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Liu A, Hammack-Aviran C, Turnbull J. Tracheostomy Decision Making and Counseling: Comparing Providers' and Caregivers' Perspectives and Perceptions. J Palliat Med 2024; 27:1163-1170. [PMID: 38990602 DOI: 10.1089/jpm.2023.0699] [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: 07/12/2024] Open
Abstract
Background: The decision to place a tracheostomy in children is complex and involves factors beyond the medical procedure, including quality of life, values, and goals. Providers play an important role in counseling caregivers and guiding them through the decision-making process. There are no established guidelines for tracheostomy counseling, leading to variations in practice. Additionally, how caregivers receive information differs from how providers believe they deliver it. Although studies have explored caregivers' and providers' viewpoints, none have examined them concurrently. Background: The primary aim of this exploratory study is to investigate differences between providers' and caregivers' perceptions of tracheostomy counseling and their perspectives regarding the decision-making process. Design: Semi-structured interviews were conducted with both caregivers and providers for children being evaluated for a tracheostomy. Qualitative analysis was applied to the interview transcripts to identify emergent themes. Subsequently, a comparative analysis was performed to compare these themes between caregivers and healthcare providers. Results: A total of 33 interviews were conducted, involving 16 caregivers and 17 providers. Notably, caregivers provided personal descriptions of their children in 81% of cases, whereas only 35% of providers did so. Concerns and fears for the children were expressed by 69% of caregivers and 59% of providers. In contrast, 75% of caregivers discussed their hopes and dreams for their children, compared with only 29% of providers. When it came to priorities, 69% of caregivers emphasized growth and development, and 38% mentioned discharge home, as opposed to 29% and 47% among providers, respectively. Conclusion: In conclusion, our study highlights a disconnect between caregivers and healthcare providers regarding tracheostomy counseling. These differing perspectives underscore the need for improved communication and understanding between the two groups. Recognizing these differences can help providers tailor their counseling approaches to better align with the values and priorities of families when making decisions about tracheostomy.
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Affiliation(s)
- Andy Liu
- Department of Pediatrics, Division of Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Jessica Turnbull
- Department of Pediatrics, Division of Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Mack C, Mailo J, Ofosu D, Hinai AA, Keto-Lambert D, Soril LJJ, van Manen M, Castro-Codesal M. Tracheostomy and long-term invasive ventilation decision-making in children: A scoping review. Pediatr Pulmonol 2024; 59:1153-1164. [PMID: 38289099 DOI: 10.1002/ppul.26884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 11/01/2023] [Accepted: 01/14/2024] [Indexed: 04/30/2024]
Abstract
An increasing number of children are surviving critical illnesses requiring tracheostomy/long-term ventilation (LTV). This scoping review seeks to collate the available evidence on decision-making for tracheostomy/LTV in children. Systematic searches of electronic databases and websites were conducted for articles and reports. Inclusion criteria included: (1) children 0-18 years old; (2) described use of tracheostomy or tracheostomy/LTV; and (3) information on recommendations for tracheostomy decision-making or decision-making experiences of family-caregivers or health care providers. Articles not written in English were excluded. Of the 4463 records identified through database search and other methods, a total of 84 articles, 2 dissertations, 1 book chapter, 3 consensus statement/society guidelines, and 8 pieces of grey literature were included. Main thematic domains identified were: (1) legal and moral standards for decision-making; (2) decision-making models, roles of decision-makers, and decisional aids towards a shared decision-making model; (3) experiences and perspectives of decision-makers; (4) health system and society considerations; and (5) conflict resolution and legal considerations. A high degree of uncertainty and complexity is involved in tracheostomy/LTV decision-making. There is a need for a standardized decision-support process that is consistent with a child's best interests and shared decision-making. Strategies for optimizing communication and mechanism for managing disputes are needed.
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Affiliation(s)
- Cheryl Mack
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Janette Mailo
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel Ofosu
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Alreem A Hinai
- Division of Pediatric Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Diana Keto-Lambert
- Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lesley J J Soril
- Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Medicine Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Michael van Manen
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Viaud-Murat EM, Bahra L, Redmann AJ, Buck LS, Carratola M. Ethics in Practice: Laryngotracheoplasty Versus Tracheostomy in a Patient With Severe Hydranencephaly. Otolaryngol Head Neck Surg 2024; 170:1474-1477. [PMID: 38353287 DOI: 10.1002/ohn.680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/21/2023] [Accepted: 12/01/2023] [Indexed: 04/30/2024]
Affiliation(s)
| | - Luka Bahra
- Department of Otolaryngology, University of Colorado Anschutz Medical Campuus, Parker, Colorado, USA
| | - Andrew J Redmann
- Department of Otolaryngology, Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lauren S Buck
- Department of Otolaryngology, Head and Neck Surgery, Louisiana State University Health Sciences Center, Our Lady of the Lake Children's Hospital, Baton Rouge, Louisiana, USA
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De Clercq E, Grotzer M, Landolt MA, von Helversen B, Flury M, Rössler J, Kurzo A, Streuli J. No wrong decisions in an all-wrong situation. A qualitative study on the lived experiences of families of children with diffuse intrinsic pontine glioma. Pediatr Blood Cancer 2022; 69:e29792. [PMID: 35652529 DOI: 10.1002/pbc.29792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Diffuse intrinsic pontine glioma (DIPG) is a rare, but lethal pediatric brain tumor with a median survival of less than 1 year. Existing treatment may prolong life and control symptoms, but may cause toxicity and side effects. In order to improve child- and family-centered care, we aimed to better understand the treatment decision-making experiences of parents, as studies on this topic are currently lacking. PROCEDURE The data for this study came from 24 semistructured interviews with parents whose children were diagnosed with DIPG in two children's hospitals in Switzerland and died between 2000 and 2016. Analysis of the dataset was done using reflexive thematic analysis. RESULTS For most parents, the decision for or against treatment was relatively straightforward given the fatality of the tumor and the absence of treatment protocols. Most of them had no regrets about their decision for or against treatment. The most distressing factor for them was observing their child's gradual loss of independence and informing them about the inescapability of death. To counter this powerlessness, many parents opted for complementary or alternative medicine in order to "do something." Many parents reported psychological problems in the aftermath of their child's death and coping strategies between mothers and fathers often differed. CONCLUSION The challenges of DIPG are unique and explain why parental and shared decision-making is different in DIPG compared to other cancer diagnoses. Considering that treatment decisions shape parents' grief trajectory, clinicians should reassure parents by framing treatment decisions in terms of family's deeply held values and goals.
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Affiliation(s)
- Eva De Clercq
- Institute of Bioethics and History of Medicine, University of Zürich, Zurich, Switzerland
| | - Michael Grotzer
- University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Markus A Landolt
- University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland.,Department of Psychology, University of Zurich, Zurich, Switzerland
| | | | - Maria Flury
- University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jochen Rössler
- Cancer Center Inselspital UCI, Inselspital University, Bern, Switzerland
| | - Andrea Kurzo
- Cancer Center Inselspital UCI, Inselspital University, Bern, Switzerland
| | - Jürg Streuli
- Institute of Bioethics and History of Medicine, University of Zürich, Zurich, Switzerland.,University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
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Fitzgerald H. In Your Capable Hands: Ethical Practice, Bias Mitigation, and Care for Children Who Rely on Chronic Mechanical Ventilation. J Pediatr Nurs 2021; 57:1-4. [PMID: 33207302 DOI: 10.1016/j.pedn.2020.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/15/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
Nurses encounter constraints, pressures and complexity in patient care which may increase reliance on implicit bias -- unconscious, mental shortcuts which shape attitudes and behavior (Kahneman, 2011). These cognitive shortcuts save time, but if unexamined, can undermine the ethical commitment to "respect…the inherent dignity, worth, unique attributes, and human rights of all individuals," (ANA Code, 2015, p.1). This is especially concerning when considering vulnerable populations, such as families with children who are dependent on tracheostomy and mechanical ventilation (trach-vent-dependent). Studies of parent caregivers of children who are trach-vent-dependent raise questions of whether implicit bias contributes to the stigmatization these families experience. Practical strategies to activate the Code of Ethics with Interpretive Statements can mitigate the risks of stigmatization and vulnerability, resulting in improved shared decision making and care for these patients and families. An objective tool to guide patient- and family-centered inquiry and care can anchor nurses' ethical practice.
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Sang S, Sun R, Coquet J, Carmichael H, Seto T, Hernandez-Boussard T. Learning From Past Respiratory Infections to Predict COVID-19 Outcomes: Retrospective Study. J Med Internet Res 2021; 23:e23026. [PMID: 33534724 PMCID: PMC7901593 DOI: 10.2196/23026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/09/2020] [Accepted: 02/01/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND For the clinical care of patients with well-established diseases, randomized trials, literature, and research are supplemented with clinical judgment to understand disease prognosis and inform treatment choices. In the void created by a lack of clinical experience with COVID-19, artificial intelligence (AI) may be an important tool to bolster clinical judgment and decision making. However, a lack of clinical data restricts the design and development of such AI tools, particularly in preparation for an impending crisis or pandemic. OBJECTIVE This study aimed to develop and test the feasibility of a "patients-like-me" framework to predict the deterioration of patients with COVID-19 using a retrospective cohort of patients with similar respiratory diseases. METHODS Our framework used COVID-19-like cohorts to design and train AI models that were then validated on the COVID-19 population. The COVID-19-like cohorts included patients diagnosed with bacterial pneumonia, viral pneumonia, unspecified pneumonia, influenza, and acute respiratory distress syndrome (ARDS) at an academic medical center from 2008 to 2019. In total, 15 training cohorts were created using different combinations of the COVID-19-like cohorts with the ARDS cohort for exploratory purposes. In this study, two machine learning models were developed: one to predict invasive mechanical ventilation (IMV) within 48 hours for each hospitalized day, and one to predict all-cause mortality at the time of admission. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, positive predictive value, and negative predictive value. We established model interpretability by calculating SHapley Additive exPlanations (SHAP) scores to identify important features. RESULTS Compared to the COVID-19-like cohorts (n=16,509), the patients hospitalized with COVID-19 (n=159) were significantly younger, with a higher proportion of patients of Hispanic ethnicity, a lower proportion of patients with smoking history, and fewer patients with comorbidities (P<.001). Patients with COVID-19 had a lower IMV rate (15.1 versus 23.2, P=.02) and shorter time to IMV (2.9 versus 4.1 days, P<.001) compared to the COVID-19-like patients. In the COVID-19-like training data, the top models achieved excellent performance (AUROC>0.90). Validating in the COVID-19 cohort, the top-performing model for predicting IMV was the XGBoost model (AUROC=0.826) trained on the viral pneumonia cohort. Similarly, the XGBoost model trained on all 4 COVID-19-like cohorts without ARDS achieved the best performance (AUROC=0.928) in predicting mortality. Important predictors included demographic information (age), vital signs (oxygen saturation), and laboratory values (white blood cell count, cardiac troponin, albumin, etc). Our models had class imbalance, which resulted in high negative predictive values and low positive predictive values. CONCLUSIONS We provided a feasible framework for modeling patient deterioration using existing data and AI technology to address data limitations during the onset of a novel, rapidly changing pandemic.
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Affiliation(s)
- Shengtian Sang
- Department of Medicine, Biomedical Informatics, Stanford University, Stanford, CA, United States
| | - Ran Sun
- Department of Medicine, Biomedical Informatics, Stanford University, Stanford, CA, United States
| | - Jean Coquet
- Department of Medicine, Biomedical Informatics, Stanford University, Stanford, CA, United States
| | | | - Tina Seto
- Technology and Digital Solutions, Stanford University, Stanford, CA, United States
| | - Tina Hernandez-Boussard
- Department of Medicine, Biomedical Informatics, Stanford University, Stanford, CA, United States
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Weaver MS, Anderson V, Beck J, Delaney JW, Ellis C, Fletcher S, Hammel J, Haney S, Macfadyen A, Norton B, Rickard M, Robinson JA, Sewell R, Starr L, Birge ND. Interdisciplinary care of children with trisomy 13 and 18. Am J Med Genet A 2020; 185:966-977. [PMID: 33381915 DOI: 10.1002/ajmg.a.62051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/21/2020] [Accepted: 12/12/2020] [Indexed: 01/20/2023]
Abstract
Children with trisomy 13 and 18 (previously deemed "incompatible with life") are living longer, warranting a comprehensive overview of their unique comorbidities and complex care needs. This Review Article provides a summation of the recent literature, informed by the study team's Interdisciplinary Trisomy Translational Program consisting of representatives from: cardiology, cardiothoracic surgery, neonatology, otolaryngology, intensive care, neurology, social work, chaplaincy, nursing, and palliative care. Medical interventions are discussed in the context of decisional-paradigms and whole-family considerations. The communication format, educational endeavors, and lessons learned from the study team's interdisciplinary care processes are shared with recognition of the potential for replication and implementation in other care settings.
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Affiliation(s)
- Meaghann S Weaver
- Division of Palliative Care, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Venus Anderson
- Division of Cardiology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jill Beck
- Division of Oncology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jeffrey W Delaney
- Division of Cardiology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Cynthia Ellis
- Division of Developmental Pediatrics, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA.,Munroe-Meyer Institute for Genetics and Rehabilitation, Omaha, Nebraska, USA
| | - Scott Fletcher
- Division of Cardiology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA.,Division of Cardiology, Department of Pediatrics, Creighton University, Omaha, Nebraska, USA
| | - James Hammel
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Suzanne Haney
- Division of Child Advocacy, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andrew Macfadyen
- Division of Critical Care, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Bridget Norton
- Division of Critical Care, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mary Rickard
- Division of Neurology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jeffrey A Robinson
- Division of Cardiology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ryan Sewell
- Division of Otolaryngology, Department of Pediatrics, Children's Hospital and Medical Center and ENT Specialists PC, Omaha, Nebraska, USA
| | - Lois Starr
- Munroe-Meyer Institute for Genetics and Rehabilitation, Omaha, Nebraska, USA.,Division of Genetics, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Nicole D Birge
- Division of Neonatology, Department of Pediatrics, Children's Hospital and Medical Center and the University of Nebraska Medical Center, Omaha, Nebraska, USA
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