Emergent Complications in the Pediatric Hematopoietic Stem Cell Transplant Patient

Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration

Context

Approximately 40%-60% of deaths in the pediatric intensive care unit (PICU) are in the context of de-escalation of life-sustaining treatments (LSTs), including compassionate extubation, withdrawal of vasopressors, or other LSTs. Suffering at the end of life (EOL) is often undertreated and underrecognized. Pain and poor quality of life are common concerns amongst parents and providers at a child’s EOL. Integration of palliative care (PC) may decrease suffering and improve symptom management in many clinical situations; however, few studies have described medical management and symptom burden in children with cancer in the pediatric intensive care unit (PICU) undergoing de-escalation of LSTs.

Methods

A retrospective chart review was completed for deceased pediatric oncology patients who experienced compassionate extubation and/or withdrawal of vasopressor support at EOL in the PICU. Demographics, EOL characteristics, and medication use for symptom management were abstracted. Descriptive analyses were applied.

Results

Charts of 43 patients treated over a 10-year period were reviewed. Most patients (69.8%) were white males who had undergone hematopoietic stem cell transplantation and experienced compassionate extubation (67.4%) and/or withdrawal of vasopressor support (44.2%). The majority (88.3%) had a physician order for scope of treatment (POST – DNaR) in place an average of 13.9 days before death. PC was consulted for all but one patient; however, in 18.6% of cases, consultations occurred on the day of death. During EOL, many patients received medications to treat or prevent respiratory distress, pain, and agitation/anxiety. Sedative medications were utilized, specifically propofol (14%), dexmedetomidine (12%), or both (44%), often with opioids and benzodiazepines.

Conclusions

Pediatric oncology patients undergoing de-escalation of LSTs experience symptoms of pain, anxiety, and respiratory distress during EOL. Dexmedetomidine and propofol may help prevent and/or relieve suffering during compassionate de-escalation of LSTs. Further efforts to optimize institutional policies, education, and collaborations between pediatric intensivists and PC teams are needed.

Racial and Ethnic Differences in Inpatient Palliative Care for Pediatric Stem Cell Transplant Patients

OBJECTIVES

Racial/ethnic disparities in utilizing inpatient palliative care services are well documented in the adult literature. However, the impact of racial/ethnic disparities in the context of pediatric palliative care is less well understood even in high-acuity patient populations such as stem cell transplant patients. We investigated racial/ethnic differences in the utilization of inpatient palliative care consultations (IPCCs) for pediatric stem cell transplant patients.

STUDY DESIGN

A retrospective cohort study was conducted using the Pediatric Health Information System database. A generalized linear mixed effects model was developed to assess demographic and clinical characteristics associated with the likelihood of receiving IPCC.

SETTING

Thirty-eight tertiary pediatric hospitals in the United States.

PATIENTS

Pediatric patients undergoing stem cell transplantation for any indication from January 2017 to December 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 1,193 inpatient encounters studied, 12% (n = 143) included a palliative care consult. IPCC rates varied across hospitals with a median rate of 5.97% (interquartile range, 0.00-20.71). In multivariable analyses, Hispanic/Latinx patients were 59% less likely to receive IPCC compared with non-Hispanic White patients (odds ratio [OR], 0.41; 95% CI, 0.21-0.78). This difference persisted after adjusting for all other sociodemographic and clinical factors. In terms of the other clinical characteristics, having a malignant condition and mechanical ventilation were associated with significantly increased odds of receiving IPCC for the entire cohort (OR Malignancy: 1.93; 95% CI: 1.07-3.51; OR Mechanical Ventilation: 2.37; 95% CI: 1.36-4.13). The remainder of the variables were not found to be significantly associated with IPCC.

CONCLUSIONS

Racial and ethnic differences exist in the likelihood of receiving palliative care consultations among hospitalized pediatric stem cell transplant recipients. Evaluating the impact of systemic racism and social determinants on palliative care medicine as well as standardizing early integration of IPCC may potentially mitigate disparities in this population.

Family Adjustment to Pediatric Hematopoietic Stem Cell Transplant During COVID-19

OBJECTIVE

The COVID-19 pandemic has been difficult for families across the world due to fears about infection risk, increased social isolation, and significant changes in family roles and routines. Families with a child undergoing pediatric hematopoietic stem cell transplant (HCT) may be at even greater risk for poor adjustment during COVID-19 given their child's increased risk for infection. The purpose of the current study was to qualitatively examine the impact of COVID-19 on family adjustment during pediatric HCT to inform clinical care.

METHODS

Twenty-nine caregivers of children (≤12 years) who underwent an HCT within the past 2 years completed semi-structured qualitative interviews and demographic questionnaires in the first 4 months following initial COVID-19 quarantine.

RESULTS

Twenty-two themes emerged from the interviews using grounded theory methodology. Although nearly half of caregivers described COVID-19 as a stressor, 69% of caregivers reported adequate adjustment to COVID-19. Caregivers generally attributed their positive adjustment to HCT preparing the family for COVID-19 and more difficult adjustment to increased physical or social isolation and COVID-19 amplifying germ fears. The child's HCT treatment status also had important implications on family adjustment to COVID-19.

CONCLUSIONS

Results suggest that families undergoing pediatric HCT are uniquely prepared to cope with the impacts of a global pandemic; however, families experiencing certain risk factors (e.g., more recent transplant, impaired access to social support, reduced access to coping tools) may experience poorer adjustment during pandemics such as COVID-19 and may benefit from increased psychosocial support from their healthcare team.

Caregiver Religious Coping and Posttraumatic Responses in Pediatric Hematopoietic Stem Cell Transplant

OBJECTIVE

Caregivers often experience their child's hematopoietic stem cell transplant (HCT) treatment as traumatic. Although many caregivers develop posttraumatic stress symptoms (PTSS) in response to supporting their child through HCT, other caregivers demonstrate posttraumatic growth (PTG). Religious coping may contribute to these different adjustment trajectories; however, more information is needed to clarify the unique associations of positive versus negative religious coping on caregiver PTSS and PTG in the context of pediatric HCT. This study aimed to examine the relationships between negative and positive religious coping on caregivers PTSS and PTG while controlling for caregiver sex, self-efficacy, and social support.

METHODS

Caregivers (N = 140) of youth admitted to the hospital for their first HCT were asked to complete self-report measures of their use of positive and negative religious coping, PTSS, PTG, social support, and self-efficacy. Two hierarchical linear regressions were conducted to test hypotheses.

RESULTS

Greater positive religious coping, but not negative religious coping, was associated with caregivers reporting more PTG in response to pediatric HCT. More negative religious coping, but not positive religious coping, was associated with caregivers experiencing greater PTSS.

CONCLUSIONS

Engaging in positive religious coping appears to promote better caregiver adjustment to pediatric HCT, whereas negative religious coping may increase caregiver risk for developing PTSS. Screening caregivers' religious beliefs, including the type of religious coping they employ, could inform providers regarding the best approach to supporting caregivers towards a growth trajectory and mitigate PTSS.

Treatment intensity and symptom burden in hospitalized adolescent and young adult hematopoietic cell transplant recipients at the end of life

Adolescent and young adult (AYA) oncology patients experience many physical and psychological symptoms at the end of life (EOL); however, data on these experiences for AYA patients who have undergone hematopoietic cell transplantation (HCT) remains sparse. We sought to investigate the characteristics of AYA patients aged 15-25 years who received allogeneic HCT and subsequently died while inpatient at our institution between the years 2008 and 2014. A standardized data extraction tool was used to collect information about patient demographics, treatment and symptoms. We found that during this time frame, 34 AYA patients had received HCT and died while inpatient at our institution, 23 (68%) of whom died because of treatment-related complications. Compared with non-HCT AYA oncology patients (n=35), patients who received HCT (n=34) were more likely to have died in the intensive care unit (71% vs 23%, P<0 .0001) and to have received mechanical ventilation (68% vs 17%, P<0.0001) or hemodialysis (53% vs 0%, P<0.0001) in the last 30 days of life. These findings demonstrate that AYA patients who receive allogeneic HCT receive intensive EOL treatment, suggesting that these patients may benefit from early integration of expert interdisciplinary services to prospectively assess and manage distressing symptoms.

Health-Related Quality of Life among Children and Adolescents during Hematopoietic Stem Cell Transplant Recovery

Health-related quality of life (HRQoL) has been noted to fluctuate among children during hematopoietic stem cell transplant (HSCT) recovery; however, the specific timing and associations of these changes are poorly understood. This repeated-measures study aimed to describe HRQoL changes among children and adolescents during the first 6 months of HSCT recovery and estimate the associations of demographic factors, diagnosis, transplant information, and symptoms with HRQoL. Twenty-three children and adolescents who received an allogeneic HSCT were recruited from a pediatric teaching institution in the southern United States. Demographic, diagnosis, and transplant information was obtained from the medical record. The Memorial Symptom Assessment questionnaire and the Peds Quality of Life Cancer Module (PedsQL CM) were completed at 1 month post-HSCT and then once monthly for 5 additional months. Mean HRQoL scores fluctuated during the study with the lowest mean HRQoL noted at 1 month post-HSCT and the highest mean HRQoL noted at 4 months post-HSCT. No significant differences in HRQoL scores were noted among demographic, diagnosis, or transplant factors. Feeling tired, sad, or worried or having insomnia at 1 month post-HSCT was negatively correlated to HRQoL. Nurses have opportunities to explore important issues with patients and need to be aware of fluctuations with HRQoL and factors associated with lower HRQoL during HSCT recovery.