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Engel M, Fahner JC, Hennus MP, Kars MC. Experiences with a national team-based learning program for advance care planning in pediatric palliative care. BMC Palliat Care 2024; 23:196. [PMID: 39095834 PMCID: PMC11297680 DOI: 10.1186/s12904-024-01515-2] [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] [Received: 02/22/2024] [Accepted: 07/11/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Advance Care Planning (ACP) enables patients and relatives to define and share values, goals and preferences for future medical treatment and care. The IMplementing Pediatric Advance Care Planning Toolkit (IMPACT), developed in the Netherlands, is a method for conducting ACP in pediatric palliative care. Healthcare professionals who were trained to use IMPACT, indicated their need for ongoing support to practice ACP communication skills optimally over time. Therefore, we developed a team-based learning program aimed at teaching participants how to transfer knowledge on ACP, continue practicing ACP communication skills and reflect on ACP conversations within their own team context. The aim of this study was to evaluate the program's transfer of knowledge as well as the professionals' experience and team reflection on ACP. METHODS A one-day IMPACT train-the-trainer course was developed and a selection of healthcare professionals (facilitators) from pediatric palliative care teams (PPCTs) from all seven Dutch university hospitals and the specialized Center for Pediatric Oncology were invited to participate. Hereafter, facilitators were asked to transfer their course-acquired knowledge to their team members (learners) by organizing two coaching-on-the-job sessions. A mixed-methods design, combining questionnaires and field notes, was used to evaluate the level of knowledge transfer and team reflection achieved. RESULTS Eighteen healthcare professionals in the role of facilitator participated in the train-the-trainer course. In seven PPCTs one (n = 3) or two (n = 4) coaching-on-the-job session(s) took place, attended by 29 and 17 learners, respectively. In the questionnaires, 11 facilitators indicated that they had to some extent transferred acquired knowledge to their team members as intended. Sixteen out of 21 learners who participated in at least one coaching-on-the-job session, reported (somewhat) increased self-confidence for conducting ACP conversations. The reported main strength of the program was practicing with/learning from colleagues whereas dealing with workload and variation in existing ACP skills within PPCTs need more attention. CONCLUSIONS The newly developed team-based learning program resulted in intended transfer of knowledge and methodical reflection on ACP in coaching-on-the-job sessions in most participating PPCTs. Planning coaching-on-the-job sessions regarding ACP in pediatric palliative care with multiple healthcare professionals is challenging and needs more emphasis in the training.
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Affiliation(s)
- Marijanne Engel
- Julius Center for Health Sciences and Primary Care, Center of Expertise in Palliative Care Utrecht, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands.
| | - Jurrianne C Fahner
- Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
| | - Marije P Hennus
- Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
- Utrecht Center for Research and Development of Health Professions Education, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marijke C Kars
- Julius Center for Health Sciences and Primary Care, Center of Expertise in Palliative Care Utrecht, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
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Adams SY, Redford K, Li R, Malfa A, Tucker R, Lechner BE. Utility of do-not-resuscitate orders for critically ill infants in the NICU. Pediatr Res 2024:10.1038/s41390-024-03367-1. [PMID: 38969816 DOI: 10.1038/s41390-024-03367-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/10/2024] [Accepted: 05/07/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVE To better understand the value of DNR orders for critically ill infants in the NICU. METHODS A prospective mixed-methods approach was utilized including chart review of infants who died in a regional NICU over a twenty-six-month period and surveys of their neonatologists, neonatal fellows, and nurses. RESULTS 40 infants died during the study period and 120 staff surveys were completed. Infants with DNR orders were of a higher gestational age at birth and a higher chronological age at death. Nurses were more likely to perceive benefit from DNR orders than physicians. Medical staff recollection of the existence of DNR orders was not always accurate. Time and fear of adding unnecessary emotional burden to parents were identified as barriers to DNR order implementation. An advanced care planning model built on open communication instead of DNR order documentation was deemed the best approach. CONCLUSION Though DNR orders are beneficial for a subset of infants, DNR orders are likely not applicable for all infants who die in the NICU. More important is supportive, individualized communication between families and the medical team to ensure quality end-of-life care. IMPACT In the adult and pediatric ICU literature, DNR orders are associated with improved qualitative "good death" assessments and decreased familial decision regret. In the NICU, rates of DNR usage aren't well reported and their overall utility is unclear. Though DNR orders can help guide clinical decision making in the NICU and may be associated with higher quality ethical discussion, our data suggest that they are not applicable in all patient cases. We hope that this work will help guide approaches to end-of-life care in the NICU and underscore the importance of frequent, open communication between families and their medical team.
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Affiliation(s)
- Shannon Y Adams
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Katherine Redford
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Randall Li
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ana Malfa
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Richard Tucker
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
| | - Beatrice E Lechner
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
- Warren Alpert Medical School of Brown University, Providence, RI, USA
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Bell CJ, Spruit JL, Deatrick JA, Weaver MS, Dickens DS, Hinds PS, Kavanaugh KL. Development and Validation of a Ready-to-Talk Measure for Use in Adolescents and Young Adults Living With Advanced Cancer. Cancer Nurs 2024:00002820-990000000-00255. [PMID: 38832797 DOI: 10.1097/ncc.0000000000001343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND In the era of evolving and emerging therapies, adolescents and young adults (AYAs) living with advanced cancer experience a high degree of uncertainty, making palliative care and end-of-life (PCEOL) discussions difficult. Clinical conversations determine values/preferences that guide shared decision-making and goals of treatment, including end-of-life care when cancer progresses. Initiating PCEOL conversations is challenging for clinicians. OBJECTIVE This study describes the development and validation of an instrument that measures AYA readiness to engage in PCEOL clinical conversations. METHODS A Ready-to-Talk Measure (R-T-M) was developed, guided by the revised conceptual model of readiness across 3 domains (awareness, acceptance, and willingness). Content experts evaluated validity, and 13 AYAs with advanced cancer participated in cognitive interviews. Acceptability (item applicability, clarity, interpretation, sensitivity, missingness) and experiences (benefit, burden) were analyzed. RESULTS The scale content validity index was ≥0.90 for each domain. Forty-two of the 55 R-T-M items were acceptable without any change. Three items were deleted. Ten items were modified, and 3 were added. Adolescents and young adults wanted more items about friends/siblings and about AYA unique qualities for clinicians to know them better. Adolescents and young adults acknowledged benefit through talking about difficult, relevant topics. CONCLUSION Ready-to-Talk Measure validity was strengthened by deleting or modifying unclear or misinterpreted items and by adding items. Next steps include psychometric analysis to determine reliability/dimensionality and stakeholder input to make the R-T-M a clinically useful tool. IMPLICATIONS FOR PRACTICE Ready-to-Talk Measure assessment of readiness to engage in PCEOL conversations while identifying unique preferences of AYAs holds promise for facilitating ongoing discussions.
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Affiliation(s)
- Cynthia J Bell
- Author Affiliations: Department of Cancer Care Services, Corewell Health, Lemmen-Holton Cancer Pavilion, Grand Rapids (Dr Bell); and Department of Pediatrics, Palliative Care, C. S. Mott Children's Hospital, Ann Arbor (Dr Spruit), Michigan; Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia (Dr Deatrick); Department of Pediatric Palliative Care, Children's Nebraska, University of Nebraska Medical Center, Omaha (Dr Weaver); Department of Pediatrics, Hematology/Oncology, University of Iowa (Dr Dickens); Department of Nursing Science, Professional Practice & Quality, Children's National Hospital, and Department of Pediatrics, George Washington University, Washington, District of Columbia (Dr Hinds); and Department of Nursing Research and Evidence Based Practice, Children's Wisconsin, Milwaukee, and University of Illinois at Chicago (Dr Kavanaugh)
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Hrdlickova L, Polakova K, Loucka M. Innovative communication approaches for initializing pediatric palliative care: perspectives of family caregivers and treating specialists. BMC Palliat Care 2023; 22:152. [PMID: 37814302 PMCID: PMC10563209 DOI: 10.1186/s12904-023-01269-3] [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: 05/27/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Effective cooperation between a pediatric palliative care team (PPCT), primary treating specialists, patients and families is crucial for high quality care of children with complex life-limiting conditions. Several barriers among patients, families and treating specialists have been identified in the context of initializing pediatric palliative care. The aim of the study was to assess the experience with initial pediatric palliative care consultations from perspectives of family caregivers and treating physicians with a special focus on two innovative approaches: attendance of the treating specialist and the opportunity for parents to give feedback on the written report from the consultation. METHODS This was a qualitative study using semi-structured interviews with family caregivers of children with malignant and non-malignant disease and their treating specialists. Framework analysis was used to guide the data collection and data analysis. RESULTS In total, 12 family caregivers and 17 treating specialists were interviewed. Four main thematic categories were identified: (1) expectations, (2) content and evaluation, (3) respect and support from the team and (4) consultation outcomes. Parents viewed the consultation as a unique opportunity to discuss difficult topics. They perceived the attendance of the treating specialist at the initial consultation as very important for facilitating communication. Treating specialists valued the possibility to learn more about psychosocial issues of the child and the family while attending the initial palliative care consultation. All participants perceived the written report from the consultation as useful for further medical decisions. Family members appreciated the chance to give feedback on the consultation report. CONCLUSIONS Our study identified several clinically relevant issues that can help initialize pediatric palliative care and establish effective collaboration between families and PPCT and treating specialists. Supporting treating specialists in their ability to explain the role of palliative care is important in order to reduce the risk of misunderstanding or unrealistic expectations. Developing more specific expectations seems to be one of the ways to further increase the effectiveness of initial consultations. The results of the study can be especially helpful for the initial phase of implementing pediatric palliative care and initializing the process of setting up a collaborative relationship with palliative care teams in the hospital.
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Affiliation(s)
- Lucie Hrdlickova
- Department of Pediatric Hematology and Oncology, University Hospital Motol, V Uvalu 84, Prague, 5,150 06, Czech Republic.
- Pediatric Supportive Care Team, University Hospital Motol, Prague, Czech Republic.
- First Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Kristyna Polakova
- Center for Palliative Care, Prague, Czech Republic
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Loucka
- Center for Palliative Care, Prague, Czech Republic
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
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Maas DS, Hughes S, Macmillan PJ, Rodriguez Carranza LP, Nguyen M. Physician Perceptions and Beliefs Regarding End-of-Life Care in a Central California Health System. Am J Hosp Palliat Care 2023; 40:1079-1086. [PMID: 36426418 DOI: 10.1177/10499091221141624] [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: 09/19/2023] Open
Abstract
Objective: We sought to describe the preparedness, beliefs, and experience regarding end-of-life (EOL) care for in-training and attending physicians. We hoped to clarify how medical training impacts views about EOL, and topics where physicians desire more EOL training. Methods: An online anonymous survey was sent to 766 physicians who worked at Community Medical Centers in Fresno, California from October to December 2016. Descriptive statistics of the population were compiled. Chi-squared and Mann-Whitney U tests comparing differences in personal experience, and preparedness and confidence with palliative care topics by training level were performed. Results: 195 physicians responded to the survey (25%). Respondents were 42% in-training, 55% male, 57% Caucasian, and 38% Christian. Compared to attendings those in-training were younger, more often female, and more likely to have a DO degree. The 2 groups did not differ in ethnicity, specialty, or religion. Attendings were more likely than those in-training (46% vs 14%, P < .001) to have an advance directive, reported a higher level of formal training in discussing prognosis (P = .037), and had higher confidence with palliative care topics like delivering bad news (P = .002), discussing resuscitation status (P = .015), and discussing the new California EOL Option Act (P < .001). Thirty-two percent of respondents believed patients often starve at EOL. Otherwise, knowledge was 90% correct. Conclusions: Physicians in-training are less prepared to discuss EOL topics. Physicians in-training and attendings desire more education in pain management at EOL.
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Affiliation(s)
- David S Maas
- Hospice and Palliative Medicine Fellowship, University of California San Francisco Fresno Family and Community Medicine, Fresno, CA, USA
| | - Susan Hughes
- University of California San Francisco Fresno Family and Community Medicine, Fresno, CA, USA
| | - Patrick J Macmillan
- University of California San Francisco Fresno Internal Medicine, Fresno, CA, USA
| | | | - Madeline Nguyen
- Family and Community Medicine, Peach Tree Health, Sacramento, CA, USA
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Lyon ME, Thompkins JD, Fratantoni K, Fraser JL, Schellinger SE, Briggs L, Friebert S, Aoun S, Cheng YI, Wang J. Family caregivers of children and adolescents with rare diseases: a novel palliative care intervention. BMJ Support Palliat Care 2022; 12:e705-e714. [PMID: 31345846 PMCID: PMC8040699 DOI: 10.1136/bmjspcare-2019-001766] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/24/2019] [Accepted: 05/29/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To develop and pilot test a palliative care intervention for family caregivers of children with rare diseases (FAmily-CEntered pediatric Advance Care Planning-Rare (FACE-Rare)). METHODS FACE-Rare development involved an iterative, family-guided process including review by a Patient and Family Advisory Council, semistructured family interviews and adaptation of two evidence-based person-centred approaches and pilot testing their integration. Eligible families were enrolled in FACE-Rare (the Carer Support Needs Assessment Tool (CSNAT) Approach Paediatric sessions 1 and 2; plus Respecting Choices Next Steps pACP intervention sessions 3 and 4). Satisfaction, quality of communication and caregiver appraisal were assessed. RESULTS Parents were mean age 40 years, and children 7 years. Children's diseases were rare enough that description would identify patients. All children were technology dependent. Telemedicine, used with four of seven families, was an effective engagement strategy and decreased subject burden. Families found FACE-Rare valuable following a strategy that first elicited palliative care needs and a support plan. Eight families were approached for pilot testing. Of the seven mothers who agreed to participate, six began session 1, and of those, 100% completed: all four FACE-Rare sessions, baseline and 2-week postintervention assessments, and a written pACP which described their preferences for medical decision-making to share with their providers. 100% reported FACE-Rare was helpful. The top three CSNAT concerns were: knowing what to expect in the future, having enough time for yourself and financial issues. Benchmarks were achieved and questionnaires were acceptable to parents and thus feasible to use in a larger trial. CONCLUSIONS FACE-Rare provides an innovative, structured approach for clinicians to deliver person-centred care.
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Affiliation(s)
- Maureen E Lyon
- Adolescent and Young Adult Medicine, Children's National Health System, Washington, DC, USA
| | - Jessica D Thompkins
- Center for Translational Research, Children's National Health System, Washington, DC, USA
| | - Karen Fratantoni
- Complex Care Program, Children's National Health System, Washington, DC, USA
| | - Jamie L Fraser
- Division of Genetics and Metabolism, Children's National Health System, Washington, DC, USA
| | | | - Linda Briggs
- A Division of C-TAC Innovations, Respecting Choices, Washington, DC, USA
| | - Sarah Friebert
- Palliative Care, Akron Children's Hospital, Akron, Ohio, USA
| | - Samar Aoun
- Perron Institute for Neurological and Translational Science, Perth, Western Australia, Australia
- School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Yao Iris Cheng
- Biostatistics, Children's National Health System, Washington, DC, USA
| | - Jichuan Wang
- Biostatistics, Children's National Health System, Washington, DC, USA
- Center for Translational Science, Children's National Health System, Washington, DC, USA
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Bennett HE, Duke S, Richardson A. Paediatric advance care planning in life-limiting conditions: scoping review of parent experiences. BMJ Support Palliat Care 2022; 13:161-173. [DOI: 10.1136/bmjspcare-2022-003544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/16/2022] [Indexed: 11/04/2022]
Abstract
BackgroundAdvance care planning is considered best practice for children and young people with life-limiting conditions but there is limited evidence how parents’ perceive, understand and engage with the process.AimTo understand parents’ experience of advance care planning for a child or young person with a life-limiting condition.DesignScoping review, theoretically informed by Family Sense of Coherence. Parents’ experience was conceptualised in terms of meaningfulness, comprehensibility and manageability.Data sourcesElectronic databases Medline, CINAHL and PyschINFO were searched for studies published between 1990 and 2021, using MeSH and broad-base terms.Results150 citations were identified and screened; 15 studies were included: qualitative (n=10), survey (n=3) and participatory research (n=2). Parents’ experience of advance care planning was contextualised by their family values and beliefs, needs and goals and the day-to-day impact of caring for their child and family. They valued conversations, which helped them to maximise their child’s quality of life and minimise their suffering. They preferred flexible, rather than definitive decisions about end-of-life care and treatment.ConclusionsAdvance care planning which solely focuses on treatment decisions is at odds with parents’ concerns about the current and future impact of illness on their child and family. Parents want advance care planning for their child to reflect what matters to them as a family. Future longitudinal and comparative studies are needed to understand the influence of advance care planning on parental decision-making over time and how social, cultural and contextual nuances influence parental experience.
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Hamre TJ, O'Shea ER, Hinderer KA, Mosha MH, Wentland BA. Impact of an Evidence-Based Pediatric Palliative Care Program on Nurses' Self-Efficacy. J Contin Educ Nurs 2022; 53:264-272. [PMID: 35647631 DOI: 10.3928/00220124-20220505-08] [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: 11/20/2022]
Abstract
Background The purpose of this study was to determine the effect of a 1-day evidence-based pediatric palliative care continuing professional development program on nurses' and advanced practice registered nurses' perceived self-efficacy regarding palliative care. Method The revised Pediatric Palliative Care Questionnaire was administered to participants before and after a 7½-hour program. A multimodal approach was used to teach topics specific to pediatric palliative care. Results Thirty-one participants completed questionnaires. Notably, most of the participants had provided palliative or end-of-life care, but few had previous education specific to pediatrics. The self-efficacy scores of the participants significantly increased after program attendance (Z = 3.53, p < .001). Conclusion Continuing professional development in pediatric palliative care improves nurses' and advanced practice registered nurses' confidence in their skills to provide this care. Findings of this study support the need for pediatric-specific education in nursing training programs and continuing professional development offerings. Continuing education may be the key to improving access to high-quality care for children living with serious illness and their families. [J Contin Educ Nurs. 2022;53(6):264-272.].
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Vemuri S, Hynson J, Williams K, Gillam L. Conceptualising paediatric advance care planning: a qualitative phenomenological study of paediatricians caring for children with life-limiting conditions in Australia. BMJ Open 2022; 12:e060077. [PMID: 35577468 PMCID: PMC9115011 DOI: 10.1136/bmjopen-2021-060077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 05/04/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES Advance care planning (ACP) helps families and paediatricians prepare and plan for end-of-life decision-making. However, there remains inconsistency in its practice with the limited literature describing what this preparation involves, and whether paediatricians recognise a difference between the process of ACP and its outcomes, such as resuscitation plans. This study aims to understand how paediatricians conceptualise ACP when caring for children with life-limiting conditions (LLC) who are unable to participate in decision-making for his/herself. DESIGN Individual, semistructured, vignette-based qualitative interviews. SETTING Acute inpatient and long-term outpatient paediatric care in three secondary and two tertiary centres in Victoria, Australia. PARTICIPANTS 25 purposively sampled paediatricians who treat children with LLC, outside the neonatal period. Paediatricians were excluded if they worked within specialist palliative care teams or assisted in this study's design. RESULTS Four key themes were identified when approaching end-of-life decision-making discussions: (1) there is a process over time, (2) there are three elements, (3) the role of exploring parental values and (4) the emotional impact. The three elements of this process are: (1) communicating the child's risk of death, (2) moving from theoretical concepts to practice and (3) documenting decisions about resuscitation or intensive technologies. However, not all paediatricians recognised all elements as ACP, nor are all elements consistently or intentionally used. Some paediatricians considered ACP to be only documentation of decisions in advance. CONCLUSION There is a preparatory process of discussions for end-of-life decision-making, with elements in this preparation practised within therapeutic relationships. Complexity in what constitutes ACP needs to be captured in guidance and training to include intentional exploration of parental values, and recognition and management of the emotional impact of ACP could increase its consistency and value.
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Affiliation(s)
- Sidharth Vemuri
- Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jenny Hynson
- Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Katrina Williams
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Lynn Gillam
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Children's Bioethics Centre, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
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Linebarger JS, Johnson V, Boss RD, Linebarger JS, Collura CA, Humphrey LM, Miller EG, Williams CSP, Rholl E, Ajayi T, Lord B, McCarty CL. Guidance for Pediatric End-of-Life Care. Pediatrics 2022; 149:186860. [PMID: 35490287 DOI: 10.1542/peds.2022-057011] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The final hours, days, and weeks in the life of a child or adolescent with serious illness are stressful for families, pediatricians, and other pediatric caregivers. This clinical report reviews essential elements of pediatric care for these patients and their families, establishing end-of-life care goals, anticipatory counseling about the dying process (expected signs or symptoms, code status, desired location of death), and engagement with palliative and hospice resources. This report also outlines postmortem tasks for the pediatric team, including staff debriefing and bereavement.
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Affiliation(s)
- Jennifer S Linebarger
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri, Kansas City, School of Medicine, Kansas City, Missouri
| | - Victoria Johnson
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Renee D Boss
- Department of Pediatrics, Johns Hopkins University School of Medicine, Berman Institute of Bioethics, Baltimore, Maryland
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Carr K, Hasson F, McIlfatrick S, Downing J. Initiation of paediatric advance care planning: Cross-sectional survey of health professionals reported behaviour. Child Care Health Dev 2022; 48:423-434. [PMID: 34873744 PMCID: PMC9306788 DOI: 10.1111/cch.12943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Globally, initiation of paediatric advance care planning discussions is advocated early in the illness trajectory; however, evidence suggests it occurs at crisis points or close to end of life. Few studies have been undertaken to ascertain the prevalence and determinants of behaviour related to initiation by the healthcare professional. METHOD Underpinned by the Capability, Opportunity, Motivation-Behaviour (COM-B) model for behaviour change, a cross-sectional online survey was conducted in United Kingdom and Ireland using a purposive sample of health professionals. Descriptive and inferential statistics were applied and nonparametric statistical analysis used. Open-ended questions were mapped and correlations between COM-B and demographic profiles identified. RESULTS Responses (n = 140): Paediatric advance care planning was viewed positively; however, initiation practices were found to be influenced by wide ranging diagnoses and disease trajectories. Whilst some tools and protocols exist, they were not used in a systematic manner, and initiation behaviour was often not guided by them. Initiation was unstandardized, individually led, guided by intuition and experience and based on a range of prerequisites. Such behaviour, combined with inconsistencies in professional development, resulted in varying practice when managing clinical deterioration. Professionals who felt adequately trained initiated more conversations (capability). Those working in palliative care specialties, hospice settings and doctors initiated more discussions (opportunity). There was no difference in Motivation between professions, clinical settings or specialisms, although 25% (n = 35) of responses indicated discomfort discussing death and 34% (n = 49) worried about families' emotional reaction. CONCLUSION Although advocated, paediatric advance care planning is a complex process, commonly triggered by the physical deterioration and rarely underpinned by support tools. The COM-B framework was useful in identifying fundamental differences in initiation behaviour; however, further research is required to explore the complexity of initiation behaviour and the system within which the care is being delivered to identify influences on initiation.
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Affiliation(s)
- Karen Carr
- Institute of Nursing and Health ResearchUlster UniversityNewtownabbeyUK
| | - Felicity Hasson
- Institute of Nursing and Health ResearchUlster UniversityNewtownabbeyUK
| | - Sonja McIlfatrick
- Institute of Nursing and Health ResearchUlster UniversityNewtownabbeyUK
| | - Julia Downing
- International Children's Palliative Care NetworkBristolUK,Department of MedicineMakerere UniversityKampalaUganda
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12
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Benini F, Avagnina I, Giacomelli L, Papa S, Mercante A, Perilongo G. Pediatric Palliative Care in Oncology: Basic Principles. Cancers (Basel) 2022; 14:cancers14081972. [PMID: 35454879 PMCID: PMC9031296 DOI: 10.3390/cancers14081972] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary About 4 million children with an oncological disease worldwide require palliative care due to the nature of their condition. The WHO defines pediatric palliative care (PPC) as the prevention and relief of suffering in patients with life-threatening or life-limiting disease and their families. PPC relies on the comprehensive and multidisciplinary management of the child and the family’s physical, psychological, spiritual, and social needs. Importantly, PPC begins at the diagnosis of incurability, or supposed incurability, and continues regardless of whether the patient receives any oncological treatment. As such, PPC is a general approach continuing over the entire disease trajectory, which includes, but is not limited to, end-of-life care. This review addresses the value of integrating PPC in treating children with cancer, focusing on the basic principles of PPC and its application in pediatric oncology. Abstract About 4 million children with an oncological disease worldwide require pediatric palliative care (PPC) due to the nature of their condition. PPC is not limited to end-of-life care; it is a general approach continuing over the entire disease trajectory, regardless of whether the patient receives any oncological treatment. This review addresses the value of integrating PPC in treating children with cancer, focusing on the basic principles of PPC and its application in pediatric oncology. Moreover, models for PPC implementation in oncology, end-of-life care, and advanced care planning are discussed.
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Affiliation(s)
- Franca Benini
- Paediatric Palliative Care, Pain Service, Department of Women’s and Children’s Health, University of Padua, 35127 Padua, Italy;
- Correspondence:
| | - Irene Avagnina
- Paediatric Palliative Care, Pain Service, Department of Women’s and Children’s Health, University of Padua, 35127 Padua, Italy;
| | | | | | - Anna Mercante
- Pediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University of Padua, 35127 Padua, Italy; (A.M.); (G.P.)
| | - Giorgio Perilongo
- Pediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University of Padua, 35127 Padua, Italy; (A.M.); (G.P.)
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Pennarola BW, Fry A, Prichett L, Beri AE, Shah NN, Wiener L. Mapping the Landscape of Advance Care Planning in Adolescents and Young Adults Receiving Allogeneic Hematopoietic Stem Cell Transplantation: A 5-Year Retrospective Review. Transplant Cell Ther 2022; 28:164.e1-164.e8. [PMID: 34936929 PMCID: PMC8923987 DOI: 10.1016/j.jtct.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/03/2021] [Accepted: 12/05/2021] [Indexed: 12/17/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) carries significant risks of morbidity and mortality. Participation in advance care planning (ACP) is crucial to promote patient-centered care and has been shown to have positive impacts on patients, caregivers, and providers. Historically, both HSCT recipients and adolescents and young adults (AYAs) are significantly less likely to engage in ACP. We sought to characterize ACP utilization in AYAs undergoing HSCT by evaluating the frequency of different types of ACP documentation over time and identifying demographic and clinical factors associated with documentation of each type of ACP. We conducted a single-center retrospective review of the electronic health record (EHR) of AYAs (age 15 to 39 years) who underwent allogeneic HSCT between 2015 and 2020. EHR documents were screened for 3 predefined categories of ACP: (1) advance directives (ADs) or medical orders (MOs), which included proof of signed paper directives, expressions of preferred code status, and identification of a healthcare proxy; (2) goals of care (GOC) conversations, which included discussions of medical care in a specific situation informed by patients' priorities; and (3) other ACP conversations, which included more general discussions of patients' values regarding their care or legacy wishes. Documents were coded by 2 researchers, and discrepant categorizations were reviewed by a third researcher. Patients age <18 years on the day of transplantation were excluded in the analyses of AD/MO documentation. Univariate and multivariate logistic regression were used to test for associations between patient factors and documentation of each type of ACP. For deceased patients, Kaplan-Meier curves were created to illustrate the time-to-event relationship between days before death and documentation of each type of ACP. Sixty-eight thousand documents associated with 219 patients were reviewed, and 666 ACP documents associated with 190 patients were identified. Few of the 219 patients had documented GOC (n = 29; 13%) or other ACP conversations (n = 81; 37%). A subset of patients (n = 28; 13%) had no documented ACP. Most of the 201 patients age ≥18 years had a documented AD/MO (n = 172; 86%). No tested factors were significantly associated with documentation of ADs/MOs. GOC and other ACP conversations were more likely to occur in patients with a palliative care consult, and patients with a malignant diagnosis were also more likely to engage in GOC conversations. More than 50% of the documentation occurred in the subset of 39 deceased patients, with one-half of AD/MO documentation in the last 67 days of life, one-half of other ACP documentation in the last 20 days of life, and one-half of GOC documentation in the final 2 days of life. Although the majority of AYA patients receiving HSCT did have documentation of ADs/MOs, few patients had documented GOC or other ACP conversations. The bulk of all ACP conversations occurred in patients that ultimately died and who were very close to the end of life. Our results support ongoing efforts to improve the implementation of ACP in this vulnerable population, particularly for those undergoing HSCT for nonmalignant conditions.
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Affiliation(s)
- Brian W. Pennarola
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD,Department of Pediatric Oncology, Johns Hopkins Hospital, Baltimore, MD
| | - Abigail Fry
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
| | - Laura Prichett
- Johns Hopkins School of Medicine, Department of Pediatrics, Biostatistics, Epidemiology, and Data Management (BEAD) Core, Baltimore, MD
| | - Andrea E. Beri
- NIH Biomedical Translational Research Information System (BTRIS), Bethesda, MD
| | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
| | - Lori Wiener
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
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14
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Daxer M, Monz A, Hein K, Heitkamp N, Knochel K, Borasio GD, Führer M. How to Open the Door: A Qualitative, Observational Study on Initiating Advance Care Discussions with Parents in Pediatric Palliative Care. J Palliat Med 2021; 25:562-569. [PMID: 34807732 DOI: 10.1089/jpm.2021.0183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Context: Advance care discussions (ACD) between health care professionals (HCPs) and parents of children with a life-limiting disease are a core element of successful pediatric advance care planning (pACP). Yet, they are perceived as a challenging situation for all participants. Objectives: Our goal was to investigate the first step of ACD and identify its challenges and helpful communication strategies to develop a conversation guide for initiating the pACP process and structure the conversational opening. Methods: We performed a participant observation of 11 initial ACD and 24 interviews with 13 HCPs and 20 parents of 11 children cared for by 3 different palliative care teams in southern Germany. Qualitative data collection was supplemented by a questionnaire. Content analysis and conversation analysis were used for evaluation. Results: Parents and HCPs start the process with different expectations, which can lead to misunderstandings and confusion. HCPs gain parental cooperation when they express the purpose of the meeting clearly and early, provide structure and guidance, and give parents time to talk about their experiences and feelings. Addressing dying and death is hard for both sides and requires a sensitive approach. Conclusions: Initiating ACD is extremely challenging for all participants. HCPs and parents should clarify expectations and aims at the beginning of the conversation. Future research should focus on how HCPs can be trained for this task and how the right timing for introducing ACD to families can be identified. Clinical Trial Registration number 049-12.
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Affiliation(s)
- Marion Daxer
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Anna Monz
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Kerstin Hein
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Nari Heitkamp
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Kathrin Knochel
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monika Führer
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
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15
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Johnson KA. Advance Care Planning in Pediatric Serious Illness: Centering in the Family Experience. Pediatrics 2021; 147:peds.2020-048660. [PMID: 33958437 PMCID: PMC8396068 DOI: 10.1542/peds.2020-048660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Khaliah A. Johnson
- Pediatric Palliative Care, Children’s Healthcare of Atlanta and Grady Medical Center, Atlanta, Georgia; and Department of Pediatrics, Emory University, Atlanta, Georgia
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16
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Thompkins JD, Needle J, Baker JN, Briggs L, Cheng YI, Wang J, Friebert S, Lyon ME. Pediatric Advance Care Planning and Families' Positive Caregiving Appraisals: An RCT. Pediatrics 2021; 147:peds.2020-029330. [PMID: 33958436 PMCID: PMC8442842 DOI: 10.1542/peds.2020-029330] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Little is known about how families respond to pediatric advance care planning. Physicians are concerned that initiating pediatric advance care planning conversations with families is too distressing for families. We examined the effect of family centered pediatric advance care planning intervention for teens with cancer (FACE-TC) advance care planning on families' appraisals of their caregiving, distress, and strain. METHODS In a randomized clinical trial with adolescents with cancer and their families conducted from July 2016 to April 2019 in 4 tertiary pediatric hospitals, adolescents and family dyads were randomly assigned at a 2:1 intervention/control ratio to either the 3 weekly sessions of FACE-TC (Advance Care Planning Survey; Next Steps: Respecting Choices; Five Wishes) or treatment-as-usual. Only the family member was included in this study. Generalized estimating equations assessed the intervention effect measured by Family Appraisal of Caregiving Questionnaire. RESULTS Families' (n = 126) mean age was 46 years; 83% were female, and 82% were white. FACE-TC families significantly increased positive caregiving appraisals at 3-months postintervention, compared with those in the control group (β = .35; 95% confidence interval [CI] 0.19 to 0.36; P = .03). No significant differences were found between groups for strain (β = -.14; 95% CI = -0.42 to 0.15; P = .35) or distress (β = -.01; CI = -0.35 to 0.32; P = .93). CONCLUSIONS Families benefited from participation in FACE-TC, which resulted in positive appraisals of their caregiving for their child with cancer, while not significantly burdening them with distress or strain. Clinicians can be assured of the tolerability of this family-supported model.
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Affiliation(s)
| | - Jennifer Needle
- Department of Pediatrics, Medical School and,Center for Bioethics, University of Minnesota,
Minneapolis, Minnesota
| | | | - Linda Briggs
- Respecting Choices, Coalition to Transform Advanced
Care Innovations, Washington, DC
| | | | - Jichuan Wang
- Division of Biostatistics and Study Methodology and
Children’s National Research Institute, Washington, DC
| | - Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center
and,Rebecca D. Considine Research Institute, Akron
Children’s Hospital, Akron, Ohio
| | - Maureen E. Lyon
- Center for Translational Research and,Department of Pediatrics, School of Medicine and
Health Sciences, George Washington University, Washington, DC; and,Division of Adolescent and Young Adult Medicine,
Children’s National Hospital, Washington, DC
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17
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Verberne LM, Fahner JC, Sondaal SFV, Schouten–van Meeteren AYN, de Kruiff CC, van Delden JJM, Kars MC. Anticipating the future of the child and family in pediatric palliative care: a qualitative study into the perspectives of parents and healthcare professionals. Eur J Pediatr 2021; 180:949-957. [PMID: 33030601 PMCID: PMC7886816 DOI: 10.1007/s00431-020-03824-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/15/2020] [Accepted: 10/01/2020] [Indexed: 11/24/2022]
Abstract
Preparing for future scenarios in pediatric palliative care is perceived as complex and challenging by both families and healthcare professionals. This interpretative qualitative study using thematic analysis aims to explore how parents and healthcare professionals anticipate the future of the child and family in pediatric palliative care. Single and repeated interviews were undertaken with 42 parents and 35 healthcare professionals of 24 children, receiving palliative care. Anticipating the future was seen in three forms: goal-directed conversations, anticipated care, and guidance on the job. Goal-directed conversations were initiated by either parents or healthcare professionals to ensure others could align with their perspective regarding the future. Anticipated care meant healthcare professionals or parents organized practical care arrangements for future scenarios with or without informing each other. Guidance on the job was a form of short-term anticipation, whereby healthcare professionals guide parents ad hoc through difficult situations.Conclusion: Anticipating the future of the child and family is mainly focused on achievement of individual care goals of both families and healthcare professionals, practical arrangements in advance, and short-term anticipation when a child deteriorates. A more open approach early in disease trajectories exploring perspectives on the future could allow parents to anticipate more gradually and to integrate their preferences into the care of their child. What is Known: • Anticipating the future in pediatric palliative care occurs infrequently and too late. What is New: • Healthcare professionals and parents use different strategies to anticipate the future of children receiving palliative care, both intentionally and unwittingly. Strategies to anticipate the future are goal-directed conversations, anticipated care, and guidance on the job. • Parents and healthcare professionals are engaged to a limited extent in ongoing explorative conversations that support shared decision-making regarding future care and treatment.
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Affiliation(s)
- Lisa M. Verberne
- Department of pediatrics, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
| | - Jurrianne C. Fahner
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - Stephanie F. V. Sondaal
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | | | - Chris C. de Kruiff
- Emma Children’s Hospital, Amsterdam University Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Johannes J. M. van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - Marijke C. Kars
- Center of Expertise Palliative Care, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
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18
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Neuburg L. Early Initiation of Pediatric Palliative Care. J Pediatr Health Care 2021; 35:114-119. [PMID: 32660809 DOI: 10.1016/j.pedhc.2020.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 11/20/2022]
Abstract
Pediatric palliative care (PPC) literature was utilized to identify barriers for early initiation of palliative care at diagnosis among children with life-threatening diseases. Early integration of PPC enhances quality of life and reduces suffering in these children, but many clinicians fail to initiate advanced care planning, establish goals of care, and refer to specialists. Barriers to early PPC initiation include clinician misperceptions, emotional toll on clinicians, and prognostic uncertainty about treatment options and care management strategies. Pediatric nurse practitioners can increase awareness, educate, and support other clinicians to promote early initiation of PPC in children with life-threatening diseases.
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19
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Lin CJ, Cheng YI, Garvie PA, D’Angelo LJ, Wang J, Lyon ME. The Effect of FAmily-CEntered (FACE ®) Pediatric Advanced Care Planning Intervention on Family Anxiety: A Randomized Controlled Clinical Trial for Adolescents With HIV and Their Families. JOURNAL OF FAMILY NURSING 2020; 26:315-326. [PMID: 33283612 PMCID: PMC8015181 DOI: 10.1177/1074840720964093] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Clinicians fear pediatric advance care planning (pACP) for adolescents is too distressing for families. Multisite longitudinal randomized controlled trial of adolescents with HIV tested the effect of FAmily-CEntered (FACE®) pACP intervention on families' anxiety and depression. One hundred five adolescent/family dyads were randomized to FACE® (n = 54 dyads) or control (n = 51 dyads). Families were 90% African American, 37% HIV-positive, and 22% less than high school educated. Families reported lower anxiety 3 months post-FACE® intervention than control (β = -4.71, 95% confidence interval [CI] = [-8.20, -1.23], p = .008). Male family members were less anxious than female family members (β = -4.55, 95% CI = [-6.96, -2.138], p ≤ .001). Family members living with HIV reported greater depressive symptoms than HIV-uninfected families (β = 3.32, 95% CI = [0.254, 6.38], p = .034). Clinicians can be assured this structured, facilitated FACE® pACP model minimized family anxiety without increasing depressive symptoms. Adolescent/family dyads should be invited to have access to, and provision of, evidence-based pACP as part of patient-centered/family-supported care in the HIV continuum of care.
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Affiliation(s)
| | - Yao I. Cheng
- Children’s National Hospital & Center for Translational Research, Washington, DC, USA
| | | | | | - Jichuan Wang
- Children’s National Hospital, Washington, DC, USA
- George Washington University School of Medicine and Health Sciences, DC, USA
| | - Maureen E. Lyon
- Children’s National Hospital & Center for Translational Research, Washington, DC, USA
- George Washington University School of Medicine and Health Sciences, DC, USA
- Children’s National Research Institute, Washington, DC, USA
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20
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Song IG, Kang SH, Kim MS, Kim CH, Moon YJ, Lee J. Differences in perspectives of pediatricians on advance care planning: a cross-sectional survey. BMC Palliat Care 2020; 19:145. [PMID: 32948177 PMCID: PMC7500719 DOI: 10.1186/s12904-020-00652-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/10/2020] [Indexed: 12/03/2022] Open
Abstract
Background The increase in the number of pediatric patients with complex health conditions necessitates the application of advance care planning for children. Earlier, withdrawal of life-sustaining treatment was taboo in the medical society in South Korea due to the history of such practice being punishable by law, and physicians tended to pursue aggressive treatment. With changes in public opinion on end-of-life care, the Korean government enacted a new law that protect human dignity by respecting patients’ self-determination and facilitating advance care planning. However, little is known about current state of advance care planning for pediatric patients. The study aimed to assess perceptions regarding advance care planning among South Korean pediatricians and clarify any differences in perception among pediatric subspecialties. Methods This study was an observational cross-sectional survey that used a web-based self-report questionnaire. Participants comprised of pediatricians currently caring for children with life-limiting conditions in 2018. Results Of the 96 respondents, 89 were included in the analysis. In a hypothetical patient scenario, more hemato-oncologists and intensivists than neonatologists and neurologists preferred to provide comfort care than aggressive treatment. While 72.2% of hemato-oncologists reported that they usually or always discuss advance care plans with parents during treatment, more than half of other pediatricians reported that they seldom do so. Furthermore, 65% of respondents said that they never discuss advance care planning with adolescent patients. Moreover, there were no notable differences among subspecialties. The most prevalent answers to factors impeding advance care planning were lack of systemic support after performing advance care planning (82.0%) and uncertain legal responsibilities (70.8%). Conclusions The pediatricians differed in their experiences and attitudes toward advance care planning based on their subspecialty. Consequently, institutional support and education should be provided to physicians so that they can include children and families in discussions on prognosis.
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Affiliation(s)
- In Gyu Song
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung Han Kang
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, South Korea
| | - Min Sun Kim
- Department of Pediatrics, Seoul National University Children's Hospital, 101, Daehak-ro, Jungno-gu, Seoul, 03080, South Korea.
| | - Cho Hee Kim
- College of Nursing, Seoul National University, Seoul, South Korea
| | - Yi Ji Moon
- Integrative Care Hub, Seoul National University Children's Hospital, Seoul, South Korea
| | - Jung Lee
- Integrative Care Hub, Seoul National University Children's Hospital, Seoul, South Korea
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21
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Bradford N, Rolfe M, Ekberg S, Mitchell G, Beane T, Ferranti K, Herbert A. Family meetings in paediatric palliative care: an integrative review. BMJ Support Palliat Care 2020; 11:288-295. [PMID: 32680893 DOI: 10.1136/bmjspcare-2020-002333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/21/2020] [Accepted: 06/01/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Our aim was to synthesise the available evidence surrounding the structure, processes and outcomes of family meetings in the paediatric palliative care literature. METHODS We undertook an integrative literature review informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was registered with PROSPERO (CRD42019138938). Electronic databases were systematically search using keywords and hand searching of reference articles and grey literature was also completed. RESULTS Ten empirical studies and five theoretical articles were included in the synthesis. Empirical studies provided more information about meeting structure, whereas theoretical articles more frequently described a desired process for planning and undertaking meetings. No articles identified how the success of a meeting was defined or made recommendations for doing so. Despite reports that family meetings are commonly occurring, few articles described outcomes from either the family or clinician perspectives. CONCLUSIONS Family meetings are essential communication strategies commonly used in paediatric palliative care, yet there is little guidance about how meetings should be organised and conducted, who should participate and when they should occur. The limited data available on the outcomes of family meetings suggest improvements are required to meet the needs of families. We present a framework that synthesises the available evidence. The framework offers an overview of the elements to consider when planning for and undertaking family meetings in paediatric palliative care and may be useful for both clinicians and researchers.
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Affiliation(s)
- Natalie Bradford
- Centre for Healthcare Transformation at Centre for Children's Health Research, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Melanie Rolfe
- Centre for Healthcare Transformation at Centre for Children's Health Research, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Stuart Ekberg
- Institute of Health and Biomedical Innovation/School of Psychology and Counselling/Centre for Children's Health Research, Queensland University of Technology Kelvin Grove, Brisbane, Queensland, Australia
| | - Geoffrey Mitchell
- Primary Care Clinical Unit, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Theresa Beane
- Cancer Care Service, Hervey Bay Hospital, Hervey Bay, Queensland, Australia
| | - Kahli Ferranti
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Anthony Herbert
- Institute of Health and Biomedical Innovation/Centre for Children's Health Research, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,Paediatric Palliative Care Service, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
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Fahner JC, Rietjens JAC, van der Heide A, van Delden JJM, Kars MC. Survey of paediatricians caring for children with life-limiting conditions found that they were involved in advance care planning. Acta Paediatr 2020; 109:1011-1018. [PMID: 31625623 PMCID: PMC7216915 DOI: 10.1111/apa.15061] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/04/2019] [Accepted: 10/15/2019] [Indexed: 12/01/2022]
Abstract
AIM Advance care planning (ACP) is a strategy to align future care and treatment with preferences of patients and families. This study assesses the experiences of ACP among paediatricians caring for children with life-limiting conditions. METHODS Paediatricians from five Dutch university hospitals and the national oncology centre completed a survey during May to September 2017, which investigated experiences with ACP in their most recent case of a deceased child and with ACP in general. RESULTS A total of 207 paediatricians responded (36%). After exclusion of responses with insufficient data (n = 39), 168 were analysed (29%). These included experiences with an individual case in 86%. ACP themes were discussed with parents in all cases. Topics common to many cases were diagnosis, life expectancy, care goals, the parent's fears and code status. ACP conversations occurred with children in 23% of cases. The joy in living was the most frequent topic. The frequency of ACP conversations was insufficient according to 49% of the respondents. In 60%, it was stated that ACP has to result in a documented code status. CONCLUSION Paediatricians reported having ACP conversations mainly with parents focusing on medical issues. There was limited insight into the child's preferences for care and treatment.
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Affiliation(s)
- Jurrianne C. Fahner
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
| | | | | | - Johannes J. M. van Delden
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Marijke C. Kars
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
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Friebert S, Grossoehme DH, Baker JN, Needle J, Thompkins JD, Cheng YI, Wang J, Lyon ME. Congruence Gaps Between Adolescents With Cancer and Their Families Regarding Values, Goals, and Beliefs About End-of-Life Care. JAMA Netw Open 2020; 3:e205424. [PMID: 32427325 PMCID: PMC7237980 DOI: 10.1001/jamanetworkopen.2020.5424] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/13/2020] [Indexed: 11/14/2022] Open
Abstract
Importance Lack of pediatric advance care planning has been associated with poor communication, increased hospitalization, poor quality of life, and legal actions. Clinicians presume that families understand adolescents' treatment preferences for end-of-life care. Objective To examine patient-reported end-of-life values and needs of adolescents with cancer and congruence with their families' understanding of these needs. Design, Setting, and Participants This cross-sectional survey was conducted among adolescent-family dyads from July 16, 2016, to April 30, 2019, at 4 tertiary care pediatric US hospitals. Participants included 80 adolescent-family dyads (160 participants) within a larger study facilitating pediatric advance care planning. Adolescent eligibility criteria included being aged 14 to 21 years, English speaking, being diagnosed with cancer at any stage, and knowing their diagnosis. Family included legal guardians for minors or chosen surrogate decision-makers for those aged 18 years or older. Data analysis was performed from April 2019 to November 2019. Exposure Session 1 of the 3-session Family Centered Pediatric Advance Care Planning for Teens With Cancer intervention. Main Outcomes and Measures The main outcome was congruence between adolescents with cancer and their families regarding adolescents' values, goals, and beliefs about end-of-life care. Prevalence-adjusted and bias-adjusted κ (PABAK) values were used to measure congruence on the Lyon Advance Care Planning Survey-Revised (Patient and Surrogate versions). Results A total of 80 adolescent-family dyads (160 participants) were randomized to the intervention group in the original trial. Among the adolescents, 44 (55.0%) were female and 60 (75.0%) were white, with a mean (SD) age of 16.9 (1.8) years. Among family members, 66 (82.5%) were female and 65 (81.3%) were white, with a mean (SD) age of 45.3 (8.3) years. Family members' understanding of their adolescent's beliefs about the best time bring up end-of-life decisions was poor: 86% of adolescents wanted early timing (before getting sick, while healthy, when first diagnosed, when first sick from a life-threatening illness, or all of the above), but only 39% of families knew this (PABAK, 0.18). Families' understanding of what was important to their adolescents when dealing with their own dying was excellent for wanting honest answers from their physician (PABAK, 0.95) and understanding treatment choices (PABAK, 0.95) but poor for dying a natural death (PABAK, 0.18) and being off machines that extend life, if dying (PABAK, 0). Conclusions and Relevance Many families had a poor understanding of their adolescent's values regarding their own end-of-life care, such as when to initiate end-of-life conversations and preference for being off machines that extend life. Pediatric advance care planning could minimize these misunderstandings with the potential for a substantial impact on quality of care.
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Affiliation(s)
- Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center, Akron Children’s Hospital, Akron, Ohio
- Rebecca D. Considine Research Institute, Akron Children’s Hospital, Akron, Ohio
| | - Daniel H. Grossoehme
- Haslinger Family Pediatric Palliative Care Center, Akron Children’s Hospital, Akron, Ohio
- Rebecca D. Considine Research Institute, Akron Children’s Hospital, Akron, Ohio
| | - Justin N. Baker
- Division of Quality of Life and Palliative Care, St Jude Research Hospital, Memphis, Tennessee
| | - Jennifer Needle
- Center for Bioethics, Department of Pediatrics, University of Minnesota, Minneapolis
| | - Jessica D. Thompkins
- Center for Translational Research, Children’s Research Institute, Children’s National Hospital, Washington, DC
| | - Yao I. Cheng
- Division of Biostatistics and Study Methodology, Center for Translational Research, Children’s Research Institute, Children’s National Hospital, Washington, DC
| | - Jichuan Wang
- Division of Biostatistics and Study Methodology, Center for Translational Research, Children’s Research Institute, Children’s National Hospital, Washington, DC
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Maureen E. Lyon
- George Washington University School of Medicine and Health Sciences, Washington, DC
- Division of Adolescent and Young Adult Medicine, Center for Translational Research, Children’s Research Institute, Children’s National Hospital, Washington, DC
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Sinclair S, Kondejewski J, Schulte F, Letourneau N, Kuhn S, Raffin-Bouchal S, Guilcher GMT, Strother D. Compassion in Pediatric Healthcare: A Scoping Review. J Pediatr Nurs 2020; 51:57-66. [PMID: 31901770 DOI: 10.1016/j.pedn.2019.12.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/10/2019] [Accepted: 12/15/2019] [Indexed: 12/30/2022]
Abstract
PROBLEM Compassion has been described as a central construct or essential feature of quality healthcare and is as important to patients' and families' overall healthcare experience as the health interventions and treatments they receive. However, there is little shared understanding of what constitutes compassion, how it is delivered within a pediatric setting, and pediatric patients' and families perspectives and preferences for receiving it. ELIGIBILITY CRITERIA Studies that (1) described the nature of the existing literature on compassion in pediatric healthcare; (2) summarized key concepts in the existing evidence base that pertain to compassion in pediatric healthcare; and 3) identified factors that are associated with compassion in pediatric healthcare were eligible for inclusion in this review. SAMPLE Twenty-nine papers were included in the review. RESULTS Findings revealed several factors are associated with compassion in pediatric healthcare, including continuity of care, communication, and coordination of care. Most notably, identified studies treated compassion in a subsidiary fashion, and this review revealed no studies that provided a patient-informed evidence-based definition of compassion in the pediatric healthcare setting. CONCLUSION Future research is required to generate a comprehensive and accurate understanding of the terms 'compassion' and 'compassionate care' when used in the context of pediatric healthcare. IMPLICATIONS This research will inform the therapeutic processes and ultimately enable the development of strategies to improve the delivery of compassionate healthcare to pediatric patients.
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Affiliation(s)
- Shane Sinclair
- Faculty of Nursing, University of Calgary, Canada; Compassion Research Lab, University of Calgary, Canada; Department of Oncology, Division of Palliative Medicine, Cumming School of Medicine, University of Calgary, Canada.
| | - Jane Kondejewski
- Faculty of Nursing, University of Calgary, Canada; Compassion Research Lab, University of Calgary, Canada
| | - Fiona Schulte
- Department of Oncology, Division of Psychosocial Oncology, Cumming School of Medicine, University of Calgary, Canada
| | - Nicole Letourneau
- Faculty of Nursing, University of Calgary, Canada; Departments of Psychiatry & Community Health Sciences, Cumming School of Medicine, University of Calgary, Canada; Department of Pediatrics, Cumming School of Medicine, University of Calgary, Canada
| | - Susan Kuhn
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Canada
| | | | - Gregory M T Guilcher
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Canada; Department of Oncology, Cumming School of Medicine, University of Calgary, Canada
| | - Douglas Strother
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Canada; Department of Oncology, Cumming School of Medicine, University of Calgary, Canada
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Fahner JC, Thölking TW, Rietjens JAC, van der Heide A, van Delden JJM, Kars MC. Towards advance care planning in pediatrics: a qualitative study on envisioning the future as parents of a seriously ill child. Eur J Pediatr 2020; 179:1461-1468. [PMID: 32193658 PMCID: PMC7413894 DOI: 10.1007/s00431-020-03627-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/16/2020] [Accepted: 02/27/2020] [Indexed: 12/03/2022]
Abstract
Advance care planning enables parents to discuss goals and preferences for future care and treatment of their seriously ill child. Although clinicians report parental factors as common barriers for advance care planning, parental views on reflecting on their child's future have had limited exploration. A clear understanding of their perspectives might help clinicians to implement advance care planning tailored to parental needs. This interpretive qualitative study using thematic analysis aims to identify how parents envision the future when caring for their seriously ill child. Single interviews and two focus groups were attended by 20 parents of 17 seriously ill children. Parents reported to focus on the near future of their child. However, their actions and deeper thoughts showed perspectives towards a further future. Future perspectives initial focused on practical, disease-related themes, but more existential elaborations, reflecting underlying life values, were also identified. Parents needed acknowledgement of their challenging situation, care tasks, and expertise as a precondition for sharing their deepest thoughts regarding the future of their child.Conclusion: When envisioning the future of their seriously ill child, parents tend to stay in the near future, whereas they value the opportunity to share further thoughts within a compassionate relationship with clinicians. What is Known: • Parents prefer open and honest information about their child's illness and prognosis and they value the concept of advance care planning, while they emphasize the need for an individualized approach. • Health care professionals see parental factors like unease and emotional burden as key barriers for advance care planning. What is New: • When envisioning the future of their seriously ill child, parents tended to stay close to the near future initially, with a focus on disease-related, practical themes. Ongoing conversations uncovered deeper, value-based elaborations towards the future. To engage parents in advance care planning, the future needs to be discussed in relation to the present and the past. • There is "no sharing without caring". Parents who felt cared for and acknowledged in their challenging context by clinicians, were open to share their perspectives on the future of their seriously ill child. To share deeper motives and values underlying goals and preferences for future care and treatment, parents need a stimulating attitude of listening and encouragement from clinicians to express their feelings.
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Affiliation(s)
- Jurrianne C. Fahner
- grid.7692.a0000000090126352Julius Center for Health Sciences and Primary Care, Medical Humanities, University Medical Center Utrecht, Internal mail no Str. 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Thessa W. Thölking
- grid.7692.a0000000090126352Julius Center for Health Sciences and Primary Care, Medical Humanities, University Medical Center Utrecht, Internal mail no Str. 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Judith A. C. Rietjens
- grid.5645.2000000040459992XDepartment of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Agnes van der Heide
- grid.5645.2000000040459992XDepartment of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johannes J. M. van Delden
- grid.7692.a0000000090126352Julius Center for Health Sciences and Primary Care, Medical Humanities, University Medical Center Utrecht, Internal mail no Str. 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Marijke C. Kars
- grid.7692.a0000000090126352Julius Center for Health Sciences and Primary Care, Medical Humanities, University Medical Center Utrecht, Internal mail no Str. 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
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Udo C, Kreicbergs U, Axelsson B, Björk O, Lövgren M. Physicians working in oncology identified challenges and factors that facilitated communication with families when children could not be cured. Acta Paediatr 2019; 108:2285-2291. [PMID: 31206784 PMCID: PMC6899467 DOI: 10.1111/apa.14903] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/08/2019] [Accepted: 06/13/2019] [Indexed: 11/26/2022]
Abstract
Aim We explored physicians’ experiences of communicating with families when their child had cancer and a cure was no longer an option, by focusing on barriers and facilitating factors. Methods Physicians from the six cancer centres in Sweden took part in focus group discussions between December 2017 and May 2018, and the data were analysed using qualitative content analysis. Focus groups enabled us to gather individual and shared perspectives. Results The 35 physicians (20 male) had a mean age of 47 (range 31‐74) and a mean of 11 years’ experience in oncology, ranging from under one year to 43 years. They reported communication challenges when a cure was not possible, namely: emotional and mental drain, lack of mutual understanding and uncertainty about communication skills. They also reported facilitating factors: flexibility in complex conversations, the child’s position in the conversations, continuity and trusting relationships, support from colleagues and having discussed the potentially life‐threatening nature of cancer from the very start of treatment. Conclusion Training to overcome communication issues could support the early integration of palliative care.
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Affiliation(s)
- Camilla Udo
- School of Education, Health and Social Studies Dalarna University Falun Sweden
- CKF Center for Clinical Research Dalarna Falun Sweden
- Department of Health Care Sciences, Palliative Research Centre Ersta Sköndal Bräcke University College Stockholm Sweden
| | - Ulrika Kreicbergs
- Department of Health Care Sciences, Palliative Research Centre Ersta Sköndal Bräcke University College Stockholm Sweden
- Department of Women’s and Children’s Health, Paediatric Oncology and Haematology, Childhood Cancer Research Unit Karolinska Institutet Stockholm Sweden
| | - Bertil Axelsson
- Department of Radiation Sciences, Unit of Clinical Research Centre‐Östersund Umeå University Umeå Sweden
| | | | - Malin Lövgren
- Department of Health Care Sciences, Palliative Research Centre Ersta Sköndal Bräcke University College Stockholm Sweden
- Department of Women’s and Children’s Health, Paediatric Oncology and Haematology, Childhood Cancer Research Unit Karolinska Institutet Stockholm Sweden
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Feudtner C, Rosenberg AR, Boss RD, Wiener L, Lyon ME, Hinds PS, Bluebond-Langner M, Wolfe J. Challenges and Priorities for Pediatric Palliative Care Research in the U.S. and Similar Practice Settings: Report From a Pediatric Palliative Care Research Network Workshop. J Pain Symptom Manage 2019; 58:909-917.e3. [PMID: 31445136 PMCID: PMC8499153 DOI: 10.1016/j.jpainsymman.2019.08.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/07/2019] [Accepted: 08/08/2019] [Indexed: 12/11/2022]
Abstract
CONTEXT To dramatically advance the evidence base for pediatric palliative care (PPC) interventions, practices, and programs in the U.S. and similar practice settings, the field needs to better understand the challenges and opportunities for rigorous scholarship. OBJECTIVES The Pediatric Palliative Care Research Network conducted a workshop to clarify challenges and identify key priorities. METHODS The workshop focused on PPC research topics and methods, including outcomes measurement, qualitative inquiry, analyses of big data, prospective collection of research data, case series and cohort studies, and intervention trials, with synthesizing summary and follow-up discussions. All attendees reviewed and approved the final report. RESULTS Five common challenges were identified: patient diversity and small population size; interdependencies and dynamic interactions between child, family members, and disease processes over time; outcomes and measurement; workforce and infrastructure limitations; and presumed burden of PPC research on participants. Seven priorities emerged: bolster training and development of PPC investigators; develop core resources; advance symptom measurement (and measurements of other exposures and outcomes); improve symptom management and quality of life interventions; improve communication, elicitation of goals of care, and decision making; understand family impact and facilitate or improve family adaptation and coping; and analyze and improve systems of care, policy, and education. CONCLUSION These challenges and priorities identify key research areas that can guide individual investigators and research funders to advance the field.
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Affiliation(s)
- Chris Feudtner
- The Ingerman Center for Pediatric Palliative Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Abby R Rosenberg
- Palliative Care and Resilience Program, Seattle Children's Research Institute, Seattle, Washington, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Renee D Boss
- Department of Pediatrics, Johns Hopkins School of Medicine and Berman Institute of Bioethics, Baltimore, Maryland, USA
| | - Lori Wiener
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Maureen E Lyon
- Center for Translational Research, Children's National Health System, Washington, District of Columbia, USA; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Pamela S Hinds
- Children's National Health System, Department of Nursing Science, Professional Practice & Quality, and the George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Myra Bluebond-Langner
- Louis Dundas Centre for Children's Palliative Care, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom; Department of Sociology, Anthropology, and Criminal Justice, Rutgers University, Camden, New Jersey, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Sasazuki M, Sakai Y, Kira R, Toda N, Ichimiya Y, Akamine S, Torio M, Ishizaki Y, Sanefuji M, Narama M, Itai K, Hara T, Takada H, Kizawa Y, Ohga S. Decision-making dilemmas of paediatricians: a qualitative study in Japan. BMJ Open 2019; 9:e026579. [PMID: 31431444 PMCID: PMC6707677 DOI: 10.1136/bmjopen-2018-026579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To delineate the critical decision-making processes that paediatricians apply when treating children with life-threatening conditions and the psychosocial experience of paediatricians involved in such care. DESIGN We conducted semistructured, individual face-to-face interviews for each participant from 2014 to 2015. The content of each interview was subjected to a comprehensive qualitative analysis. The categories of dilemma were extracted from a second-round content analysis. PARTICIPANTS Participants were board-certified paediatricians with sufficient experience in making decisions in relation to children with severe illnesses or disabilities. We repeated purposive sampling and analyses until we reached saturation of the category data. RESULTS We performed interviews with 15 paediatricians. They each reported both unique and overlapping categories of dilemmas that they encountered when making critical decisions. The dilemmas included five types of causal elements: (1) paediatricians' convictions; (2) the quest for the best interests of patients; (3) the quest for medically appropriate plans; (4) confronting parents and families and (5) socioenvironmental issues. Dilemmas occurred and developed as conflicting interactions among these five elements. We further categorised these five elements into three principal domains: the decision-maker (decider); consensus making among families, colleagues and society (process) and the consequential output of the decision (consequence). CONCLUSIONS This is the first qualitative study to demonstrate the framework of paediatricians' decision-making processes and the complex structures of dilemmas they face. Our data indicate the necessity of establishing and implementing an effective support system for paediatricians, such as structured professional education and arguments for creating social consensus that assist them to reach the best plan for the management of severely ill children.
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Affiliation(s)
- Momoko Sasazuki
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Health and Welfare, Seinan Jogakuin University, Kitakyushu, Japan
| | - Yasunari Sakai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryutaro Kira
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Naoko Toda
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuko Ichimiya
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Satoshi Akamine
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Michiko Torio
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshito Ishizaki
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Sanefuji
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Miho Narama
- Department of Nursing, Kyoto Tachibana University, Kyoto, Japan
| | - Koichiro Itai
- Department of Bio/Medical Ethics, Interdisciplinary Graduate School of Medicine and Veterinary Medicine, University of Miyazaki, Miyazaki, Japan
| | - Toshiro Hara
- President, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Hidetoshi Takada
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Hemsley B, Meredith J, Bryant L, Wilson NJ, Higgins I, Georgiou A, Hill S, Balandin S, McCarthy S. An integrative review of stakeholder views on Advance Care Directives (ACD): Barriers and facilitators to initiation, documentation, storage, and implementation. PATIENT EDUCATION AND COUNSELING 2019; 102:1067-1079. [PMID: 30799141 DOI: 10.1016/j.pec.2019.01.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/05/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To examine the views and experiences of patients and their health care providers on developing advance care planning (ACP) and advance care directives (ACD); and determine barriers and facilitators to ACD development, storage, and use, including implications for people with communication disability. METHOD An integrative review of 93 studies, analysed according to their content themes. RESULTS Content themes encapsulated the initiation, documentation, and implementation stages of ACP/ACD. Lack of guidance for initiating and supporting ACP/ACD impedes discussions, and both patients and healthcare providers avoid discussions owing to fear of dying and reluctance to think about end-of-life. CONCLUSIONS There are several barriers and facilitators to the initiation of ACP discussions, documentation and implementation of ACD, and little research exploring the views of legal professionals on the development, storage, or use of ACP documents. Further research is needed to explore the timing and responsibility of both legal and health professionals in initiating and supporting ACP discussions. PRACTICE IMPLICATIONS It is important for healthcare providers to raise ACP discussions regularly so that patients have time to make informed advance care decisions. Storage of the document in an electronic health record might facilitate better access to and implementation of patients' end-of-life care decisions.
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Affiliation(s)
- Bronwyn Hemsley
- The University of Technology Sydney, Building 7, Faculty of Science and Graduate School of Health Building, 67 Thomas Street, Ultimo, Australia @BronwynHemsley.
| | - Jacqueline Meredith
- The University of Newcastle, University Drive, Callaghan, 2308, NSW, Australia.
| | - Lucy Bryant
- The University of Technology Sydney, Building 7, Faculty of Science and Graduate School of Health Building, 67 Thomas Street, Ultimo, Australia @BronwynHemsley.
| | - Nathan J Wilson
- Western Sydney University, Building G10/Office 10, Hawkesbury Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia.
| | - Isabel Higgins
- The University of Newcastle, University Drive, Callaghan, 2308, NSW, Australia.
| | - Andrew Georgiou
- Macquarie University, Room L6 36, Level 6, 75 Talavera Road, NSW, 2109, Australia.
| | - Sophie Hill
- La Trobe University, School of Psychology and Public Health, College of Science, Health and Engineering, VIC, 3086, Australia.
| | - Susan Balandin
- Deakin University, Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC, 3125, Australia.
| | - Shaun McCarthy
- The University of Newcastle, University Drive, Callaghan, 2308, NSW, Australia.
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Refinement of a Conceptual Model for Adolescent Readiness to Engage in End-of-Life Discussions. Cancer Nurs 2019; 41:E21-E39. [PMID: 28114261 DOI: 10.1097/ncc.0000000000000465] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adolescents living with incurable cancer require ongoing support to process grief, emotions, and information as disease progresses including treatment options (phase 1 clinical trials and/or hospice/palliative care). Little is known about how adolescents become ready for such discussions. OBJECTIVE The purpose of this study was to explore the process of adolescent readiness for end-of-life preparedness discussions, generating a theoretical understanding for guiding clinical conversations when curative options are limited. METHODS We explored 2 in-depth cases across time using case-study methodology. An à priori conceptual model based on current end-of-life research guided data collection and analysis. Multiple sources including in-depth adolescent interviews generated data collection on model constructs. Analysis followed a logical sequence establishing a chain of evidence linking raw data to study conclusions. Synthesis and data triangulation across cases and time led to theoretical generalizations. Initially, we proposed a linear process of readiness with 3 domains: a cognitive domain (awareness), an emotional domain (acceptance), and a behavioral domain (willingness), which preceded preparedness. RESULTS Findings led to conceptual model refinement showing readiness is a dynamic internal process that interacts with preparedness. Current awareness context facilitates the type of preparedness discussions (cognitive or emotional). Furthermore, social constraint inhibits discussions. CONCLUSIONS Data support theoretical understanding of the dynamism of readiness. Future research that validates adolescent conceptualization will ensure age-appropriate readiness representation. IMPLICATIONS FOR PRACTICE Understanding the dynamic process of readiness for engaging in end-of-life preparedness provides clinician insight for guiding discussions that facilitate shared decision making and promote quality of life for adolescents and their families.
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Abstract
This article describes the preparation, rationale, and benefits of talking with adolescents who have life-threatening or life-limiting illness about advance care planning (ACP) and end-of-life concerns in a developmentally sensitive manner. The first step is to ensure that a health care provider is ready to work with adolescents in ACP discussions by taking a self-inventory, learning communication skills, and understanding individual barriers. The authors then outline how to assess patient and family readiness, including developmental, cultural, personal, and psychosocial considerations. Evidence-based techniques for respectfully and productively engaging adolescents in ACP conversations are discussed.
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Affiliation(s)
- Maryland Pao
- National Institute of Mental Health, 10 Center Drive MSC 1276, NIH Building 10 CRC 6-5340, Bethesda, MD 20892-1276, USA.
| | - Margaret Rose Mahoney
- Office of the Clinical Director, National Institute of Mental Health, 10 Center Drive MSC 1276, NIH Building 10 CRC 6-5360, Bethesda, MD 20892-1276, USA
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Bogetz JF, Hauer J. Certainty of Decisions: A Process-Based Model for Decision Making for Children With Severe Neurological Impairment. Clin Pediatr (Phila) 2018; 57:1227-1231. [PMID: 29113499 DOI: 10.1177/0009922817740668] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jori F Bogetz
- 1 University of California, San Francisco, CA, USA.,2 UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Julie Hauer
- 3 Harvard School of Medicine, Boston, MA, USA.,4 Seven Hills Pediatric Center, Groton, MA, USA
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Hoell JI, Weber HL, Balzer S, Danneberg M, Gagnon G, Trocan L, Borkhardt A, Janßen G, Kuhlen M. Advance care planning and outcome in pediatric palliative home care. Oncotarget 2018; 9:17867-17875. [PMID: 29707152 PMCID: PMC5915160 DOI: 10.18632/oncotarget.24929] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 03/08/2018] [Indexed: 11/25/2022] Open
Abstract
Pediatric advance care planning seeks to ensure end-of-life care conforming to the patients/their families' preferences. To expand our knowledge of advance care planning and "medical orders for life-sustaining treatment" (MOLST) in pediatric palliative home care, we determined the number of patients with MOLST, compared MOLST between the four "Together for Short Lives" (TfSL) groups and analyzed, whether there was a relationship between the content of the MOLST and the patients' places of death. The study was conducted as a single-center retrospective analysis of all patients of a large specialized pediatric palliative home care team (01/2013-09/2016). MOLST were available in 179/198 children (90.4%). Most parents decided fast on MOLST, 99 (55.3%) at initiation of pediatric palliative home care, 150 (83.4%) within the first 100 days. MOLST were only changed in 7.8%. Eighty/179 (44.7%) patients decided on a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) order, 58 (32.4%) on treatment limitations of some kind and 41 (22.9%) wished for the entire spectrum of life-sustaining measures (Full Code). Most TfSL group 1 families wanted DNACPR and most TfSL group 3/4 parents Full Code. The majority (84.9%) of all DNACPR patients died at home/hospice. Conversely, all Full Code patients died in hospital (80% in an intensive care setting). The circumstances of the childrens' deaths can therefore be predicted considering the content of the MOLST. Regular advance care planning discussions are thus a very important aspect of pediatric palliative home care.
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Affiliation(s)
- Jessica I. Hoell
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Hannah L. Weber
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Stefan Balzer
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Mareike Danneberg
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Gabriele Gagnon
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Laura Trocan
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Arndt Borkhardt
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Gisela Janßen
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
| | - Michaela Kuhlen
- University of Duesseldorf, Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Duesseldorf, Germany
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Sisk BA, Mack JW, Ashworth R, DuBois J. Communication in pediatric oncology: State of the field and research agenda. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26727. [PMID: 28748597 PMCID: PMC6902431 DOI: 10.1002/pbc.26727] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/19/2017] [Accepted: 06/20/2017] [Indexed: 12/12/2022]
Abstract
From the time of diagnosis through either survivorship or end of life, communication between healthcare providers and patients or parents can serve several core functions, including fostering healing relationships, exchanging information, responding to emotions, managing uncertainty, making decisions, and enabling patient/family self-management. We systematically reviewed all studies that focused on communication between clinicians and patients or parents in pediatric oncology, categorizing studies based on which core functions of communication they addressed. After identifying gaps in the literature, we propose a research agenda to further the field.
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Affiliation(s)
- Bryan A. Sisk
- Department of Pediatrics, St. Louis Children’s, Hospital, St. Louis, Missouri
| | - Jennifer W. Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts,Department of Medicine, Boston Children’s, Hospital, Boston, Massachusetts
| | - Rachel Ashworth
- Department of Pediatrics, Washington, University School of Medicine, St. Louis, Missouri
| | - James DuBois
- Department of Medicine, Washington, University School of Medicine, St. Louis, Missouri
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Kaye EC, Snaman JM, Johnson L, Levine D, Powell B, Love A, Smith J, Ehrentraut JH, Lyman J, Cunningham M, Baker JN. Communication with Children with Cancer and Their Families Throughout the Illness Journey and at the End of Life. PALLIATIVE CARE IN PEDIATRIC ONCOLOGY 2018. [DOI: 10.1007/978-3-319-61391-8_4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Pediatric Cardiology Provider Attitudes About Palliative Care: A Multicenter Survey Study. Pediatr Cardiol 2017; 38:1324-1331. [PMID: 28664445 DOI: 10.1007/s00246-017-1663-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 06/15/2017] [Indexed: 02/07/2023]
Abstract
While availability of palliative care consultation for children with advanced heart disease increases, little is known about cardiologist attitudes towards palliative care. We sought to describe perspectives of cardiologists regarding palliative care and to characterize their perceived competence in palliative care concepts. A cross-sectional survey of pediatric cardiologists and cardiac surgeons from 19 pediatric medical centers was performed. Overall response rate was 31% (183/589). Respondents had a median of 18 years of experience since medical school (range 2-49) and most practiced at academic centers (91%). Sixty-percent of respondents felt that palliative care consultations occur "too late" and the majority (85%) agreed that palliative care consultations are helpful. Barriers to requesting palliative care consultation were most frequently described as "referring to palliative care services too early will undermine parents' hope" (45%) and "concern that parents will think I am giving up on their child" (56%). Only 33% of cardiologists reported feeling "very" or "moderately" competent in prognosticating life expectancy while over 60% felt competent caring for children with heart disease around end of life, and nearly 80% felt competent discussing goals of care and code status. Greater perceived competence was associated with subspecialty (heart failure/intensivist vs. other) (OR 3.6, 95% CI 1.6-8.1, p = 0.003) and didactic training (OR 6.27, 95% CI 1.8-21.8, p = 0.004). These results underscore the need for further training in palliative care skills for pediatric cardiologists. Enhancing palliative care skills among cardiologists and facilitating partnership with subspecialty palliative care teams may improve overall care of children with advanced heart disease.
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End-of-Life Transitions and Hospice Utilization for Adolescents: Does Having a Usual Source of Care Matter? J Hosp Palliat Nurs 2017; 19:376-382. [PMID: 28684928 DOI: 10.1097/njh.0000000000000361] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Adolescents with life-limiting illnesses have intensive end-of-life trajectories and could benefit from initiation of hospice services. The medical home model, which includes having a usual source of primary care, may help facilitate quality outcomes at the end-of-life for adolescents. The purpose of this study was to determine the relationship between having a usual source of primary care on hospice utilization and end-of-life transitions among adolescents between 15-20 years with a life-limiting illness. A retrospective cohort design used 2007-2010 California Medicaid claims data (n=585). Our dependent variables were hospice utilization (i.e., hospice enrollment, hospice length of stay) and the independent variable was usual source of primary care. Multivariate regression techniques including least squares regression, multivariate logistic regression, and negative binomial regression were used in the analysis of the relationship between usual source of primary care and hospice utilization and end-of-life transitions. Ten percent of our sample utilized hospice services. Having a usual source of primary care was associated with an increase in hospice enrollment, hospice length of stay, and end-of-life transitions. Adolescents with a cancer diagnosis were more likely to enroll in hospice services. For adolescents at the end of life, having a usual source of primary care had a significant impact on hospice enrollment and length of stay. This study is among the first to demonstrate a relationship between primary care and hospice use among this vulnerable population.
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Baumann LM, Williams K, Abdullah F, Hendrickson RJ, Oyetunji TA. Do-not-resuscitate orders and high-risk pediatric surgery: professional nuisance or medical necessity? J Surg Res 2017; 217:213-216. [PMID: 28595818 DOI: 10.1016/j.jss.2017.05.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/23/2017] [Accepted: 05/05/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND There is a paucity of data in the literature regarding end-of-life care and do-not-resuscitate (DNR) status of the pediatric surgical patient, although invasive procedures are frequently performed in very high risk and critically ill children. Despite significant efforts in adult medicine to enhance discussions around end-of-life care, little is known about similar endeavors in the pediatric population. METHODS A retrospective review of the National Surgical Quality Improvement Program Pediatric database was performed. Patients aged <18 y with American Society of Anesthesiologists class 3 or greater who underwent elective surgical procedure in 2012-2013 were included. Demographic factors, principal diagnosis, associated conditions, DNR status, and mortality were extracted. Descriptive analysis was performed. RESULTS A total of 20,164 patients met the inclusion criteria. Only 36 (0.2%) patients had a signed DNR order before surgical procedure. Of severely ill American Society of Anesthesiologists four patients, only 1% had DNR status. There were no differences in gender, race, ethnicity, or surgical specialty by the presence of a DNR order. Notably, 17.1% of children who died within this period had multiple surgical procedures performed before expiring. CONCLUSIONS The rate of documented DNR status is extremely low in the high-risk pediatric surgical population undergoing elective surgery, even among severely ill children. Well-informed end-of-life care discussions in a patient-focused approach are essential in the surgical care of children with complex medical conditions and critical illness. Better documentation of DNR discussion will also allow better tracking and benchmarking.
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Affiliation(s)
- Lauren M Baumann
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kibileri Williams
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Yotani N, Kizawa Y, Shintaku H. Differences between Pediatricians and Internists in Advance Care Planning for Adolescents with Cancer. J Pediatr 2017; 182:356-362. [PMID: 28040231 DOI: 10.1016/j.jpeds.2016.11.079] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/24/2016] [Accepted: 11/30/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate differences between pediatricians and internists in the practice of and barriers to advance care planning (ACP) for adolescent patients with cancer. STUDY DESIGN A self-reported questionnaire was administered to assess the practice of ACP, advance directives, and barriers to ACP for adolescent patients with cancer. All 3392 Japanese board-certified hematologists were surveyed, and 600 hematologists (227 pediatricians, 373 internists) who take care of adolescent patients with cancer with decision-making capacity were analyzed. RESULTS If a patient's prognosis for survival was <3 months, pediatricians were significantly less likely to discuss ACP with their patients than internists, including discussions regarding the patient's medical condition (59% vs 70%), the patient's understanding of his/her medical condition (55% vs 66%), do not attempt resuscitation orders (17% vs 24%), and ventilator treatment if the patient's condition worsened (19% vs 25%). More than 75% of hematologists (both pediatricians and internists) discussed all ACP topics with patients' families. Similarly, with regard to advance directives, pediatricians were less likely than internists to discuss cardiopulmonary resuscitation (24% vs 47%) and the use of ventilators (31% vs 51%), vasopressors (24% vs 42%), and antibiotics (21% vs 31%) with their patients. Both pediatricians and internists discussed these issues more often with patients' families than with patients, especially cardiopulmonary resuscitation (98%) as well as the use of ventilators (98%) and vasopressors (91%). CONCLUSIONS Pediatricians were less likely than internists to discuss ACP and advance directives with patients, and both pediatricians and internists tended to discuss ACP and advance directives more often with patients' families.
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Affiliation(s)
- Nobuyuki Yotani
- Kobe University Graduate School of Medicine, Kobe, Japan; Osaka City University Graduate School of Medicine, Osaka, Japan.
| | | | - Haruo Shintaku
- Osaka City University Graduate School of Medicine, Osaka, Japan
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Withdrawal of Life-Sustaining Therapy at Home: Broadening the View of End-of-Life Care in the PICU…Even in Children's Homes. Pediatr Crit Care Med 2017; 18:92-93. [PMID: 28060160 DOI: 10.1097/pcc.0000000000001005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dallas RH, Kimmel A, Wilkins ML, Rana S, Garcia A, Cheng YI, Wang J, Lyon ME. Acceptability of Family-Centered Advanced Care Planning for Adolescents With HIV. Pediatrics 2016; 138:peds.2016-1854. [PMID: 27940700 PMCID: PMC5127070 DOI: 10.1542/peds.2016-1854] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Small pilot studies support the appropriateness of engaging adolescents with chronic or life-limiting illnesses in pediatric advance care planning (pACP). We do not yet know if pACP is acceptable, feasible, and worthwhile, even if emotionally intense, in a fully powered randomized controlled trial. METHODS We conducted a prospective 2-arm randomized controlled trial at 6 US urban hospitals. Adolescent/family member dyads were randomized to receive the 1-session-a-week 3-session FAmily-CEntered Advance Care Planning (FACE) pACP intervention (1, ACP Survey; 2, Goals of Care Conversation/Treatment Preferences; 3, Completion of Advance Directive) or active comparator (1, Developmental History; 2, Safety Tips; 3, Nutrition/Exercise). The Satisfaction Questionnaire was administered to participants independently after each session by a blinded research assistant. RESULTS We enrolled 53% of eligible participants and intervened with 97 adolescent/family dyads. Adolescents ranged in age from 14 to 21 years; 54% were male individuals; 93% African American; and 73% perinatally infected. Attendance was 99% for all 3 sessions in each arm. At session 3, FACE adolescents and family dyad members, respectively, found the session useful (98%, 98%) and helpful (98%, 100%), despite feelings of sadness (25%, 17%). FACE adolescents' improvement in the total subscale A score (useful, helpful, like a load off my mind, satisfied, something I needed to do, courageous, worthwhile) was better than control adolescents at session 3 (β = 1.16, P = .02). There were no adverse events. CONCLUSIONS FACE enabled worthwhile conversations, while simultaneously eliciting intense emotions. No participants withdrew, 99% of those enrolled completed each session, and there were no adverse events, evidence of pACP's feasibility, acceptability, and safety.
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Affiliation(s)
- Ronald H. Dallas
- Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Allison Kimmel
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia
| | - Megan L. Wilkins
- Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Sohail Rana
- Howard University College of Medicine, Washington, District of Columbia
| | - Ana Garcia
- The University of Miami Miller School of Medicine, Miami, Florida; and
| | - Yao I. Cheng
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia
| | - Jichuan Wang
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia;,The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Maureen E. Lyon
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia;,The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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Sisk BA, Bluebond-Langner M, Wiener L, Mack J, Wolfe J. Prognostic Disclosures to Children: A Historical Perspective. Pediatrics 2016; 138:peds.2016-1278. [PMID: 27561728 PMCID: PMC5005028 DOI: 10.1542/peds.2016-1278] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2016] [Indexed: 11/24/2022] Open
Abstract
Prognostic disclosure to children has perpetually challenged clinicians and parents. In this article, we review the historical literature on prognostic disclosure to children in the United States using cancer as an illness model. Before 1948, there was virtually no literature focused on prognostic disclosure to children. As articles began to be published in the 1950s and 1960s, many clinicians and researchers initially recommended a "protective" approach to disclosure, where children were shielded from the harms of bad news. We identified 4 main arguments in the literature at this time supporting this "protective" approach. By the late 1960s, however, a growing number of clinicians and researchers were recommending a more "open" approach, where children were included in discussions of diagnosis, which at the time was often synonymous with a terminal prognosis. Four different arguments in the literature were used at this time supporting this "open" approach. Then, by the late 1980s, the recommended approach to prognostic disclosure in pediatrics shifted largely from "never tell" to "always tell." In recent years, however, there has been a growing appreciation for the complexity of prognostic disclosure in pediatrics. Current understanding of pediatric disclosure does not lead to simple "black-and-white" recommendations for disclosure practices. As with most difficult questions, we are left to balance competing factors on a case-by-case basis. We highlight 4 categories of current considerations related to prognostic disclosure in pediatrics, and we offer several approaches to prognostic disclosure for clinicians who care for these young patients and their families.
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Affiliation(s)
- Bryan A. Sisk
- Department of Pediatrics, St Louis Children’s Hospital, St. Louis, Missouri
| | - Myra Bluebond-Langner
- Louis Dundas Centre for Children’s Palliative Care, Institute of Child Health, University College London, London, England
| | - Lori Wiener
- National Cancer Institute, Center for Cancer Research, Pediatric Oncology Branch, Bethesda, Maryland
| | - Jennifer Mack
- Departments of Pediatric Oncology and Division of Population Sciences, and,Division of Pediatric Hematology/Oncology, and
| | - Joanne Wolfe
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; and,Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
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