Providing Palliative and Hospice Care to Children, Adolescents and Young Adults with Cancer

An Age Group Comparison of Concurrent Hospice Care: A Cost-Effectiveness Analysis

This study aimed to examine the cost-effectiveness of concurrent hospice care compared with standard care among pediatric patients of different age groups. Using a national Medicaid database of 18 152 pediatric patients enrolled in hospice care between 2011 and 2013, this study calculated and analyzed incremental cost-effectiveness ratios (ICERs) for concurrent care versus standard hospice care for children of 4 age categories: <1 year, 1 to 5 years, 6 to 14 years, and 15 to 20 years. The results indicated that the total Medicaid cost of hospice care was $3229 per patient per month (PPPM; SD, $8709) for those younger than 1 year, $4793 PPPM (SD, $8178) for those aged 1 to 5 years, $5411 PPPM (SD, $7456) for those aged 6 to 14 years, and $5625 PPPM (SD, $11459) for those aged 15 to 20 years. Incremental cost-effectiveness ratio values across all age groups showed that children enrolled in concurrent care had fewer live discharges but at a higher Medicaid cost of care as compared with those enrolled in standard hospice care. Concurrent hospice care was the most cost-effective in the age groups of <1 year and 1 to 5 years, with ICERs equal to $45 (95% confidence interval [CI], $23-$66) and $49 (95% CI, $8-$76), respectively. For the other older age groups, benefits of enrollment in concurrent care came at a much higher cost: in the age group of 6 to 14 years, ICER was equal to $217 (95% CI, $129-$217), and in the age group of 15 to 20 years, it was $107 (95% CI, $82-$183). Concurrent hospice is an effective way to reduce live discharges but has a higher total Medicaid cost than standard hospice care.

Moral Distress and Pediatric Palliative Care

Moral distress is a complex phenomenon whereby a person feels tension, constraint, or conflict with an action or circumstance because it goes against their individual or the perceived collective (e.g., community, organizational, or professional association's) moral stance. In pediatric healthcare settings, managing and mitigating feelings of moral distress can be particularly difficult to navigate through because of the intricate dynamics between the pediatric patient, parent and/or legal guardians, and clinicians. The proactive integration of an experienced pediatric palliative care (PPC) team can be an appropriate step toward reducing clinicians feeling overwhelmed by various case-specific and team management issues that contribute to the development of moral distress among healthcare professionals. Based on our experiences in a free-standing, quaternary pediatric hospital, the involvement of PPC can help reframe the approach to challenging situations, enhance communication, and provide guidance to the care team, patients, and families. Moreover, PPC teams can benefit other multidisciplinary team members through education on respecting the plurality of values of diverse families and patients and consideration of ethical implications during morally challenging situations.

Capitalizing on the Value of the Clinical Nurse Specialist in Palliative Care

The clinical nurse specialist (CNS) is 1 of the 4 advanced practice registered nurse roles and a vital component in palliative and hospice nursing care. The CNS is a specialty expert clinician capable of practicing in a variety of health care settings including acute care, primary care, and specialty ambulatory care. The CNS integrates palliative care standards across the 3 spheres of impact (patient, nurse, and system) to improve care patients receive at end of life, mentoring and coaching nurses in the unique aspects of palliative and hospice care (HPC), and serving as a clinical expert for the organization to ensure best practices and quality outcomes. Clinical nurse specialists are trained to diagnose, treat, and prescribe to provide holistic care to their patients. However, challenges exist for the CNS role due to variations in state regulations regarding title protection and scope of practice leading to inconsistency in and misperception of the CNS role. Clinical nurse specialists have a wealth of expertise that can lead to systematic improvement in patient outcomes, advances in hospice and palliative nursing practice, and management of HPC patients and their families. Clinical nurse specialists are a hidden treasure that should be integrated into HPC practice.

Pediatric Oncology Hospice: A Comprehensive Review

Pediatric hospice is a new terminology in current medical literature. Implementation of pediatric hospice care in oncology setting is a vast but subspecialized field of research and practice. However, it is accompanied by substantial uncertainties, shortages and unexplored sections. The lack of globally established definitions, principles, and guidelines in this field has adversely impacted the quality of end-of-life experiences for children with hospice needs worldwide. To address this gap, we conducted a comprehensive review of scientific literature, extracting and compiling the available but sparse data on pediatric oncology hospice from the PubMed database. Our systematic approach led to development of a well-organized structure introducing the foundational elements, highlighting complications, and uncovering hidden gaps in this critical area. This structured framework comprises nine major categories including general ideology, population specifications, role of parents and family, psychosocial issues, financial complications, service locations, involved specialties, regulations, and quality improvement. This platform can serve as a valuable resource in establishing a scientifically reliable foundation for future experiments and practices in pediatric oncology hospice.

The Impact of End-of-Life Care Among Nurses Working in the Pediatric Intensive Care Unit

Health care providers caring for patients at the end of life (EOL) are faced with a multitude of emotions such as guilt, anger, sadness, and helplessness. Because of the negative impact of initiating EOL care (EOLC) to the pediatric population, organizations must be proactive in instituting education and resources on EOLC. They must also provide advanced skills to nurses who take care of patients at their EOL. Understanding the consequences of providing EOL care to patients in the pediatric intensive care unit allows for better allocation of resources and support services for nurses. This improves patient outcomes and nurse retention.

Home Milrinone in Pediatric Hospice Care of Children with Heart Failure

CONTEXT

The symptom profile of children dying from cardiac disease, especially heart failure, differs from those with cancer and other non-cardiac conditions. Treatment with vasoactive infusions at home may be a superior therapy for symptom control for these patients, rather than traditional pain and anxiety management with morphine and benzodiazepines.

OBJECTIVES

We report our experience using outpatient milrinone in children receiving hospice care for end-stage heart failure.

METHODS

Retrospective review of a contemporary cohort of all patients at Lucile Packard Children's Hospital, Stanford who were discharged on intravenous milrinone and hospice care between 2008 and 2021. Clinical data, including cardiac diagnosis, milrinone dose and route of administration, total milrinone days, symptoms reported, rehospitalization rates, concurrent therapies and complications were analyzed.

RESULTS

Among 8 patients, median duration of home milrinone infusion was 191 (33, 572) days with the longest support duration 1,054 days. All (100%) patients were also receiving diuretics at the time of death. Five (63%) were receiving no other pain control medications until the active phase of dying. From milrinone initiation to last outpatient assessment, a reduction in the number of patients reporting respiratory discomfort, abdominal pain, weight loss/lack of appetite, and fatigue was observed. Six (75%) died at home.

CONCLUSION

We used milrinone with oral diuretics effectively for symptom control in children with heart failure on palliative care. Our experience was that this combination can be used safely in the outpatient setting for long-term use without the addition of opiates, benzodiazepines, or supplemental oxygen in most cases.

Nurses' Perceived Needs and Barriers Regarding Pediatric Palliative Care: A Mixed-Methods Study

Purpose

This study aimed to describe nurses' perceived needs and barriers to pediatric palliative care (PPC).

Methods

Mixed methods with an embedded design were applied. An online survey was conducted for nurses who participated in the End-of-Life Nursing Education Consortium- Pediatric Palliative Care (ELNEC-PPC) train-the-trainer program, of whom 63 responded. Quantitative data were collected with a survey questionnaire developed through the Delphi method. The 47 items for needs and 15 items for barriers to PPC were analyzed with descriptive statistics. Qualitative data were collected through open- ended questions and analyzed with topic modeling techniques.

Results

The mean scores of most subdomains of the PPC needs were 3.5 or higher out of 4, and those of PPC barriers ranged from 3.22 to 3.56, indicating the items in the questionnaire developed in this study properly reflect each factor. The needs for PPC were divided into 4 categories "children and adolescents," "families," "PPC management system," and "community-based PPC." Meanwhile, PPC barriers were divided into 3 categories "healthcare delivery system," "healthcare provider," and "client." The keywords derived from the topic modeling were perception, palliative, children, and education for necessities and lack, perception, medical care, professional care providers, service, and system for barriers to PPC.

Conclusion

In this study, by using mixed-methods, items of nurses' perceived needs and barriers to PPC were identified, categorized, and weighted, and their meanings were explored. For the stable establishment of PPC, the priority should be given to improving perceptions of PPC, establishing an appropriate system, and training professional care providers.

End-of-Life Care in Patients with Cancer 16–24 Years of Age

Purpose of Review

To present new findings in order to aid in the provision of high-quality symptom management and psychosocial care for adolescents and young adults with advanced cancer at the end of life.

Recent Findings

Behavioral health providers support patients by teaching them symptom control skills, building legacies, and making meaning of their lives. Integration of cultural values is essential for comprehensive assessment and decision-making. Effective management of physiological symptoms and psychological distress begins with accurate communication about prognosis and goals of care that focus on patient preferences and priorities. Oncology teams promote quality of life and the successful management of fatigue, pain, decreased mobility, poor appetite, and dyspnea with the early inclusion of palliative care.

Summary

While provision of end-of-life care in a young person with cancer presents challenges, multidisciplinary teams can effectively accompany patients in this journey by prioritizing patient and family preferences to promote quality of life.

Contributions of Pediatric Oncology Nursing to Advance Care and Reduce Disparities Among Children and Adolescents with Cancer: Introduction

OBJECTIVE

Highlight examples of pediatric oncology nursing's accomplishments during the past 2 decades with attention to specialized practice, patient/family education, research/evidence-based practice, and advocacy and how these efforts can be leveraged to reduce disparities in the cure and care of children and adolescents with cancer.

DATA SOURCES

Review of currently published literature, guidelines, and websites documenting pediatric oncology nursing's contributions.

CONCLUSION

Over the past 20 years, the collective work of pediatric oncology nurses across the world has improved the care of children with cancer and their families and brought attention to areas of disparities.

IMPLICATIONS FOR NURSING PRACTICE

Although work remains to reduce disparities, current evidence from nursing science and practice is available to address disparities and guide advocacy efforts for children and their families as well as the nurses who care for them.