system (MHS) in response to a Congressional inquiry and to inform program planning.

METHODS

We developed a case definition of LTC, using the concept ''death trajectory''(1,2) to define our cases. We conducted an unduplicated count of children with LTC in the MHS database during FY 2001/FY 2002 using selected ICD-9 codes based on our case definition. We then surveyed the literature for reported prevalence of LTC among children with similar case definitions. The concept of ''death trajectory'' describes non-categorical life-threatening conditions of four types: progressive decline to death (e.g., spinal muscular atrophy); intermittent periods of intensive care to maintain quality-of-life (e.g., cystic fibrosis); curative treatment is possible but may fail (e.g., childhood cancers); and severe but non-progressive disability with extreme health vulnerability (e.g., spastic quadriplegia with tracheotomy).

RESULTS

There were 3,976 children identified with LTC in a population of 2.6 million children, for a prevalence of 0.15%.

CONCLUSION

A prevalence of 0.15% for children with LTC in the MHS population agrees closely with that derived for similar case definitions by other authors among populations of children in other single-payer health care systems (i.e., United Kingdom). The method used here may apply to similar health care systems with ICD 9 codes in a searchable database.

Unmet Needs of Children With Special Health Care Needs in a Specialized Day School Setting

Children with Special Health Care Needs (CSHCN) represent a significant component of the pediatric population. They often present to schools with multiple and increasingly complex health issues, including medical technology dependency. Their daily variation in health status requires close monitoring and communication among caregivers. Limited research exists regarding parental concerns and communication between health providers, schools, and families. This study identifies the concerns of parents with CSHCN families, including satisfaction with communication between medical providers and schools. Parents completed a survey adapted from the American Academy of Pediatrics (AAP). Analysis of data indicated a high utilization of primary care services but highlighted persistent difficulty accessing services. This study demonstrates families have basic unmet needs in attaining services, including respite and palliative care; indicated an interest in improved communication and coordination of health information between schools and their primary health care providers; and expressed interest in augmenting school health services.

Pediatric nurses' perceptions of obstacles and supportive behaviors in end-of-life care

BACKGROUND

Each year 55 000 children die in the United States, and most of these deaths occur in hospitals. The barriers and supportive behaviors in providing end-of-life care to children should be determined.

OBJECTIVE

To determine pediatric intensive care unit nurses' perceptions of sizes, frequencies, and magnitudes of selected obstacles and helpful behaviors in providing end-of-life care to children.

METHOD

A national sample of 1047 pediatric intensive care unit nurses who were members of the American Association of Critical-Care Nurses were surveyed. A 76-item questionnaire adapted from 3 similar surveys with critical care, emergency, and oncology nurses was mailed to possible participants. Nurses who did not respond to the first mailing were sent a second mailing. Nurses were asked to rate the size and frequency of listed obstacles and supportive behaviors in caring for children at the end of life.

RESULTS

A total of 474 usable questionnaires were received from 985 eligible respondents (return rate, 48%). The 2 items with the highest perceived obstacle magnitude scores for size and frequency means were language barriers and parental discomfort in withholding and/or withdrawing mechanical ventilation. The highest supportive behavior item was allowing time alone with the child when he or she has died.

CONCLUSIONS

Pediatric intensive care unit nurses play a vital role in caring for dying children and the children's families. Overcoming language and communication barriers with children's families and between interdisciplinary team members could greatly improve the end-of-life experience for dying children.

Saúde da família e cuidados paliativos infantis: ouvindo os familiares de crianças dependentes de tecnologia

O estudo discute um modelo de cuidados paliativos infantis baseado na Saúde da Família quando da assistência domiciliar, articulado com os demais níveis de atenção e nas demandas das famílias. Participaram do estudo dezoito membros de nove famílias de crianças do Instituto Fernandes Figueira (IFF), das quais quatro estão assistidas pelo Programa de Assistência Domiciliar Interdisciplinar (PADI), três internadas aguardando a inclusão no programa e duas internadas e já pertencentes ao PADI. O PADI foi estudado por ser o único que oferece cuidados paliativos infantis na rede pública de saúde. Os resultados demonstram-se positivos quanto ao vínculo estabelecido com a equipe, ao acolhimento, ao conhecimento pelos familiares acerca da doença e à dinâmica entre o PADI e o IFF. Como pontos negativos aparecem as dificuldades, que vão desde a implantação do programa até sua continuidade; quase todos os familiares referem agravos ou doenças. Concluiu-se, que apesar de o PADI se apresentar como a forma encontrada pelo IFF para a desospitalização, os cuidados domiciliares pela Saúde da Família, bem articulado com a rede, seriam o ideal por se tratar do nível de assistência adequado para tal.

Quality of life information and trust in physicians among families of children with life-limiting conditions

Purpose:

To examine information that parents of children with life-limiting conditions want to discuss with children’s physicians to assist decision-making, and whether the desire for this information is associated with parents’ trust in physicians.

Study design:

A cross-sectional study using a telephone survey.

Patients and methods:

Subjects comprised a random sample of 266 parents whose children were enrolled in Florida’s Medicaid Program. Parents were asked if they wanted to discuss information related to their children’s treatment, including quality of life (QOL), pain relief, spiritual beliefs, clinical diagnosis/laboratory data, changes in the child’s behavior due to treatment, changes in the child’s appearance due to treatment, chances of recovery, and advice from the physician and family/friends. The Wake Forest Physician Trust Scale was used to measure parents’ trust in physicians. We tested the relationships between parents’ age, race/ethnicity, education, parent-reported children’s health status, and the desired information. We also tested whether the desire for information was associated with greater trust in physicians.

Results:

Most parents wanted information on their children’s QOL (95%), followed by chance of recovery (88%), and pain relief (84%). Compared with nonHispanic whites, nonHispanic blacks and Hispanics showed a greater desire for information and a chance to discuss QOL information had greater trust in their children’s physicians than other information after adjusting for covariates (P < 0.05).

Conclusions:

Among children with life-limiting conditions, QOL is the most frequently desired information that parents would like to receive from physicians as part of shared decision-making. Parents’ desire for QOL information is associated with greater trust in their children’s physicians.

Parental hopeful patterns of thinking, emotions, and pediatric palliative care decision making: a prospective cohort study

OBJECTIVE

To test the hypothesis that hopeful patterns of thoughts and emotions of parents of pediatric patients receiving palliative care consultative services are related to subsequent decisions, specifically regarding limit of intervention (LOI) orders.

DESIGN

Prospective cohort study.

SETTING

Children's hospital and surrounding region.

PARTICIPANTS

Thirty-three pediatric patients receiving palliative care consultative services who did not have LOI orders at time of cohort entry and their 43 parental adults.

MAIN EXPOSURES

Parental levels at time of cohort entry of hopeful patterns of thinking and emotions, in conjunction with perceptions about patients' health trajectories.

MAIN OUTCOME MEASURE

Enactment of an LOI order after entry into the cohort.

RESULTS

During the 6 months of observation, 14 patients (42.4%) had an LOI order enacted. In adjusted analyses, higher levels of parental hopeful patterns of thinking were significantly associated with increased odds of enactment of an LOI order (adjusted odds ratio [AOR], 2.73; 95% confidence interval [CI], 1.04-7.22). Increased odds of LOI enactment were associated to nonsignificant degrees with lower levels of parental positive affect (AOR, 0.44; 95% CI, 0.17-1.12), higher levels of parental negative affect (AOR, 2.02; 95% CI, 0.98-4.16), and parental perceptions of worsening health over time (AOR, 1.72; 95% CI, 0.73-4.07).

CONCLUSION

For pediatric patients receiving palliative care consultative services, higher levels of parents' hopeful patterns of thinking are associated with subsequent enactment of LOI orders, suggesting that emotional and cognitive processes have a combined effect on medical decision making.

Pediatric palliative care

Palliative care has always been a part of the care of children. It includes any intervention that focuses on relieving suffering, slowing the progression of disease, and improving quality of life at any stage of disease. In addition, for even the child with the most unpredictable disease, there are predictable times in this child's life when the child, family, and care team will be suffering in ways that can be mitigated by specific interventions. Rather than defining pediatric palliative care in terms of a patient base, severity of disease, or even a general philosophy of care, palliative care can best be understood as a specific set of tasks directed at mitigating suffering. By understanding these tasks; learning to identify predictable times and settings of suffering; and learning to collaborate with multidisciplinary specialists, use communication skills, and identify clinical resources, the pediatrician can more effectively support children with life-threatening illnesses and their families. In this article, we define palliative care as a focus of care integrated in all phases of life and as a set of interventions aimed at easing suffering associated with life-threatening conditions. We detail an approach to these interventions and discuss how they can be implemented by the pediatrician with the support of specialists in hospice and palliative medicine. We discuss common and predictable times of suffering when these interventions become effective ways to treat suffering and improve quality of life. Finally, we discuss those situations that pediatricians most commonly and intensely interface with palliative care-the care of the child with complex, chronic conditions and severe neurologic impairment (SNI).

Honoring do-not-attempt-resuscitation requests in schools

Increasingly, children and adolescents with complex chronic conditions are living in the community. Federal legislation and regulations facilitate their participation in school. Some of these children and adolescents and their families may wish to forego life-sustaining medical treatment, including cardiopulmonary resuscitation, because they would be ineffective or because the risks outweigh the benefits. Honoring these requests in the school environment is complex because of the limited availability of school nurses and the frequent lack of supporting state legislation and regulations. Understanding and collaboration on the part of all parties is essential. Pediatricians have an important role in helping school nurses incorporate a specific action plan into the student's individualized health care plan. The action plan should include both communication and comfort-care plans. Pediatricians who work directly with schools can also help implement policies, and professional organizations can advocate for regulations and legislation that enable students and their families to effectuate their preferences.

When clinicians and a parent disagree on the extent of medical care

TG is a 32-month-old girl with a rare lysosomal storage disease. The diagnosis was confirmed at 8 months of age; she underwent bone marrow transplant at 14 months. TG's father remained at home with her siblings whereas her mother lived at the transplant hospital with TG for 1 year. Significant respiratory infections led to dependency on a tracheotomy and ventilator. She was transferred to the current hospital 10 months ago for respiratory rehabilitation, which has been complicated by pulmonary hemorrhages. On examination, TG was in a wheelchair with truncal support and leg splints. She is a small child with coarse facial features, generalized hypotonia, and significant joint restriction. She exhibited intermittent repetitive arm movements. A tracheotomy was in place, and she did not vocalize. Variable levels of alertness were observed although she rarely signaled to others for social engagement or to express her needs. Eye contact was limited and she responded inconsistently to her name. TG's mother states that her daughter interacts well with her and uses a number of signs for communication. The rehabilitation staff reported limited progress and recommends withdrawal of services. TG's mother expressed frustration with her daughter's poor developmental improvement and believes she needs more intensive therapy, not less. Staff members are now frustrated with TG's mother's level of involvement with her daughter's care. Although TG's mother spends full weekdays at her daughter's bedside, she is often working on her computer managing her business. TG's father works full time and visits on the weekends, when her mother returns home. TG's mother has expressed frustration with her daughter's level of improvement; she believes TG needs more intensive therapy that the hospital is not providing. She informed the staff that other children with this type of storage disease may have delays, but are often higher functioning. TG's mother made the point to the staff that the family's reason for pursuing a bone marrow transplant was to attempt to correct the enzyme deficiency and improve her daughter's outcome.

Saúde da família e cuidados paliativos infantis: ouvindo os familiares de crianças dependentes de tecnologia

O estudo discute um modelo de cuidados paliativos infantis baseado na Saúde da Família quando da assistência domiciliar, articulado com os demais níveis de atenção e nas demandas das famílias. Participaram do estudo dezoito membros de nove famílias de crianças do Instituto Fernandes Figueira (IFF), das quais quatro estão assistidas pelo Programa de Assistência Domiciliar Interdisciplinar (PADI), três internadas aguardando a inclusão no programa e duas internadas e já pertencentes ao PADI. O PADI foi estudado por ser o único que oferece cuidados paliativos infantis na rede pública de saúde. Os resultados demonstram-se positivos quanto ao vínculo estabelecido com a equipe; o acolhimento; o conhecimento pelos familiares acerca da doença e a dinâmica entre o PADI e o IFF. Como pontos negativos, aparecem as dificuldades, que vão desde a implantação do programa até sua continuidade e que quase todos os familiares referem agravos ou doenças. Concluiu-se que, apesar do PADI se apresentar como a forma encontrada pelo IFF para a desospitalização, os cuidados domiciliares pela Saúde da Família, bem articulados com a rede, seria o ideal por ser o nível de assistência adequado para tal.

Measuring quality of life in pediatric palliative care: challenges and potential solutions

Annually, about 500,000 children are coping with life-limiting illnesses in the USA. Integrated pediatric palliative care program could benefit some of these children by improving their health-related quality of life (HRQOL). To measure the effect of pediatric palliative care programs on HRQOL, a valid and reliable tool must be identified. This study aimed to validate the psychometric properties of a generic HRQOL instrument, the Pediatric Quality of Life 4.0, for children with life-limiting illnesses. Analyses were conducted using telephone survey data collected from 266 parents whose Medicaid-enrolled children had life-limiting illnesses. Results of the analyses suggest the Pediatric Quality of Life 4.0 does not have valid psychometric properties for measuring HRQOL within this population. Our study documents several challenges in using the generic instrument to measure HRQOL in pediatric palliative care setting. We point out future directions to refine or develop HRQOL instruments for this population of vulnerable children.

Impact of a pediatric palliative care program

BACKGROUND

The question of where a child should die at home or in the hospital has been a subject of recent debate. We instituted a palliative care program with advanced end-of-life planning and hypothesized that a significant number of families would prefer that their child be at home rather than at a hospital at the end-of-life and that the overall quality of care would thereby improve.

PROCEDURE

Study design was single group, retrospective parent report of satisfaction with a new palliative care program. Participants were the caregivers, primarily parents, involved in the palliative care program. They completed a satisfaction survey, and their choice of environment at the end-of-life was noted.

RESULTS

Fifty-one families experienced the death of a child between 2001 and 2003. Most of the patients had had cancer (n = 29, 57%), and the most frequent non-oncologic patient had had cystic fibrosis. The parents (caregiver) participation rate was 69%. After a palliative care program was instituted, 69% of families preferred their child to be at home at the end-of-life, compared with 18% before the program was instituted (P = 0.0049 chi(2)-test). The satisfaction with the medical services was high (very good, 26; good, 4; satisfying, 2; acceptable, 3; deficient, 0; unacceptable, 0), independent of locale at time of death.

CONCLUSION

When palliative care was offered either at hospital or home, palliative care occurred more frequently at home.

End of life in children with cancer: experience at the pediatric oncology department of the istituto nazionale tumori in Milan

BACKGROUND

Coping with end-stage pediatric cancer patients and the related bereavement is a challenge for all the caregivers involved.

PROCEDURE

Forty-seven cancer patients who died in 2006 were assessed as concerns the main place of care in the end stage of their disease, their symptoms, the palliative treatments received, and the site of death.

RESULTS

The end stage was managed at the Istituto Nazionale Tumori Pediatric Oncology Department in 61% of cases, at home in 26%, and in hospices or other hospital facilities in 11%. Pain was the most common symptom, followed by asthenia, anorexia, dyspnea, and nausea/vomiting. About half the patients died at home, 8.5% at our institute, 43% at other hospitals, and 8.5% in hospices.

CONCLUSIONS

The care of pediatric cancer patients during the end stage of their disease is the responsibility of the caregivers who have followed them up since their diagnosis. However, it would be useful to establish an exchange of information and expertise between pediatric oncologists and the other facilities involved (hospices, other hospitals) or people assisting patients at home (family, family pediatrician/general practitioner GP).

[Talking about death to children with cancer]

INTRODUCTION

Paediatric cancer treatment includes a multidisciplinary intervention in all treatment phases, and particularly in the palliative phase. One of the main skills is information. This study tries to explore the level of information that children on palliative care have about their own death.

SAMPLE AND METHODS

We retrospectively collected the psychosocial variables of 45 oncology patients who died as inpatients in the Hospital Niño Jesús Hospital (HNJS) between 2006 and 2007. The concept of death is analysed according to each child development stage.

RESULTS

We found a relationship between the age of the children and the information they have about their own death, as well as a statistical significance between the information that the child has and the information received from their parents. Children between 3 to 6 years old have more information about their own death than children between 7 to 11 years old.

CONCLUSIONS

Our results confirmed that the older age group had more information on their imminent death. However children between 3 to 6 years old have more information than children between 7 to 11 years old. Probably as children between 3 to 6 years old have a magical concept of death, it makes it easier to talk about their terminal phase. Over-protection and the difficulty to talk about death shows differences between what children know and what parents tell them about their palliative phase.

An assessment of the current state of palliative care education in pediatric hematology/oncology fellowship training

BACKGROUND

Despite improved survival rates for pediatric oncology patients, childhood cancers continue to be the number one cause of non-accidental death in children. Studies show that many children receiving end-of-life care, and their families, believe that physicians can improve significantly in the delivery of palliative care. This has led to the recommendation that increased palliative care training for physicians taking care of terminally ill pediatric patients is needed.

PROCEDURE

We designed a 28-question survey and sent it via electronic mail to all 66 pediatric oncology fellowship program directors in the United States. The questionnaire assessed fellowship training programs' current practice in educating pediatric oncology fellows on palliative care.

RESULTS

Thirty-six pediatric oncology program directors responded to the survey for a 55% response rate. Ninety-four percent of all respondents reported that it is very important or extremely important for pediatric oncology fellows to learn about palliative care during their training. Seventy-one percent of fellowship training programs do not currently have a palliative care curriculum, and less than one-third of training programs have any evidence-based journal clubs devoted to palliative care issues. Eighty-eight percent of program directors believe their program will increase palliative care education for their fellows within 5 years.

CONCLUSIONS

Pediatric oncology fellowship directors believe it is very important for fellows to learn about palliative care during training; however, currently the majority of fellowship programs do not have a palliative care curriculum and lack significant formal education in end-of-life care.

The supportive and palliative care needs of Australian families of children who die from cancer

OBJECTIVE

To identify the perceptions of parents of children who died from cancer regarding the palliative and supportive care they received in hospital and in community settings.

METHOD

Face-to-face or telephone questionnaires. Setting Tertiary paediatric oncology centres in Western Australia, New South Wales, Queensland and Victoria.

PARTICIPANTS

69 parents.

RESULTS

Parents indicated the need for clear and honest information about their child's condition and prognosis throughout the trajectory of illness. Parents also required access to, and advice from, multidisciplinary health professionals when caring for their child at home. Parents preferred to care for their child at home wherever possible throughout the palliative care trajectory of their child's cancer and were well supported by immediate and extended family and friends. However, many families were affected emotionally and financially by the burden of caring for their child with incurable cancer. Families required financial and practical assistance with providing care from their child. Parents wanted and needed more practical resources and information to assist with the management of their child's nutrition and pain, as well as for the support of their other children.

CONCLUSION

Care for children and their families should be coordinated by a multidisciplinary team in consultation with children and their families, and should be linked and integrated with the treating hospital in collaboration with community services.

An evaluation of two decision-making scales for children with life-limiting illnesses

PURPOSE

Annually, about 500,000 children are coping with life-limiting illnesses. Many of these children could benefit from pediatric palliative care which provides supportive services. These services can also aid parents in decision making. In order to measure the effect of pediatric palliative care programs on decision making, a valid and reliable tool must be identified. This study aims to validate the psychometric properties of the Decisional Conflict Scale (DCS) and the COMRADE instruments for children with life-limiting illnesses.

METHODS

Analyses were conducted using survey data collected from 266 parents whose Medicaid enrolled children have life-limiting illnesses.

RESULTS

Results of the analyses suggest that the DCS has better psychometric properties for measuring decision making within the population of children with life-limiting illnesses than the COMRADE.

CONCLUSION

Pediatric palliative care programs should use the DCS to measure the effectiveness of services aimed at supporting families with high levels of decisional conflict.

Effect of a pediatric palliative care program on nurses' referral preferences

PURPOSE

Florida was the first state to develop and implement a publicly funded pediatric palliative care program, which provides supportive care services to children and families from the point of diagnosis onward. Nurses employed by the Florida Department of Health, Children's Medical Services Network (CMSN) play an important role in this program as they are charged with identifying children with life-limiting illnesses in their caseloads for referral to the program. This study aims to estimate the differtences in referral preferences of nurses who work in Partners in Care: Together for Kids (PIC:TFK) program areas versus nurses who work in non-PIC:TFK areas.

METHODS

Mail and Web-based surveys were conducted with 279 nurses, 141 of whom work in a PIC:TFK site and 138 did not.

RESULTS

Results of the multivariate analyses suggest that few significant differences exist in the nurse's preferences to refer children to pediatric palliative care; however, there were significant differences in the preferred timing of referral. Nurses who work in an PIC:TFK area were 3.7 to 10.4 times as likely as nurses who do not work in a PIC:TFK area to refer children prior to the end of life.

CONCLUSION

Our study provides evidence that nurses who have experience with a pediatric palliative care program are more likely to refer children to programs before the end of life. While our study results are encouraging, they also suggest that as the PIC:TFK program expands nurse training will be essential for equitable and appropriate referrals across a diverse set of illnesses.

Clinical report--Forgoing medically provided nutrition and hydration in children

There is broad consensus that withholding or withdrawing medical interventions is morally permissible when requested by competent patients or, in the case of patients without decision-making capacity, when the interventions no longer confer a benefit to the patient or when the burdens associated with the interventions outweigh the benefits received. The withdrawal or withholding of measures such as attempted resuscitation, ventilators, and critical care medications is common in the terminal care of adults and children. In the case of adults, a consensus has emerged in law and ethics that the medical administration of fluid and nutrition is not fundamentally different from other medical interventions such as use of ventilators; therefore, it can be forgone or withdrawn when a competent adult or legally authorized surrogate requests withdrawal or when the intervention no longer provides a net benefit to the patient. In pediatrics, forgoing or withdrawing medically administered fluids and nutrition has been more controversial because of the inability of children to make autonomous decisions and the emotional power of feeding as a basic element of the care of children. This statement reviews the medical, ethical, and legal issues relevant to the withholding or withdrawing of medically provided fluids and nutrition in children. The American Academy of Pediatrics concludes that the withdrawal of medically administered fluids and nutrition for pediatric patients is ethically acceptable in limited circumstances. Ethics consultation is strongly recommended when particularly difficult or controversial decisions are being considered.

Paediatricians' perceptions on referrals to paediatric palliative care

Children have traditionally been referred to palliative care when curative treatments were exhausted. Recently, experts have suggested that children could benefit from palliative care early in their courses of illness. Using survey data from 303 paediatricians in Florida and California, this study assesses if paediatricians would refer children to palliative care early in their course of illness. Results showed that more years in practice were associated with decreased odds of referring children to palliative care. Academic practice setting and more Medicaid patients were associated with greater odds of referral prior to the end of life. Hispanic paediatricians, those with more experience and those who practice in a hospital setting were associated with decreased odds of referral prior to the end of life. Results suggest that health planners who wish to implement or refine integrated paediatric palliative care programs should consider outreach strategies targeted at paediatricians with specific characteristics.

When clinicians and a parent disagree on the extent of medical care

TG is a 32-month-old girl with a rare lysosomal storage disease. The diagnosis was confirmed at 8 months of age; she underwent bone marrow transplant at 14 months. TG's father remained at home with her siblings whereas her mother lived at the transplant hospital with TG for 1 year. Significant respiratory infections led to dependency on a tracheotomy and ventilator. She was transferred to the current hospital 10 months ago for respiratory rehabilitation, which has been complicated by pulmonary hemorrhages. On examination, TG was in a wheelchair with truncal support and leg splints. She is a small child with coarse facial features, generalized hypotonia, and significant joint restriction. She exhibited intermittent repetitive arm movements. A tracheotomy was in place, and she did not vocalize. Variable levels of alertness were observed although she rarely signaled to others for social engagement or to express her needs. Eye contact was limited and she responded inconsistently to her name. TG's mother states that her daughter interacts well with her and uses a number of signs for communication. The rehabilitation staff reported limited progress and recommends withdrawal of services. TG's mother expressed frustration with her daughter's poor developmental improvement and believes she needs more intensive therapy, not less. Staff members are now frustrated with TG's mother's level of involvement with her daughter's care. Although TG's mother spends full weekdays at her daughter's bedside, she is often working on her computer managing her business. TG's father works full time and visits on the weekends, when her mother returns home. TG's mother has expressed frustration with her daughter's level of improvement; she believes TG needs more intensive therapy that the hospital is not providing. She informed the staff that other children with this type of storage disease may have delays, but are often higher functioning. TG's mother made the point to the staff that the family's reason for pursuing a bone marrow transplant was to attempt to correct the enzyme deficiency and improve her daughter's outcome.

Pediatric residents' and fellows' perspectives on palliative care education

BACKGROUND

The American Academy of Pediatrics recommends that pediatricians become knowledgeable in and comfortable with providing palliative care.

OBJECTIVE

The study goals included: determining the extent of training, knowledge, experience, comfort and competence in palliative care communication and symptom management of pediatric residents and fellows; obtaining residents' and fellows' views on key palliative care concepts; identifying topics and methods for palliative care education; and identifying differences in responses between residents and fellows.

DESIGN/METHODS

In academic year 2006-2007 pediatrics residents and fellows completed a survey on: training, experience, knowledge, competence, and comfort in delivering palliative care; palliative care practices; and suggestions for delivering palliative care education.

RESULTS

Fifty-two (60%) and 44 (62%) residents and fellows respectively completed the survey. Residents and fellows described none to moderate levels of training, experience, knowledge, competence and comfort in palliative care. Most respondents said they would benefit from more formal palliative care training. Respondents identified discussing prognosis, delivering bad news, and pain control as the three most important areas of needed education. Learning about supporting families spiritually and emotional support for physicians were among the least important educational areas identified. Respondents recommended delivering education via observation, bedside teaching, and participation in multidisciplinary groups.

CONCLUSIONS

Efforts to improve education in pediatric palliative care are needed. A palliative care team could facilitate palliative care education through engaging trainees in "real-life" interactions. The role of physicians in providing spiritual support and the need for educating physicians in obtaining emotional support for themselves merit further investigation.

Partners in care: together for kids: Florida's model of pediatric palliative care

BACKGROUND

Many children with life-limiting illnesses in the United States could benefit from pediatric palliative care. However, national, state, and local barriers exist that hinder provision. One national barrier is the Medicare hospice reimbursement regulation that limits the provision of government subsidized hospice care to the final 6 months of life. In response to the critical need to provide palliative care earlier in children's illnesses, Florida became the first state to develop and implement an innovative model of care that provides services from the point of diagnosis onward, thereby waiving the 6-month reimbursement rule. In July 2005, the Partners in Care: Together for Kids program began. The program relies on partnerships between state-employed care coordinators who identify the children for possible enrollment and hospice staff who provide home and community-based services.

OBJECTIVE

Our objective was to describe Florida's experiences in designing, implementing, and operating the program.

DESIGN

Surveys were conducted with parents, hospices, and state agencies. Enrollment trends were identified using administrative data.

RESULTS

As of January 2008, 468 children have been enrolled in the program. Approximately 85% of parents report they are satisfied with the program and 95% of parents would recommend the program.

CONCLUSION

Florida's program is the first in the nation to provide government-subsidized pediatric palliative care from the point of diagnosis onwards. Lessons learned from Florida's experiences will help guide other states and health plans that desire to implement a similar model of care.

Improving Psychological and Psychiatric Aspects of Palliative Care: The National Consensus Project and the National Quality Forum Preferred Practices for Palliative and Hospice Care

As patients with terminal disease enter into the final stage of their illness, psychiatric symptoms and psychological responses to the disease contribute to overall suffering of both patient and family. Until recently, no nationally accepted guidelines or practices had been established to support assessment and management of this type of suffering. In 2007, the National Quality Forum published A National Framework and Preferred Practices for Palliative and Hospice Care Quality that included a list of preferred practices for assessing and treating symptoms of psychiatric illness, anticipatory grief and psychologic distress prior to death, and bereavement after the death, of the patient. While specialized care may be provided to patient and families in the context of advanced disease, all clinicians involved in palliative and end-of-life care are responsible for having a basic understanding of effectively managing psychologic and psychiatric aspects of this care. Evidence from current literature supports these best practices.

Pediatric palliative care

The WHO defines pediatric palliative care as the active total care of the child's body, mind and spirit, which also involves giving support to the family. Its purpose is to improve the quality of life of young patients and their families, and in the vast majority of cases the home is the best place to provide such care, but for cultural, affective, educational and organizational reasons, pediatric patients rarely benefit from such an approach. In daily practice, it is clear that pediatric patients experience all the clinical, psychological, ethical and spiritual problems that severe, irreversible disease and death entail. The international literature indicates a prevalence of incurable disease annually affecting 10/10,000 young people from 0 to 19 years old, with an annual mortality rate of 1/10,000 young people from birth to 17 years old. The needs of this category of patients, recorded in investigations conducted in various parts of the world, reveal much the same picture despite geographical, cultural, organizational and social differences, particularly as concerns their wish to be treated at home and the demand for better communications between the professionals involved in their care and a greater availability of support services. Different patient care models have been tested in Italy and abroad, two of institutional type (with children staying in hospitals for treating acute disease or in pediatric hospices) and two based at home (the so-called home-based hospitalization and integrated home-based care programs). Professional expertise, training, research and organization provide the essential foundations for coping with a situation that is all too often underestimated and neglected.

Developing a pediatric palliative care program: addressing the lack of baseline expenditure information

An estimated 500 000 children annually cope with life-limiting conditions expected to lead to premature death, but little is known about their health care expenditures at the end of life. This information is crucial for health planners to propose pediatric palliative care programs. This study aims to estimate predicted health care expenditures for Medicaid-eligible infants and children across several health service categories. Across these categories, infants and children were predicted to spend about US$110 000 and US$62 000 at the end of life, respectively. About 5% of infants and 8% of children incurred hospice expenditures. Results from the multivariate models suggest that black, non-Hispanic children are less likely than white, non-Hispanic children to use hospice care. Baseline expenditure information from this study can be used to develop integrated pediatric palliative care models. Our findings also suggest that many more children could potentially benefit by using hospice care at the end of life.