Helping Parents Make and Survive End of Life Decisions for Their Seriously Ill Child

Palliative Care Needs Assessment for Pediatric Complex Care Providers

CONTEXT

Children with medical complexity (CMC) are often cared for by both complex care and palliative care pediatric teams. No prior research has investigated the relationship between these two disciplines.

OBJECTIVES

The purpose of this article is to investigate challenges that complex care programs face in caring for children with medical complexity (CMC), as well as to explore whether identified challenges could be met through collaboration with pediatric palliative care or additional training for complex care teams.

METHODS

Medical providers who self-identified as providing clinical care to children with medical complexity were asked to complete an online anonymous survey. Subjects were recruited through a Complex Care listerv. Data were analyzed using descriptive statistics.

RESULTS

85 subjects completed the survey, of whom 87.1% (n=74) were physicians, and 12.0% (n=11) were nurse practitioners. Subjects reported several challenges in caring for CMC, including symptom management, establishing goals of care, advance care planning, and coordination of care. A majority of subjects reported benefitting from palliative care consultative assistance in each subject area. Most subjects described their relationship with palliative care as a close partnership with frequent overlap.

CONCLUSIONS

The evolving field of pediatric complex care is associated with an array of challenges in caring for CMC. Many of these challenges include competency areas where palliative care providers receive concerted training. Our research suggests greater palliative care involvement in the CMC population can benefit complex care teams and patients, given the expertise palliative providers can bring to the population and the discipline of complex care.

Broaching goals-of-care conversations in advancing pediatric cancer

Broaching conversations about goals of care can be difficult for clinicians. Presently, the communication strategies used by pediatric oncologists to approach goals of care conversations are not well understood. We recorded disease re-evaluation conversations between pediatric oncologists, patients, and parents, capturing 141 conversations (∼2400 minutes) for 17 patients with advancing illness across the study period. We conducted content analysis to identify strategies for broaching goals-of-care conversations and found five distinct communication approaches, which were not mutually exclusive. Further research is needed to explore patient and family views on best practices for broaching discussions about goals of care.

Decision aids available for parents making end-of-life or palliative care decisions for children: A scoping review

AIM

To identify and assess the quality of decision aids that align the decision, values and information provided for parents making end-of-life or palliative care decisions for children with life-threatening conditions.

METHODS

Six databases and the grey literature were searched in December 2018. Two reviewers independently reviewed database citations, and one reviewed grey literature citations. Citation chaining via Scopus was conducted. Quality was assessed using IPDAS Collaboration Criteria.

RESULTS

After reviewing 18 671 database citations and 10 988 grey literature citations, 18 citations describing 11 decision aids remained. Decision aids targeted premature infants, children requiring airway management, children with cancer and children with scoliosis. Three aids underwent testing beyond initial development. Quality scores averaged 27 of 50 points.

CONCLUSIONS

There are few high-quality decision aids available for use and a lack evidence of widespread clinical use. Additional research is needed to support systematic development and the use of decision aids with families.

Parental Perspectives on Roles in End-of-Life Decision Making in the Pediatric Intensive Care Unit: An Integrative Review

PROBLEM

Little is known about how parents perceive their role or the role of health care providers (HCPs) during end-of-life decision making (EOL DM) in the context of the pediatric intensive care unit (PICU).

ELIGIBILITY CRITERIA

The authors searched CINAHL, PubMed, Ovid Medline, Web of Science, Social Science Database, PsycINFO, and Google scholar for English language studies performed in the United States related to parental perception of parental or HCP roles in EOL DM in the PICU since 2008.

SAMPLE

Eleven studies of parents and health care providers (HCPs) of critically ill children in the PICU and/or receiving inpatient pediatric palliative care, and bereaved parents of PICU patients.

RESULTS

Most parents reported belief that EOL DM is within the domain of parental role, a minority felt it was a physician's responsibility. Parental EOL DM is rooted more firmly in emotion and perception and a desire to be a 'good parent' to a child at EOL in the way they see fit than HCP recommendations or 'medical facts'. Parents need HCPs to treat them as allies, communicate well, and be trustworthy.

CONCLUSIONS

Role conflict may exist between parents and HCPs who are prioritizing different attributes of the parental role. The role of the nurse in support of parental role in the PICU is not well-elucidated in the extant literature.

IMPLICATIONS

Future research should focus on what parents need from HCPs, especially nurses, to support their parental role, and factors that facilitate the development of trust and good communication.

Supporting Family Decision-making for a Child Who Is Seriously Ill: Creating Synchrony and Connection

The families of children with chronic or serious illness are sometimes faced with difficult decisions never previously imagined. We offer a stepwise approach in building a human connection with these families to support them through the decision-making process. We encourage the clinician to stop talking and to actively listen and find common ground. We suggest that offering open and honest information begins with an invitation. We encourage clinicians to explore concepts with the family, including their fears and hopes. We discuss nurturing an emotional connection between the child and family and describe ways to discover a family's preference for involvement in the decision-making process. Central to supporting a family is to place infinite value on the life of their child. We argue that attention to these matters will help the clinician remain in sync with the family to ensure meaningful and high-quality decision-making during highly vulnerable times for families.

The enactment stage of end-of-life decision-making for children

OBJECTIVES

Typically pediatric end-of-life decision-making studies have examined the decision-making process, factors, and doctors' and parents' roles. Less attention has focussed on what happens after an end-of-life decision is made; that is, decision enactment and its outcome. This study explored the views and experiences of bereaved parents in end-of-life decision-making for their child. Findings reported relate to parents' experiences of acting on their decision. It is argued that this is one significant stage of the decision-making process.

METHODS

A qualitative methodology was used. Semi-structured interviews were conducted with bereaved parents, who had discussed end-of-life decisions for their child who had a life-limiting condition and who had died. Data were thematically analysed.

RESULTS

Twenty-five bereaved parents participated. Findings indicate that, despite differences in context, including the child's condition and age, end-of-life decision-making did not end when an end-of-life decision was made. Enacting the decision was the next stage in a process. Time intervals between stages and enactment pathways varied, but the enactment was always distinguishable as a separate stage. Decision enactment involved making further decisions - parents needed to discern the appropriate time to implement their decision to withdraw or withhold life-sustaining medical treatment. Unexpected events, including other people's actions, impacted on parents enacting their decision in the way they had planned. Several parents had to re-implement decisions when their child recovered from serious health issues without medical intervention. Significance of results A novel, critical finding was that parents experienced end-of-life decision-making as a sequence of interconnected stages, the final stage being enactment. The enactment stage involved further decision-making. End-of-life decision-making is better understood as a process rather than a discrete once-off event. The enactment stage has particular emotional and practical implications for parents. Greater understanding of this stage can improve clinician's support for parents as they care for their child.

What information do parents need when facing end-of-life decisions for their child? A meta-synthesis of parental feedback

Background

The information needs of parents facing end-of-life decisions for their child are complex due to the wide-ranging dimensions within which such significant events unfold. While parents acknowledge that healthcare professionals are their main source of information, they also turn to a variety of additional sources of written information in an attempt to source facts, discover solutions, and find hope.

Much has been written about the needs of parents faced with end-of-life decisions for their child but little is known about the written information needs such parents have. Research in the adult intensive care context has shown that written resources impact positively on the understanding of medical facts, including diagnoses and prognoses, communication between families and healthcare professionals, and the emotional wellbeing of families after their relative’s death.

Methods

A meta-synthesis of predominantly empirical research pertaining to features which assist or impede parental end-of-life decisions was undertaken to provide insight and guidance in our development of written resources (short print and online comprehensive version) for parents.

Results

The most prominently cited needs in the literature related to numerous aspects of information provision; the quantity, quality, delivery, and timing of information and its provision impacted not only on parents’ ability to make end-of-life decisions but also on their emotional wellbeing. The meta-synthesis supports the value of written materials, as these provide guidance for both parents and healthcare professionals in pertinent content areas.

Conclusions

Further research is required to determine the impact that written resources have on parental end-of-life decision-making and on parents’ wellbeing during and after their experience and time in the hospital environment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-015-0024-0) contains supplementary material, which is available to authorized users.

Caring until the end: a systematic literature review exploring Paediatric Intensive Care Unit end-of-life care

AIMS AND OBJECTIVES

A systematic review of the literature focusing on the provision of end-of-life care (EOLC) on Paediatric Intensive Care Units (PICUs) and the options available to children and families within contemporary clinical practice.

BACKGROUND

The death of a child is recognized as a uniquely traumatic experience for a parent. The care delivered to a child and family surrounding death can have a lasting effect on the grieving process. The majority of paediatric deaths occur within PICUs, often as a result of withdrawing or withholding treatment. Withdrawal of intensive care is becoming more common within UK PICUs, and this review will focus on the options available when a child's on-going treatment is deemed to be futile.

SEARCH STRATEGIES

Literature published from 2002 to 2013 was obtained from a range of sources and critically reviewed. Cormack's (2000) framework for systematic literature review was utilized to critically review literature before analysis and synthesis of the literature was undertaken within the qualitative approach.

INCLUSION/EXCLUSION CRITERIA

Each article focused on issues surrounding the topic area, excluded adult and neonatal intensive care and was published in English.

CONCLUSIONS

Eight papers met the inclusion criteria and were suitable for review (highlighting difficulties in reviewing a small, complex subject area). Key themes identified included family views, staff views, decision-making, medico-legal issues and resources.

RELEVANCE TO CLINICAL PRACTICE

Although the number of relevant articles is limited, a wide range of challenges facing children, parents and staff are highlighted, whilst generally supporting the facilitation of transferring children to their homes or hospice for withdrawal of intensive care and continuing EOLC. Further research is required, particularly regarding long-term implications, legal issues and the effectiveness of clinical protocols.

What parents want from doctors in end-of-life decision-making for children

OBJECTIVE

End-of-life decision-making is difficult for everyone involved, as many studies have shown. Within this complexity, there has been little information on how parents see the role of doctors in end-of-life decision-making for children. This study aimed to examine parents' views and experiences of end-of-life decision-making.

DESIGN

A qualitative method with a semistructured interview design was used.

SETTING

Parent participants were living in the community.

PARTICIPANTS

Twenty-five bereaved parents.

MAIN OUTCOMES

Parents reported varying roles taken by doctors: being the provider of information without opinion; giving information and advice as to the decision that should be taken; and seemingly being the decision maker for the child. The majority of parents found their child's doctor enabled them to be the ultimate decision maker for their child, which was what they very clearly wanted to be, and consequently enabled them to exercise their parental autonomy. Parents found it problematic when doctors took over decision-making. A less frequently reported, yet significant role for doctors was to affirm decisions after they had been made by parents. Other important aspects of the doctor's role were to provide follow-up support and referral.

CONCLUSIONS

Understanding the role that doctors take in end-of-life decisions, and the subsequent impact of that role from the perspective of parents can form the basis of better informed clinical practice.

Understanding parental behavior in pediatric palliative care: Attachment theory as a paradigm

OBJECTIVE

The objective of this conceptual paper was to present important constructs in attachment theory as they apply to parent and caregiver behavior in pediatric palliative care. Clarification of these constructs is provided with specific reference to their clinical application as well as their reflection in current empirical literature. Social attachment theory is proposed as a developmentally contextual model for the study of parenting in pediatric palliative and end-of-life care.

METHOD

A comprehensive search was conducted of pertinent literatures. These included classic as well as recent theory and research in attachment theory in addition to the empirical literatures on parent and family experience in pediatric palliative care, serious illness, and beyond to parental bereavement. Other relevant literature was examined with respect to the phenomena of concern.

RESULTS

The empirical literature in pediatric palliative care supports the use of central concepts in attachment theory as foundational for further inquiry. This is evidenced in the emphasis on the importance of parental protection of the child, as well as executive activities such as decision making and other prominent parental operations, parental psychological resolution of the child's diagnosis and illness as well as coping and meaning making, and the core significance of parental relationships with providers who provide secure-base and safe-haven functions.

SIGNIFICANCE OF RESULTS

The promise for developing integrated, conceptually based interventions from construction through implementation is of urgent importance to children and families receiving pediatric palliative care services. Focusing on key parental behaviors and processes within the context of a well-studied and contextually appropriate model will inform this task efficiently. The attachment paradigm meets these criteria and has promise in allowing us to move forward in developing well-defined, inclusive, and conceptually grounded protocols for child and family psychosocial research, practice, and education in this specialty.

The duty of the physician to care for the family in pediatric palliative care: context, communication, and caring

Pediatric palliative care physicians have an ethical duty to care for the families of children with life-threatening conditions through their illness and bereavement. This duty is predicated on 2 important factors: (1) best interest of the child and (2) nonabandonment. Children exist in the context of a family and therefore excellent care for the child must include attention to the needs of the family, including siblings. The principle of nonabandonment is an important one in pediatric palliative care, as many families report being well cared for during their child's treatment, but feel as if the physicians and team members suddenly disappear after the death of the child. Family-centered care requires frequent, kind, and accurate communication with parents that leads to shared decision-making during treatment, care of parents and siblings during end-of-life, and assistance to the family in bereavement after death. Despite the challenges to this comprehensive care, physicians can support and be supported by their transdisciplinary palliative care team members in providing compassionate, ethical, and holistic care to the entire family when a child is ill.

The challenge of quality care for family caregivers in pediatric cancer care

OBJECTIVES

To discuss the needs and potential interventions for parental caregivers of children with cancer.

DATA SOURCES

Published articles between 2002 and 2012.

CONCLUSION

In general, parents do adjust and cope with their child's cancer, but a significant majority experience post-traumatic stress symptoms. Families also report that the shift to parenting a child with cancer is very disruptive to identity and family structure and can cause negative outcomes for mothers, father, and siblings. There is growing evidence of post-traumatic growth and resilience in parents of children with cancer. Recent studies have suggested that targeted interventions may relieve distress.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can support families in the difficult transition to having a child with cancer and may be able to intervene to reduce long-term distress in families.

End of life care sedation for children

PURPOSE OF REVIEW

This article is aimed to review updated research on end-of-life care sedation (EOLC-S) for children and aspects surrounding this issue.

RECENT FINDINGS

Prevalence of EOLC-S for children may vary across countries on account of cultural differences, in terms of settings, legal issues and perceptions about EOLC-S, which lead to variation in patient selection and management. Although home is the preferred place of death for families, research shows hospital settings and ICUs to be the most frequent places where children die. Data on how to define refractory symptoms and update research on drug selection and dosing are lacking. Nature of symptoms at end of life (EOL) is described for cancer patients, but few articles focused on nononcological conditions. Decision making at EOL is commonly discussed with families but children are less frequently involved.

SUMMARY

A thorough search of databases was conducted for articles published in the last year. We found few articles describing EOLC-S as a last resort. But how, when and by whom a symptom is defined as refractory, is not well established. Aggressive symptom management at EOL along with advanced care planning conducted by pediatric palliative care teams could diminish EOLC-S. More research is needed.