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Crain N, Miller J. Palliative Care in the Pediatric Intensive Care Unit. AACN Adv Crit Care 2024; 35:134-145. [PMID: 38848559 DOI: 10.4037/aacnacc2024104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
The purposes of this review are to describe differences between palliative care for adult patients and palliative care for pediatric patients, both generally and in the intensive care unit; to highlight ethical considerations for pediatric intensive care unit patients by using illustrative cases; and to examine the impact of these ethical considerations on decision-making for children and their families.
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Affiliation(s)
- Noreen Crain
- Noreen Crain is Associate Professor of Pediatrics and Anesthesia, Division of Pediatric Critical Care, and Medical Director of Pediatric Palliative Care, University of Virginia Children's Hospital, 1215 Lee St, Charlottesville, VA 22908-0386
| | - Joy Miller
- Joy Miller is Pediatric Nurse Practitioner, Pediatric Palliative Care, University of Virginia Children's Hospital, Charlottesville, Virginia
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Sartor N, Bass AK, Overstreet K. Changing the Landscape of the Neighborhood: The Expanding Role of the Pediatric Palliative Advanced Practice Registered Nurse. J Hosp Palliat Nurs 2024; 26:68-73. [PMID: 38363149 DOI: 10.1097/njh.0000000000001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
There is a dearth of information on the role of the pediatric palliative advanced practice registered nurse (APRN) reported in the literature, and yet, the role is expanding. Advances in technology and health care are helping children with medical complexity live longer, and the demand for pediatric palliative care is growing. As programs expand to meet this need, there are new opportunities for pediatric palliative APRNs to practice outside acute care consultative models, within large children's hospitals. The aim of this article was to describe the expanding role of the pediatric palliative APRN using a progressive case study that describes how these expanding roles can collaborate using evidence-based practice and expert consensus to define their roles. If pediatric palliative APRNs hesitate to define their practice, others will define it for them.
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Postier AC, Root MC, O'Riordan DL, Purser L, Friedrichsdorf SJ, Pantilat SZ, Bogetz JF. The Pediatric Palliative Care Quality Network: Palliative Care Consultation and Patient Outcomes. Hosp Pediatr 2024; 14:1-10. [PMID: 38044667 DOI: 10.1542/hpeds.2023-007222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Quality benchmarking in pediatric palliative care (PPC) helps identify gaps in care and guides quality improvement. Our study objective was to characterize inpatient PPC referral processes, interdisciplinary PPC delivery, and patient outcomes from a multisite PPC data repository. METHODS Cross-sectional, administrative data analysis of 1587 PPC inpatient encounters at 5 US hospitals enrolled in the Pediatric Palliative Care Quality Network (2016-2022). PPC clinicians submitted data to a national repository for key quality indicators. Program and referral characteristics, care processes, and outcomes were examined descriptively. Time to referral, time on PPC service, and total hospital length of stay were compared by discharge disposition (alive or dead). RESULTS Programs were in service for 13 (range 6-17) years on average. Most encounters involved children >1 year old (77%). Common diagnoses were solid tumor cancer (29%) and congenital or chromosomal conditions (14%). Care was often provided by ≤2 PPC team members (53%) until discharge (median = 7d, interquartile range 2-23). There were often multiple reasons for PPC referral, including psychosocial support (78%), goals of care discussions/advance care planning (42%), management of non-pain symptoms (34%), and pain (21%). Moderate-severe symptoms improved by second assessment for pain (71%), dyspnea (51%), fatigue (46%), and feeding issues (39%). CONCLUSIONS Referrals to PPC were made early during hospitalization for psychosocial and physical symptom management. Moderate-severe symptom distress scores at initial assessment often improved. Findings highlight the need to ensure interdisciplinary PPC team staffing to meet the complex care needs of seriously ill children.
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Affiliation(s)
- Andrea C Postier
- Division of Pediatric Pain, Palliative and Integrative Medicine, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, California
- Stad Center for Pediatric Pain, Palliative and Integrative Medicine, University of California San Francisco Benioff Children's Hospitals, Oakland and San Francisco, California
| | - Maggie C Root
- School of Nursing, Vanderbilt University, Nashville, Tennessee
| | - David L O'Riordan
- Division of Palliative Medicine, University of California San Francisco, San Francisco, California
| | - Lisa Purser
- Stad Center for Pediatric Pain, Palliative and Integrative Medicine, University of California San Francisco Benioff Children's Hospitals, Oakland and San Francisco, California
| | - Stefan J Friedrichsdorf
- Division of Pediatric Pain, Palliative and Integrative Medicine, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, California
- Stad Center for Pediatric Pain, Palliative and Integrative Medicine, University of California San Francisco Benioff Children's Hospitals, Oakland and San Francisco, California
| | - Steven Z Pantilat
- Division of Palliative Medicine, University of California San Francisco, San Francisco, California
| | - Jori F Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Treuman Katz Center for Pediatric Bioethics and Palliative Care and Resilience Laboratory, Center for Clinical and Translational Research, Seattle Children's Hospital and Research Institute, Seattle, Washington
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Greenmyer JR, Ngo T, Smith M, Collura C, Schiltz B, McCarthy SR. Consultation patterns before and after embedding pediatric palliative care into a pediatric hematology/oncology clinic. Pediatr Blood Cancer 2023; 70:e30663. [PMID: 37710331 DOI: 10.1002/pbc.30663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION Palliative care is a critical component of pediatric oncology care. Embedded pediatric palliative care (PPC) is relatively new in pediatric hematology/oncology (PHO) and may improve access, utilization, and quality of PPC. In June 2020, the Mayo Clinic PPC service transitioned from an afternoon, physically independent clinic to an all-day clinic embedded within PHO. METHODS Retrospective chart review was used to quantify consultation rates from PHO to PPC in 12-month study periods before and after establishment of an embedded clinic. Changes in descriptive statistics and consult patterns were calculated. Study periods were compared using either chi-square or Fisher's exact tests for categorical variables and Wilcox rank sum tests for continuous variables. RESULTS There was an 89% increase in consultations from PHO to PPC after initiation of an embedded clinic (n = 20 vs. n = 38 per 12 months). The absolute number of completed outpatient consults increased from three (15% of visits) pre-embedment to fourteen (37%) post-embedment (p = .082). The median number of days from first oncology visit to PPC assessment was unchanged after embedment (36 vs. 47 days, p = .98). Consults for solid tumors increased from 22% (n = 4) pre-embedment to 60% (n = 18) post-embedment (p < .05). Consults for symptom management increased from 60% (n = 12) to 87% (n = 33) (p < .05). CONCLUSIONS Embedment of PPC into a PHO workspace was associated with an increased number of total consults, outpatient consults, solid tumor consults, and consults for symptom management. Our "partial-PPO" model allowed for provision of PPC in the outpatient oncology setting in a clinic where there is not enough volume to support a full-time oncology-focused clinician team.
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Affiliation(s)
- Jacob R Greenmyer
- Pediatric and Adolescent Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Tiffany Ngo
- Pediatric and Adolescent Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Melissa Smith
- Hospice and Palliative Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Christopher Collura
- Neonatal and Perinatal Medicine, Hospice and Palliative Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Brenda Schiltz
- Hospice and Palliative Medicine, Pediatric Critical Care, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Sarah R McCarthy
- Pediatric and Adolescent Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
- Psychiatry and Psychology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
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Keim-Malpass J, Lunsford C, Letzkus LC, Scheer E, Valdez RS. Establishing the Need for Anticipatory Symptom Guidance and Networked Models of Disease in Adaptive Family Management Among Children With Medical Complexity: Qualitative Study. JMIR Form Res 2023; 7:e52454. [PMID: 37801346 PMCID: PMC10704321 DOI: 10.2196/52454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Caregivers of children with medical complexity navigate complex family management tasks for their child both in the hospital and home-based setting. The roles and relationships of members of their social network and the dynamic evolution of these family management tasks have been underexamined. OBJECTIVE The purpose of this study was to explore the structures and processes of family management among caregivers of children with medical complexity, with a focus on the underlying dynamic nature of family management practices and the role of members of their social network. METHODS This study used a qualitative approach to interview caregivers of children with medical complexity and members of their social network. Caregivers of children with medical complexity were recruited through an academic Children's Hospital Complex Care Clinic in the mid-Atlantic region and interviewed over a period of 1 to 3 days. Responses were analyzed using constructivist grounded theory and situational analysis to construct a new conceptual model. Only caregiver responses are reported here. RESULTS In total, 20 caregivers were included in this analysis. Caregiver perspectives revealed the contextual processes that allowed for practices of family management within the setting of rapidly evolving symptoms and health concerns. The dynamic and adaptive nature of this process is a key underlying action supporting this novel conceptual model. The central themes underpinning the adaptive family management model include symptom cues, ongoing surveillance, information gathering, and acute on chronic health concerns. The model also highlights facilitators and threats to successful family management among children with medical complexity and the networked relationship among the structures and processes. CONCLUSIONS The adaptive family management model provides a basis for further quantitative operationalization and study. Previously described self- or family management frameworks do not account for the underlying dynamic nature of the disease trajectory and the developmental stage progression of the child or adolescent, and our work extends existing work. For future work, there is a defined role for technology-enhanced personalized approaches to home-based monitoring. Due to the disparities caregivers and the children in this population already experience, technology-enhanced approaches must be built alongside key stakeholders with an equity orientation to technology co-development. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/14810.
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Affiliation(s)
- Jessica Keim-Malpass
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Christopher Lunsford
- Department of Physical Medicine and Rehabilitation, Duke University School of Medicine, Durham, NC, United States
| | - Lisa C Letzkus
- Division of Developmental Pediatrics, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Eleanore Scheer
- Department of Systems and Information Engineering, University of Virginia School of Engineering and Applied Sciences, Charlottesville, VA, United States
| | - Rupa S Valdez
- Department of Systems and Information Engineering, University of Virginia School of Engineering and Applied Sciences, Charlottesville, VA, United States
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States
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Holmen H, Winger A, Steindal SA, Riiser K, Castor C, Kvarme LG, Mariussen KL, Lee A. Patient-reported outcome measures in children, adolescents, and young adults with palliative care needs-a scoping review. BMC Palliat Care 2023; 22:148. [PMID: 37798706 PMCID: PMC10557323 DOI: 10.1186/s12904-023-01271-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/27/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Measuring outcomes facilitates evaluation of palliative services for children, adolescents, and young adults (CAYAs) with life-limiting and/or life-threatening (LL/LT) conditions. Implementation of patient-reported, proxy-reported, or patient-centered outcome measures (hereafter PROMs) is recommended to ensure palliative services. The purpose of this scoping review was to provide an overview of PROMs relevant for CAYAs living with LL/LT conditions eligible for pediatric palliative care (PPC). METHODS Arksey and O'Malley's 6-stage scoping review framework was used to guide the review. The identified citations had to report on PROMs in any context including CAYAs with LL/LT conditions up to 25 years of age. A systematic search of Medline, EMBASE, CINAHL, APA PsycInfo, Health and Psychosocial Instruments, and AMED took place in January 2021 and was updated in June 2022. Citations were screened independently by pairs of researchers. The scoping review protocol was registered, and peer-review published. RESULTS Of 3690 identified citations, 98 reports were included, of which the majority were from Western countries and about PROMs in CAYAs living with cancer or organ failure. A total of 80 PROMs were identified, assessing a range of phenomena, where quality of life and symptoms (especially pain) during the stage of ongoing care were the most frequent. There were only a few reports about outcome measures at time of diagnosis or in end-of-life care. CAYAs self-reported on the PROMs or collaborated with their parents in about half of the reports, while the remaining had proxies answering on behalf of the CAYAs. In the identified reports, PROMs were used to characterize a sample through cross-sectional or longitudinal research, and less often to assess effects of interventions. CONCLUSION The identified PROMs in the CAYA population eligible for PPC is characterized by studies in high-income countries during ongoing care, primarily in patients with cancer or organ failure. More research is needed in patients living with other LL/LT conditions, and during different stages of the disease course, especially at time of diagnosis, during transition to adulthood, and in end-of-life care. This scoping review of PROMs relevant for young patients eligible for PPC may inform future research about patient-/proxy-reported or patient-centered outcome measures in PPC. TRIAL REGISTRATION Review registration: ( https://osf.io/yfch2/ ) and published protocol (Holmen et al. Syst Rev. 10:237, 2021).
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Affiliation(s)
- Heidi Holmen
- Department of Nursing and Health Promotion, Oslo Metropolitan University, St. Olavs Place, Post Box 4, 0130, Oslo, Norway.
| | - Anette Winger
- Department of Nursing and Health Promotion, Oslo Metropolitan University, St. Olavs Place, Post Box 4, 0130, Oslo, Norway
| | - Simen A Steindal
- Lovisenberg Diaconal University College, Lovisenberggt, 15B, 0456, Oslo, Norway
- Faculty of Health Studies, VID Specialized University, Oslo, Norway
| | - Kirsti Riiser
- Department of Rehabilitation Science and Health Technology, Oslo Metropolitan University, St. Olavs Place, Post Box 4, 0130, Oslo, Norway
| | - Charlotte Castor
- Department of Health Sciences, Lund University, Box 157, 221 00, Lund, Sweden
| | - Lisbeth Gravdal Kvarme
- Department of Nursing and Health Promotion, Oslo Metropolitan University, St. Olavs Place, Post Box 4, 0130, Oslo, Norway
| | - Kari L Mariussen
- Lovisenberg Diaconal University College, Lovisenberggt, 15B, 0456, Oslo, Norway
| | - Anja Lee
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital HF, Nydalen, Box 4950, 0424, Oslo, Norway
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Feudtner C, Beight LJ, Boyden JY, Hill DL, Hinds PS, Johnston EE, Friebert SE, Bogetz JF, Kang TI, Hall M, Nye RT, Wolfe J. Goals of Care Among Parents of Children Receiving Palliative Care. JAMA Pediatr 2023; 177:800-807. [PMID: 37306979 PMCID: PMC10262061 DOI: 10.1001/jamapediatrics.2023.1602] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/15/2023] [Indexed: 06/13/2023]
Abstract
Importance While knowing the goals of care (GOCs) for children receiving pediatric palliative care (PPC) are crucial for guiding the care they receive, how parents prioritize these goals and how their priorities may change over time is not known. Objective To determine parental prioritization of GOCs and patterns of change over time for parents of children receiving palliative care. Design, Setting, and Participants A Pediatric Palliative Care Research Network's Shared Data and Research cohort study with data collected at 0, 2, 6, 12, 18, and 24 months in hospital, outpatient, or home settings from April 10, 2017, to February 15, 2022, at 7 PPC programs based at children's hospitals across the US. Participants included parents of patients, birth to 30 years of age, who received PPC services. Exposures Analyses were adjusted for demographic characteristics, number of complex chronic conditions, and time enrolled in PPC. Main Outcomes Parents' importance scores, as measured using a discrete choice experiment, of 5 preselected GOCs: seeking quality of life (QOL), health, comfort, disease modification, or life extension. Importance scores for the 5 GOCs summed to 100. Results A total of 680 parents of 603 patients reported on GOCs. Median patient age was 4.4 (IQR, 0.8-13.2) years and 320 patients were male (53.1%). At baseline, parents scored QOL as the most important goal (mean score, 31.5 [SD, 8.4]), followed by health (26.3 [SD, 7.5]), comfort (22.4 [SD, 11.7]), disease modification (10.9 [SD, 9.2]), and life extension (8.9 [SD, 9.9]). Importantly, parents varied substantially in their baseline scores for each goal (IQRs more than 9.4), but across patients in different complex chronic conditions categories, the mean scores varied only slightly (means differ 8.7 or less). For each additional study month since PPC initiation, QOL was scored higher by 0.06 (95% CI, 0.04-0.08) and comfort scored higher by 0.3 (95% CI, 0-0.06), while the importance score for life extension decreased by 0.07 (95% CI, 0.04-0.09) and disease modification by 0.02 (95% CI, 0-0.04); health scores did not significantly differ from PPC initiation. Conclusions and Relevance Parents of children receiving PPC placed the highest value on QOL, but with considerable individual-level variation and substantial change over time. These findings emphasize the importance of reassessing GOCs with parents to guide appropriate clinical intervention.
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Affiliation(s)
- Chris Feudtner
- Justin Ingerman Center for Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Leah J. Beight
- Doctor of Medicine Program, Georgetown University School of Medicine, Washington, DC
| | - Jackelyn Y. Boyden
- Justin Ingerman Center for Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia
| | - Douglas L. Hill
- Justin Ingerman Center for Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pamela S. Hinds
- Children’s National Hospital, Department of Nursing Science, Professional Practice & Quality, Department of Pediatrics, the George Washington University, Washington, DC
| | - Emily E. Johnston
- Department of Pediatrics, Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham
| | - Sarah E. Friebert
- Department of Pediatrics, Division of Palliative Care, Akron Children’s Hospital and Rebecca D. Considine Research Institute, Akron, Ohio
| | - Jori F. Bogetz
- Department of Pediatrics, Division of Bioethics and Palliative Care, University of Washington School of Medicine, Seattle
| | - Tammy I. Kang
- Department of Pediatrics, Section of Palliative Care, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Russell T. Nye
- Justin Ingerman Center for Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute and Department of Pediatrics Boston Children’s Hospital, Boston, Massachusetts
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Siddiqui MF, Nohra L, Saleh M, Thakkar K, Trivedi R, Moujally SN, Deeb H, Nicolas G, Emmanuel N. Pediatric Oncology, Palliative Care and Low- or Middle- Income Countries: A Call for Action. Glob Pediatr Health 2023; 10:2333794X231188591. [PMID: 37492651 PMCID: PMC10363861 DOI: 10.1177/2333794x231188591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 07/27/2023] Open
Abstract
Pediatric oncology, which includes cancer screening and therapy in children, poses significant challenges in low- and middle-income countries (LMICs). Palliative care improves children's and their families' quality of life. In LMICs, palliative care resources are scarce, resulting in poor symptom management, psychological support, and spiritual care. All relevant English-language articles on pediatric palliative oncology were searched in PubMed, Google Scholar, Scopus, and Medline databases using the following keywords: "Pediatric Oncology," "Pediatric Palliative Oncology," "Pediatric Palliative Care," "Palliative Care," "Child Cancer," and "Lower- and Middle-Income Countries." This study highlights the significance of incorporating palliative care early in therapy and the recommendations may improve the competence of information provided by medical professionals to patients and families. LMICs have the potential to improve overall treatment and outcomes for child cancer patients and their families by prioritizing the integration of palliative care, guaranteeing a compassionate and dignified attitude toward the disease.
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Affiliation(s)
| | - Lea Nohra
- Faculty of Medical Science, Lebanese University, Beirut, Lebanon
| | - Mustafa Saleh
- Faculty of Medical Science, Lebanese University, Beirut, Lebanon
| | - Keval Thakkar
- Medstar Georgetown University Hospital, Washington, DC, USA
| | - Rishika Trivedi
- Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
| | | | - Hadeel Deeb
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Gregory Nicolas
- Hospital das Clinicas of the Faculty of Medicine of the University of Sao Paulo, Sao Paulo, Brazil
| | - Nancy Emmanuel
- Hospital das Clinicas of the Faculty of Medicine of the University of Sao Paulo, Sao Paulo, Brazil
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Taam B, Lim F. Best Practices in Pediatric Oncology Pain Management. Am J Nurs 2023; 123:52-58. [PMID: 37077020 DOI: 10.1097/01.naj.0000933948.84251.f3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
ABSTRACT Pediatric oncology patients are vulnerable to pain that may be caused by the disease or its treatment, and this symptom can be challenging to manage. This article focuses on the importance of pain control, pain assessment and treatment, and special considerations in pediatric oncology pain management, including preparing children for painful procedures and the family's role in managing pain.
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Affiliation(s)
- Brittany Taam
- Brittany Taam is a pediatric hematology/oncology clinical nurse at Stanford Medicine Children's Health in Palo Alto, CA. At the time of this writing, she was a pediatric clinical nurse at Memorial Sloan Kettering Cancer Center in New York City. Fidelindo Lim is a clinical associate professor at New York University's Rory Meyers College of Nursing in New York City. Contact author: Brittany Taam, . The authors have disclosed no potential conflicts of interest, financial or otherwise
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Ananth P, Lindsay M, Mun S, McCollum S, Shabanova V, de Oliveira S, Pitafi S, Kirch R, Ma X, Gross CP, Boyden JY, Feudtner C, Wolfe J. Parent Priorities in End-of-Life Care for Children With Cancer. JAMA Netw Open 2023; 6:e2313503. [PMID: 37184834 PMCID: PMC10878399 DOI: 10.1001/jamanetworkopen.2023.13503] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Importance Robust quality measures to benchmark end-of-life care for children with cancer do not currently exist; 28 candidate patient-centered quality measures were previously developed. Objective To prioritize quality measures among parents who lost a child to cancer. Design, Setting, and Participants This survey study was conducted using an electronic, cross-sectional discrete choice experiment (DCE) with maximum difference scaling from January to June 2021 in the US. In each of 21 questions in the DCE, participants were presented with a set of 4 quality measures and were asked to select the most and least important measures within each set. All 28 quality measures were presented an equal number of times in different permutations. In the volunteer sample, 69 eligible bereaved parents enrolled in the study; 61 parents completed the DCE (participation rate, 88.4%). Main Outcomes and Measures Using choices participants made, a hierarchical bayesian multinomial logistic regression was fit to derive mean importance scores with 95% credible intervals (95% Crs) for each quality measure, representing the overall probability of a quality measure being selected as most important. Importance scores were rescaled proportionally from 0 to 100, with the sum of scores for all quality measures adding up to 100. This enabled interpretation of scores as the relative importance of quality measures. Results Participants included 61 bereaved parents (median [range] age, 48 [24-74] years; 55 individuals self-identified as women [90.2%]; 1 American Indian or Alaska Native [1.6%], 1 Asian [1.6%], 2 Black or African American [3.3%], 1 Native Hawaiian or Pacific Islander, and 58 White [91.8%]; 58 not Hispanic or Latinx [95.1%]). Highest-priority quality measures by mean importance score included having a child's symptoms treated well (9.25 [95% Cr, 9.06-9.45]), feeling that a child's needs were heard by the health care team (8.39 [95% Cr, 8.05-8.73]), and having a goal-concordant end-of-life experience (7.45 [95% Cr, 6.84-8.05]). Lowest-priority quality measures included avoiding chemotherapy (0.33 [95% Cr, 0.21-0.45]), provision of psychosocial support for parents (1.01 [95% Cr, 0.57-1.45]), and avoiding the intensive care unit (1.09 [95% Cr, 0.74-1.43]). Rank-ordering measures by mean importance revealed that symptom management was 9 times more important to parents than psychosocial support for themselves. Conclusions and Relevance This study found that bereaved parents prioritized end-of-life quality measures focused on symptom management and goal-concordant care while characterizing quality measures assessing their own psychosocial support and their child's hospital resource use as substantially less important. These findings suggest that future research should explore innovative strategies to measure care attributes that matter most to families of children with advanced cancer.
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Affiliation(s)
- Prasanna Ananth
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Yale Cancer Outcomes, Public Policy and Effectiveness Research Center, New Haven, Connecticut
| | - Meghan Lindsay
- Yale Cancer Outcomes, Public Policy and Effectiveness Research Center, New Haven, Connecticut
| | - Sophia Mun
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Sarah McCollum
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Veronika Shabanova
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | | | - Sarah Pitafi
- University College London, London, United Kingdom
| | - Rebecca Kirch
- National Patient Advocate Foundation, Washington, District of Columbia
| | - Xiaomei Ma
- Yale Cancer Outcomes, Public Policy and Effectiveness Research Center, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Cary P Gross
- Yale Cancer Outcomes, Public Policy and Effectiveness Research Center, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jackelyn Y Boyden
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia
- Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Departments of Pediatrics, Medical Ethics, and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joanne Wolfe
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston
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11
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Hammer NM, Bidstrup PE, Brok J, Devantier M, Sjøgren P, Schmiegelow K, Larsen A, Kurita GP, Olsen M, Larsen HB. Home-Based Specialized Pediatric Palliative Care: A Systematic Review and Meta-Analysis. J Pain Symptom Manage 2023; 65:e353-e368. [PMID: 36621694 DOI: 10.1016/j.jpainsymman.2022.12.139] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/05/2022] [Accepted: 12/17/2022] [Indexed: 01/07/2023]
Abstract
CONTEXT Although specialized pediatric palliative care (SPPC) teams increasingly provide home-based care, the evidence of its impact has not yet been systematically evaluated. OBJECTIVES To examine the impact of home-based SPPC in children and adolescents with life-limiting conditions, regarding place of death, quality of life and symptom burden. METHODS We searched Medline, EMBASE, CINAHL, PsycINFO, the Cochrane Central Register of Controlled Trials, Web of Science and Scopus for studies comparing children and adolescents with life-limiting conditions receiving home-based SPPC with children and adolescents not receiving home-based SPPC, or studies reporting before-and-after measurements. We included studies that reported on place of death, quality of life and/or symptoms. Two authors independently screened the articles, extracted data, and assessed quality. Results were synthesized as a systematic narrative synthesis and meta-analysis, using a random-effects model. RESULTS We included five studies, which reported on 392 children and adolescents. Meta-analysis showed that receiving home-based SPPC was associated with a more than fourfold increased likelihood of home death (risk ratio 4.64, 95% confidence interval 3.06-7.04; 3 studies; n=296). Most studies reported improved quality of life and reduced symptom burden. The included studies were of low to moderate quality with a high risk of bias. CONCLUSION This systematic review suggests that home-based SPPC is associated with increased likelihood of home death, and might be associated with improved quality of life and reduced symptom burden. The small number of studies and an overall high risk of bias, however, makes the overall strength of evidence low.
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Affiliation(s)
- Nanna Maria Hammer
- Copenhagen Palliative Team for Children and Adolescents, Department of Paediatrics and Adolescent Medicine (N.M.H., M.D., M.O.), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Paediatric Oncology Research Laboratory, Department of Paediatrics and Adolescent Medicine (N.M.H., M.D., K.S., M.O., H.B.L.), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences (N.M.H., M.D., K.S., G.P.K., H.B.L.), University of Copenhagen, Copenhagen, Denmark
| | - Pernille Envold Bidstrup
- Psychological aspects of Cancer, Danish Cancer Society Research Center (P.E.B.), Copenhagen, Denmark; Institute of Psychology (P.E.B.), University of Copenhagen, Copenhagen, Denmark
| | - Jesper Brok
- Department of Paediatric Oncology and Haematology, Department of Paediatrics and Adolescent Medicine (J.B.), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Minna Devantier
- Copenhagen Palliative Team for Children and Adolescents, Department of Paediatrics and Adolescent Medicine (N.M.H., M.D., M.O.), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Paediatric Oncology Research Laboratory, Department of Paediatrics and Adolescent Medicine (N.M.H., M.D., K.S., M.O., H.B.L.), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences (N.M.H., M.D., K.S., G.P.K., H.B.L.), University of Copenhagen, Copenhagen, Denmark
| | - Per Sjøgren
- Section of Palliative Medicine, Department of Oncology (P.S., G.P.K.), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Paediatric Oncology Research Laboratory, Department of Paediatrics and Adolescent Medicine (N.M.H., M.D., K.S., M.O., H.B.L.), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences (N.M.H., M.D., K.S., G.P.K., H.B.L.), University of Copenhagen, Copenhagen, Denmark
| | - Anders Larsen
- The University Hospitals' Centre for Health Research (A.L.), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Geana Paula Kurita
- Department of Clinical Medicine, Faculty of Health and Medical Sciences (N.M.H., M.D., K.S., G.P.K., H.B.L.), University of Copenhagen, Copenhagen, Denmark; Section of Palliative Medicine, Department of Oncology (P.S., G.P.K.), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Multidisciplinary Pain Centre, Department of Anaesthesiology, Pain and Respiratory Support (G.P.K.), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Marianne Olsen
- Copenhagen Palliative Team for Children and Adolescents, Department of Paediatrics and Adolescent Medicine (N.M.H., M.D., M.O.), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Paediatric Oncology Research Laboratory, Department of Paediatrics and Adolescent Medicine (N.M.H., M.D., K.S., M.O., H.B.L.), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Pediatrics and Adolescent Medicine (M.O.), Section of Pediatric Hematology and Oncology, Aalborg University Hospital, Aalborg, Denmark.
| | - Hanne Bækgaard Larsen
- Paediatric Oncology Research Laboratory, Department of Paediatrics and Adolescent Medicine (N.M.H., M.D., K.S., M.O., H.B.L.), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences (N.M.H., M.D., K.S., G.P.K., H.B.L.), University of Copenhagen, Copenhagen, Denmark
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12
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Kubek LA, Claus B, Rostasy K, Bertolini A, Schimmel M, Frühwald MC, Classen G, Zernikow B, Wager J. Development and preliminary validation of the Sleep Screening for Children and Adolescents with Complex Chronic Conditions (SCAC). J Sleep Res 2023:e13881. [PMID: 36929532 DOI: 10.1111/jsr.13881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/18/2023]
Abstract
Children and adolescents with complex chronic conditions, including those with life-threatening or life-limiting conditions, are a heterogeneous population. Many individuals exhibit sleep abnormalities that are measurable by proxy questionnaires. No suitable instrument to assess the wide range of different complex chronic conditions is currently available. The aim of the present study was to develop a screening tool-the Sleep Screening for Children and Adolescents with Complex Chronic Conditions-to effectively obtain sleep behaviour information in this population. Following a mixed-method design, potential items for the Sleep Screening for Children and Adolescents with Complex Chronic Conditions questionnaire were defined through literature research and expert meetings. In a pre-test with N = 60 family and professional caregivers, the items' relevance and comprehensibility as well as the instrument's overall design were assessed. For the main test, N = 315 participants were recruited in three tertiary paediatric hospitals. A principal components analysis detected the questionnaire's scales. Item analysis focused on mean values, range, difficulty and discriminatory power. Convergent validation of the Sleep Screening for Children and Adolescents with Complex Chronic Conditions was assessed via correlations between scale items. Most patients had neurological or neuromuscular diseases. Four scales ("Falling and staying asleep", "Sleep-associated respiration and arousal", "Daytime sleepiness" and "Sleep-associated movements") emerged. The item analysis showed satisfactory discriminative power. In the preliminary validation, all scales correlated positively with a child's care level and with various sleep circumstances items. Three scales additionally correlated with the number of complex chronic condition diagnoses. This newly developed questionnaire can provide clinicians with first indications of possible sleep problems in a growing paediatric population.
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Affiliation(s)
- Larissa Alice Kubek
- PedScience Research Institute, Datteln, Germany.,Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Benedikt Claus
- PedScience Research Institute, Datteln, Germany.,Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, Datteln, Germany
| | - Kevin Rostasy
- Department of Pediatric Neurology, Children's and Adolescents' Hospital Datteln, Witten/Herdecke University, Witten, Germany
| | - Annikki Bertolini
- Department of Pediatric Neurology, Children's and Adolescents' Hospital Datteln, Witten/Herdecke University, Witten, Germany
| | - Mareike Schimmel
- Pediatric Neurology, University Medical Center Augsburg, Augsburg, Germany
| | - Michael C Frühwald
- Pediatrics and Adolescent Medicine, University Medical Center Augsburg, Augsburg, Germany
| | - Georg Classen
- Department of Pediatric Neurology, Bethel Evangelical Hospital, Bielefeld, Germany
| | - Boris Zernikow
- PedScience Research Institute, Datteln, Germany.,Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany.,Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, Datteln, Germany
| | - Julia Wager
- PedScience Research Institute, Datteln, Germany.,Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany.,Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, Datteln, Germany
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13
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Ellis DI, Nye RT, Wolfe J, Feudtner C. Surgical Intervention in Patients Receiving Pediatric Palliative Care Services. Pediatrics 2023; 151:e2022058905. [PMID: 36606343 PMCID: PMC9890391 DOI: 10.1542/peds.2022-058905] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Many patients receiving pediatric palliative care (PPC) present with surgically treatable problems. The role of surgery in the care of these patients, however, has not yet been defined. We conducted a cohort study of children receiving PPC to assess the incidence, type, and likely purpose of surgical interventions performed after the initiation of PPC. METHODS We performed a cohort analysis of surgical interventions performed on children enrolled in an ongoing, multicenter, prospective cohort study. Patients aged <30 years receiving PPC services were eligible for inclusion in the study. Analyses included descriptive and comparative statistics, as well as logistic regression models. RESULTS After initiation of PPC, 81.1% (n = 488) of patients had undergone at least 1 surgical intervention (range, 1-71) with a median of 4 interventions (interquartile range, 1-9). The most frequent surgical interventions were feeding tubes, endoscopic biopsy, tracheostomy, bone marrow biopsy, tunneled catheters, bronchoscopy, and chest tube placement, followed by sternum closure, abdominal closure, atrial and ventricular septal defect repairs, and heart transplantation. Children who underwent surgical interventions were statistically less likely to die while receiving PPC (29% vs 40%, P < .03). CONCLUSIONS Most children receiving PPC services undergo at least 1 surgical intervention, and many undergo numerous interventions. Undergoing intervention is not futile because surgical intervention is associated with longer survival. Various patient populations that are more likely, as well as less likely, to undergo surgical intervention warrant specific focus.
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Affiliation(s)
| | - Russell T. Nye
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute
- Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chris Feudtner
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Pediatric Advanced Care Team and Department of Medical Ethics, Children’s Hospital of Philadelphia, the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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14
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Blume ED, Kirsch R, Cousino MK, Walter JK, Steiner JM, Miller TA, Machado D, Peyton C, Bacha E, Morell E. Palliative Care Across the Life Span for Children With Heart Disease: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2023; 16:e000114. [PMID: 36633003 PMCID: PMC10472747 DOI: 10.1161/hcq.0000000000000114] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
AIM This summary from the American Heart Association provides guidance for the provision of primary and subspecialty palliative care in pediatric congenital and acquired heart disease. METHODS A comprehensive literature search was conducted from January 2010 to December 2021. Seminal articles published before January 2010 were also included in the review. Human subject studies and systematic reviews published in English in PubMed, ClinicalTrials.gov, and the Cochrane Collaboration were included. Structure: Although survival for pediatric congenital and acquired heart disease has tremendously improved in recent decades, morbidity and mortality risks remain for a subset of young people with heart disease, necessitating a role for palliative care. This scientific statement provides an evidence-based approach to the provision of primary and specialty palliative care for children with heart disease. Primary and specialty palliative care specific to pediatric heart disease is defined, and triggers for palliative care are outlined. Palliative care training in pediatric cardiology; diversity, equity, and inclusion considerations; and future research directions are discussed.
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15
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Kubek LA, Kutz P, Roll C, Zernikow B, Wager J. Applicability of Actigraphy for Assessing Sleep Behaviour in Children with Palliative Care Needs Benchmarked against the Gold Standard Polysomnography. J Clin Med 2022; 11:jcm11237107. [PMID: 36498681 PMCID: PMC9739292 DOI: 10.3390/jcm11237107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/18/2022] [Accepted: 11/29/2022] [Indexed: 12/02/2022] Open
Abstract
In children with life-limiting conditions and severe neurological impairment receiving pediatric palliative care (PPC), the degree to which actigraphy generates meaningful sleep data is uncertain. Benchmarked against the gold standard polysomnography (PSG), the applicability of actigraphy in this complex population was to be assessed. An actigraph was placed on N = 8 PPC patients during one-night polysomnography measurement in a pediatric tertiary care hospital's sleep laboratory. Patient characteristics, sleep phase data, and respiratory abnormalities are presented descriptively. Bland-Altman plots evaluated actigraphy's validity regarding sleep onset, sleep offset, wake after sleep onset (WASO), number of wake phases, total sleep time (TST) and sleep efficiency compared to PSG. PSG revealed that children spent most of their time in sleep stage 2 (46.6%) and most frequently showed central apnea (28.7%) and irregular hypopnea (14.5%). Bland-Altman plots showed that actigraphy and PSG gave similar findings for sleep onset, sleep offset, wake after sleep onset (WASO), total sleep time (TST) and sleep efficiency. Actigraphy slightly overestimated TST and sleep efficiency while underestimating all other parameters. Generally, the Actiwatch 2 low and medium sensitivity levels showed the best approximation to the PSG values. Actigraphy seems to be a promising method for detecting sleep problems in severely ill children.
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Affiliation(s)
- Larissa Alice Kubek
- PedScience Research Institute, 45711 Datteln, Germany
- Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58455 Witten, Germany
| | - Patrizia Kutz
- Department of Neonatology, Pediatric Intensive Care and Sleep Medicine, Children's and Adolescents' Hospital, Witten/Herdecke University, 45711 Datteln, Germany
| | - Claudia Roll
- Department of Neonatology, Pediatric Intensive Care and Sleep Medicine, Children's and Adolescents' Hospital, Witten/Herdecke University, 45711 Datteln, Germany
| | - Boris Zernikow
- PedScience Research Institute, 45711 Datteln, Germany
- Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58455 Witten, Germany
- Palliative Care Centre, Children's and Adolescents' Hospital, 45711 Datteln, Germany
| | - Julia Wager
- PedScience Research Institute, 45711 Datteln, Germany
- Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58455 Witten, Germany
- Palliative Care Centre, Children's and Adolescents' Hospital, 45711 Datteln, Germany
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16
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Broden EG, Hinds PS, Werner-Lin AV, Curley MAQ. "I Didn't Want My Baby to Pass, But I Didn't Want Him Suffering Either": Comparing Bereaved Parents' Narratives With Nursing End-of-Life Assessments in the Pediatric Intensive Care Unit. J Hosp Palliat Nurs 2022; 24:271-280. [PMID: 35666188 PMCID: PMC9437116 DOI: 10.1097/njh.0000000000000884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Little is known about how nursing care at the end of a child's life impacts long-term parental bereavement. We aimed to explain, contextualize, and examine comparisons between quantitative trends in children's end-of-life care and parents' qualitative perceptions. We used a mixed methods design, combining quantitative data from the RESTORE clinical trial with qualitative interviews with bereaved parents. Patients who died during RESTORE were included in quantitative analyses. A subset of their parents was interviewed 7 to 11 years later. The quantitative analyses included 104 children. Eight parents were interviewed; 4 had a child die after cancer, and 4 had a child die after a complex chronic illness. Quantitatively, patients' pain and sedation scores were generally comfortable. Children died with multiple invasive devices in place. Parents' descriptions of their child's comfort and critical care requirements differed by illness trajectory (cancer, complex chronic illness). Parents' memories of their child's suffering aligned with peaks in clinical scores, rather than averages. Invasive devices and equipment altered parents' ability to make meaningful final memories with the dying child. Pediatric intensive care clinicians may need to broaden how they attend to dying children's pain and corresponding parental distress, as parents' memories of their dying child's suffering persist for years.
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17
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Ananth P, Lindsay M, Nye R, Mun S, Feudtner C, Wolfe J. End-of-life care quality for children with cancer who receive palliative care. Pediatr Blood Cancer 2022; 69:e29841. [PMID: 35686746 PMCID: PMC10498672 DOI: 10.1002/pbc.29841] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND We previously developed stakeholder-informed quality measures to assess end-of-life care quality for children with cancer. We sought to implement a subset of these quality measures in the multi-center pediatric palliative care (PPC) database. PROCEDURES We utilized the Shared Data and Research database to evaluate the proportion of childhood cancer decedents from 2017-2021 who, in the last 30 days of life, avoided chemotherapy, mechanical ventilation, intensive care unit admissions, and > 1 hospital admission; were enrolled in hospice services, and reported ≤ 2 highly distressing symptoms. We then explored patient factors associated with the attainment of quality benchmarks. RESULTS Across 79 decedents, 82% met ≥ 4 quality benchmarks. Most (76%) reported > 2 highly distressing symptoms; 17% were enrolled in hospice. In univariable analyses, patients with an annual household income ≤$50,000 had lower odds of hospice enrollment and avoidance of mechanical ventilation or intensive care unit admissions near end of life (odds ratio [OR] 0.10 [95% confidence interval (C.I.) 0.01, 0.86], p = 0.04; OR 0.13 [0.02, 0.64], p = 0.01; OR 0.36 [0.13, 0.98], p = 0.04, respectively). In multivariable analyses, patients with an income ≤$50,000 remained less likely to enroll in hospice, after adjusting for cancer type (OR 0.10 [0.01, 0.87]; p = 0.04). CONCLUSIONS Childhood cancer decedents who received PPC met a large proportion of quality measures near the end of their life. Yet, many reported highly distressing symptoms. Moreover, patients with lower household incomes appeared less likely to enroll in hospice and more likely to receive intensive hospital services near the end of life. This study identifies opportunities for palliative oncology quality improvement.
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Affiliation(s)
- Prasanna Ananth
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, Connecticut, USA
| | - Meghan Lindsay
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Russell Nye
- Justin Michael Ingerman Center for Palliative Care, Children’s Hospital of Philadelphia; Departments of Pediatrics, Medical Ethics, and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sophia Mun
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Chris Feudtner
- Justin Michael Ingerman Center for Palliative Care, Children’s Hospital of Philadelphia; Departments of Pediatrics, Medical Ethics, and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute; Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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18
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Fraser LK, Gibson-Smith D, Jarvis S, Papworth A, Neefjes V, Hills M, Doran T, Taylor J. Polypharmacy in Children and Young People With Life-limiting Conditions From 2000 to 2015: A Repeated Cross-sectional Study in England. J Pain Symptom Manage 2022; 64:213-221.e1. [PMID: 35675847 DOI: 10.1016/j.jpainsymman.2022.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/06/2022] [Accepted: 05/31/2022] [Indexed: 11/20/2022]
Abstract
CONTEXT Polypharmacy is often appropriate for children with life-limiting conditions but is associated with an increase in hospitalizations and inappropriate prescribing, and can affect the quality of life of children and their families as they manage complex medication schedules. Despite this, little is known about polypharmacy in this population. OBJECTIVE To describe the prevalence and patterns of polypharmacy in children with a life-limiting condition in a nationally representative cohort in England. METHODS Observational study of children (age 0-19 years) with a life-limiting condition in a national database from 2000 to 2015. Common definitions of polypharmacy were used to determine polypharmacy prevalence in each year based on unique medications and regular medications. Hierarchical regression analyses were used to explore factors associated with polypharmacy. RESULTS Data on 15,829 individuals were included. Each year 27%-39% of children were prescribed ≥5 unique medications and 8%-12% were prescribed ≥10. Children with a respiratory (OR 7.6, 95%CI 6.4-9.0), neurological (OR 2.8, 95%CI 2.4-3.2), or metabolic (OR 2.2, 95%CI 1.7-2.8) condition were more likely than those with a congenital condition to experience polypharmacy. Increasing age, being diagnosed with a LLC under one year of age, having >1 life-limiting or chronic condition or living in areas of higher deprivation were also associated with higher prevalence of polypharmacy. CONCLUSION Children with life-limiting conditions have a high prevalence of polypharmacy and some children are at greater risk than others. More research is needed to understand and address the factors that lead to problematic polypharmacy in this population.
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Affiliation(s)
- Lorna K Fraser
- Department of Health Sciences (L.K.F., D.G-S., S.J. A.P., J.T.), University of York, York, UK; Martin House Research Centre (L.K.F., D.G-S., S.J., A.P., J.T.), University of York, York, UK.
| | - Deborah Gibson-Smith
- Department of Health Sciences (L.K.F., D.G-S., S.J. A.P., J.T.), University of York, York, UK; Martin House Research Centre (L.K.F., D.G-S., S.J., A.P., J.T.), University of York, York, UK
| | - Stuart Jarvis
- Department of Health Sciences (L.K.F., D.G-S., S.J. A.P., J.T.), University of York, York, UK; Martin House Research Centre (L.K.F., D.G-S., S.J., A.P., J.T.), University of York, York, UK
| | - Andrew Papworth
- Department of Health Sciences (L.K.F., D.G-S., S.J. A.P., J.T.), University of York, York, UK; Martin House Research Centre (L.K.F., D.G-S., S.J., A.P., J.T.), University of York, York, UK
| | | | - Michelle Hills
- Martin House Hospice (M.H.), Wetherby, UK; Leeds Teaching Hospitals NHS Trust (M.H.), Leeds, UK
| | - Tim Doran
- University Hospitals of Leicester NHS Trust (V.N., T.D.), UK
| | - Johanna Taylor
- Department of Health Sciences (L.K.F., D.G-S., S.J. A.P., J.T.), University of York, York, UK; Martin House Research Centre (L.K.F., D.G-S., S.J., A.P., J.T.), University of York, York, UK
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19
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Home-Based Care for Children with Serious Illness: Ecological Framework and Research Implications. CHILDREN 2022; 9:children9081115. [PMID: 35892618 PMCID: PMC9330186 DOI: 10.3390/children9081115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/15/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022]
Abstract
Care for U.S. children living with serious illness and their families at home is a complex and patchwork system. Improving home-based care for children and families requires a comprehensive, multilevel approach that accounts for and examines relationships across home environments, communities, and social contexts in which children and families live and receive care. We propose a multilevel conceptual framework, guided by Bronfenbrenner’s ecological model, that conceptualizes the complex system of home-based care into five levels. Levels 1 and 2 contain patient and family characteristics. Level 3 contains factors that influence family health, well-being, and experience with care in the home. Level 4 includes the community, including community groups, schools, and providers. Level 5 includes the broader regional system of care that impacts the care of children and families across communities. Finally, care coordination and care disparities transcend levels, impacting care at each level. A multilevel ecological framework of home-based care for children with serious illness and families can be used in future multilevel research to describe and test hypotheses about aspects of this system of care, as well as to inform interventions across levels to improve patient and family outcomes.
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20
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Nye RT, Hill DL, Carroll KW, Boyden JY, Katcoff H, Griffis H, Campos D, Hall M, Wolfe J, Feudtner C. The Design of a Data Management System for a Multicenter Palliative Care Cohort Study. J Pain Symptom Manage 2022; 64:e53-e60. [PMID: 35339611 PMCID: PMC10484234 DOI: 10.1016/j.jpainsymman.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/10/2022] [Accepted: 03/16/2022] [Indexed: 11/23/2022]
Abstract
CONTEXT Prospective cohort studies of individuals with serious illness and their family members, such as children receiving palliative care and their parents, pose challenges regarding data management. OBJECTIVE To describe the design and lessons learned regarding the data management system for the Pediatric Palliative Care Research Network's Shared Data and Research (SHARE) project, a multicenter prospective cohort study of children receiving pediatric palliative care (PPC) and their parents, and to describe important attributes of this system, with specific considerations for the design of future studies. METHODS The SHARE study consists of 643 PPC patients and up to two of their parents who enrolled from April 2017 to December 2020 at seven children's hospitals across the United States. Data regarding demographics, patient symptoms, goals of care, and other characteristics were collected directly from parents or patients at 6 timepoints over a 24-month follow-up period and stored electronically in a centralized location. Using medical record numbers, primary collected data was linked to administrative hospitalization data containing diagnostic and procedure codes and other data elements. Important attributes of the data infrastructure include linkage of primary and administrative data; centralized availability of multilingual questionnaires; electronic data collection and storage system; time-stamping of instrument completion; and a separate but connected study administrative database used to track enrollment. CONCLUSIONS Investigators planning future multicenter prospective cohort studies can consider attributes of the data infrastructure we describe when designing their data management system.
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Affiliation(s)
- Russell T Nye
- Justin Ingerman Center for Palliative Care (R.T.N., D.L.H., K.W.C., J.Y.B., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Data Science and Biostatistics Unit (R.T.N., H.K., H.G.), Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Douglas L Hill
- Justin Ingerman Center for Palliative Care (R.T.N., D.L.H., K.W.C., J.Y.B., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Division of General Pediatrics (D.L.H., J.Y.B., C.F.), The Children's Hospital of Philadelphia Philadelphia, Pennsylvania, USA
| | - Karen W Carroll
- Justin Ingerman Center for Palliative Care (R.T.N., D.L.H., K.W.C., J.Y.B., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jackelyn Y Boyden
- Justin Ingerman Center for Palliative Care (R.T.N., D.L.H., K.W.C., J.Y.B., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Division of General Pediatrics (D.L.H., J.Y.B., C.F.), The Children's Hospital of Philadelphia Philadelphia, Pennsylvania, USA
| | - Hannah Katcoff
- Data Science and Biostatistics Unit (R.T.N., H.K., H.G.), Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heather Griffis
- Data Science and Biostatistics Unit (R.T.N., H.K., H.G.), Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Diego Campos
- Department of Biomedical and Health Informatics (D.C.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matt Hall
- Children's Hospital Association (M.H.), Lenexa, Kansas, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care (J.W.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Pediatrics, Boston Children's Hospital (J.W.), Boston, Massachusetts, USA
| | - Chris Feudtner
- Justin Ingerman Center for Palliative Care (R.T.N., D.L.H., K.W.C., J.Y.B., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Division of General Pediatrics (D.L.H., J.Y.B., C.F.), The Children's Hospital of Philadelphia Philadelphia, Pennsylvania, USA
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21
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Boyden JY, Hill DL, Nye RT, Bona K, Johnston EE, Hinds P, Friebert S, Kang TI, Hays R, Hall M, Wolfe J, Feudtner C. Pediatric Palliative Care Parents' Distress, Financial Difficulty, and Child Symptoms. J Pain Symptom Manage 2022; 63:271-282. [PMID: 34425212 PMCID: PMC8816828 DOI: 10.1016/j.jpainsymman.2021.08.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 02/03/2023]
Abstract
CONTEXT Parents of patients with a serious illness experience psychological distress, which impacts parents' wellbeing and, potentially, their ability to care for their children. Parent psychological distress may be influenced by children's symptom burden and by families' financial difficulty. OBJECTIVES This study examined the associations among parent psychological distress, parent-reported patient symptoms, and financial difficulty, seeking to determine the relative association of financial difficulty and of patient symptoms to parent psychological distress. METHODS Cross-sectional study of baseline data for 601 parents of 532 pediatric palliative care patients enrolled in a prospective cohort study conducted at seven US children's hospitals. Data included self-reported parent psychological distress and parent report of child's symptoms and family financial difficulty. We used ordinary least squares multiple regressions to examine the association between psychological distress and symptom score, between psychological distress and financial difficulty, and whether the degree of financial difficulty modified the relationship between psychological distress and symptom score. RESULTS The majority of parents were moderately to severely distressed (69%) or severely distressed (17%) and experienced some degree of financial difficulty (65%). While children's symptom scores and family financial difficulty together explained more of the variance in parental psychological distress than either variable alone, parental distress was associated more strongly, and to a larger degree, with financial difficulty than with symptom scores alone. CONCLUSIONS Parent psychological distress was associated with parent-reported patient symptoms and financial difficulty. Future work should examine these relationships longitudinally, and whether interventions to improve symptom management and ameliorate financial difficulties improve parental outcomes.
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Affiliation(s)
- Jackelyn Y Boyden
- Justin Ingerman Center for Palliative Care (J.Y.B., D.L.H., R.T.N., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Douglas L Hill
- Justin Ingerman Center for Palliative Care (J.Y.B., D.L.H., R.T.N., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Russell T Nye
- Justin Ingerman Center for Palliative Care (J.Y.B., D.L.H., R.T.N., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kira Bona
- Department of Pediatric Oncology and Division of Population Sciences (K.B.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School (K.B.), Boston, Massachusetts, USA
| | - Emily E Johnston
- Department of Pediatrics (E.E.J.), Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pamela Hinds
- Children's National Hospital (P.H.), Department of Nursing Science, Professional Practice & Quality, Department of Pediatrics, The George Washington University, Washington, District of Columbia, USA
| | - Sarah Friebert
- Department of Pediatrics( S.F.), Division of Palliative Care, Akron Children's Hospital and Rebecca D. Considine Research Institute, Akron, Ohio, USA
| | - Tammy I Kang
- Department of Pediatrics (T.I.K.), Section of Palliative Care, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Ross Hays
- Department of Pediatrics (R.H.), Division of Bioethics and Palliative Care, University of Washington School of Medicine, Seattle, Washington, USA
| | - Matt Hall
- Children's Hospital Association (M.H.), Lenexa, Kansas, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology (J.W.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Pediatrics (J.W.), Boston Children's Hospital, Boston, Massachusetts, USA
| | - Chris Feudtner
- Justin Ingerman Center for Palliative Care (J.Y.B., D.L.H., R.T.N., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics (C.F.), Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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22
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Achieving child-centred care for children and young people with life-limiting and life-threatening conditions-a qualitative interview study. Eur J Pediatr 2022; 181:3739-3752. [PMID: 35953678 PMCID: PMC9371630 DOI: 10.1007/s00431-022-04566-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/07/2022] [Accepted: 07/13/2022] [Indexed: 11/20/2022]
Abstract
UNLABELLED This study aims to identify the symptoms, concerns, and care priorities of children with life-limiting conditions and their families. A semi-structured qualitative interview study was conducted, seeking perspectives from multiple stakeholders on symptoms, other concerns, and care priorities of children and young people with life limiting and life-threatening conditions and their families. Participants were recruited from six hospitals and three children's hospices in the UK. Verbatim transcripts were analysed using framework analysis. A total of 106 participants were recruited: 26 children (5-17 years), 40 parents (of children 0-17 years), 13 siblings (5-17 years), 15 health and social care professionals, 12 commissioners. Participants described many inter-related symptoms, concerns, and care priorities impacting on all aspects of life. Burdensome symptoms included pain and seizures. Participants spoke of the emotional and social impacts of living with life-limiting conditions, such as being able to see friends, and accessing education and psychological support. Spiritual/existential concerns included the meaning of illness and planning for an uncertain future. Data revealed an overarching theme of pursuing 'normality', described as children's desire to undertake usual childhood activities. Parents need support with practical aspects of care to help realise this desire for normality. CONCLUSION Children with life-limiting conditions and their families experience a wide range of inter-related symptoms, concerns, and care priorities. A holistic, child-centred approach to care is needed, allowing focus on pursuit of normal childhood activities. Improvements in accessibility, co-ordination, and availability of health services are required to achieve this. WHAT IS KNOWN • Existing evidence regarding symptoms, concerns, and care priorities for children with life-limiting conditions is largely limited to proxy-reported data and those with a cancer diagnosis. • Child-centred care provision must be directed by children's perspectives on their priorities for care. WHAT IS NEW • Social and educational activities are more important to children with life-limiting conditions than their medical concerns. • A holistic approach to care is required that extends beyond addressing medical needs, in order to support children with life-limiting conditions to focus on pursuit of normal childhood activities.
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