Pain and symptom control in terminally ill children

Pain assessment tools in paediatric palliative care: A systematic review of psychometric properties and recommendations for clinical practice

BACKGROUND

Assessing pain in infants, children and young people with life-limiting conditions remains a challenge due to diverse patient conditions, types of pain and often a reduced ability or inability of patients to communicate verbally.

AIM

To systematically identify pain assessment tools that are currently used in paediatric palliative care and examine their psychometric properties and feasibility and make recommendations for clinical practice.

DESIGN

A systematic literature review and evaluation of psychometric properties of pain assessment tools of original peer-reviewed research published from inception of data sources to April 2021.

DATA SOURCES

PsycINFO via ProQuest, Web of Science Core, Medline via Ovid, EMBASE, BIOSIS and CINAHL were searched from inception to April 2021. Hand searches of reference lists of included studies and relevant reviews were performed.

RESULTS

From 1168 articles identified, 201 papers were selected for full-text assessment. Thirty-four articles met the eligibility criteria and we examined the psychometric properties of 22 pain assessment tools. Overall, the Faces Pain Scale-Revised (FPS-R) had high cross-cultural validity, construct validity (hypothesis testing) and responsiveness; while the Faces, Legs, Activity, Cry and Consolability (FLACC) scale and Paediatric Pain Profile (PPP) had high internal consistency, criterion validity, reliability and responsiveness. The number of studies per psychometric property of each pain assessment tool was limited and the methodological quality of included studies was low.

CONCLUSION

Balancing aspects of feasibility and psychometric properties, the FPS-R is recommended for self-assessment, and the FLACC scale/FLACC Revised and PPP are the recommended observational tools in their respective age groups.

Evaluation of Therapies for Peripheral and Neuraxial Opioid-induced Pruritus based on Molecular and Cellular Discoveries

Opioids are a mainstay of treatment for pain worldwide. Pruritus, a common side effect of opioids, is a patient dissatisfier that limits their use in many clinical settings. Both parenteral and neuraxial administration of opioids frequently evoke pruritus. The ability of opioids to suppress pain while causing itch continues to perplex clinicians and researchers alike. Several mechanisms have been proposed to explain how opioids can give rise to pruritus, but specific knowledge gaps perpetuate debate. This review summarizes the clinical burden of opioid-induced pruritus and emphasizes recent discoveries of peripheral and central mechanisms for opioid-induced pruritus, particularly with respect to scientific and conceptual advances in spinal cord circuitry and mast cell biology. The mechanisms and effectiveness of existing medications used for clinical management of pruritus will be evaluated, and we will highlight the emerging preclinical utility of selective κ-opioid receptor agonists, such as nalfurafine, for the management of opioid-induced pruritus.

Pharmacological Management of Restless Legs Syndrome and Periodic Limb Movement Disorder in Children

Restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) are under-recognized sleep disorders in children and adolescents. Several recent epidemiological studies have shown that RLS and PLMD are common in the pediatric population, and if left untreated, may lead to cardiovascular and neurocognitive consequences. Therefore, early diagnosis and intervention may help preventing long-term consequences. The management of RLS and PLMD in children involves both non-pharmacologic and pharmacologic approaches. Although there is emerging literature supporting medical therapy in children with RLS and PLMD, the overall experiences with these medications remain limited. Most children and adolescents with RLS and PLMD have low iron storage; therefore, iron therapy should be considered as the first line of treatment in children. Currently, there is no FDA-approved medication for RLS and PLMD in children. There is increasing evidence on the effectiveness of dopaminergic medications in children but the data are quite limited. Other medications such as α2δ-1 ligands, benzodiazepine, and clonidine are frequently used, but have not been adequately investigated in children. Further studies are needed to evaluate the safety and efficacy of pharmacologic therapy for RLS and PLMD in children.

Concerns About Pain Management Among Adolescents With Cancer: Developing the Adolescent Barriers Questionnaire

Investigators have examined barriers to pain management in adults with cancer, but these patient-related barriers have rarely been studied in adolescents. This article summarizes 2 studies used in the development and initial psychometric testing of the Adolescent Barriers Questionnaire (ABQ). Building on the Barriers Questionnaire-II, the ABQ is designed to measure the extent to which adolescents with cancer have concerns about reporting pain and using analgesics. Study 1 was a qualitative study investigating pain management concerns of 5 adolescents with cancer. Concerns emerged that could potentially impede pain management such as fear of addiction and worry about communicating pain to parents and providers. Each of the adolescents revealed at least 1 concern about pain management or held fatalistic beliefs that cancer pain cannot be relieved. In study 2, content validity of the preliminary ABQ (52 items assessing 13 barrier sub-scales) was assessed by 2 panels, adolescents with cancer and clinicians. Based on results, the ABQ was modified to contain 45 items that assess 11 barriers. Further examination of barriers in adolescents with cancer is warranted.

Listening to parents: The role of symptom perception in pediatric palliative home care

Objective:

This study analyzes symptom perception by parents and healthcare professionals and the quality of symptom management in a pediatric palliative home care setting and identifies which factors contribute to a high quality of palliative and end-of-life care for children.

Methods:

In this retrospective, cross-sectional study, parents were surveyed at the earliest three months after their child's death. All children were cared for by a specialized home pediatric palliative care team that provides a 24/7 medical on-call service. Questionnaires assessed symptom prevalence and intensity during the child's last month of life as perceived by parents, symptom perception, and treatment by medical staff. The responses were correlated with essential palliative care outcome measures (e.g., satisfaction with the care provided, quality-of-life of affected children and parents, and peacefulness of the dying phase).

Results:

Thirty-eight parent dyads participated (return rate 84%; 35% oncological disorders). According to parental report, dyspnea (61%) and pain (58%) were the dominant symptoms with an overall high symptom load (83%). Pain, agitation, and seizures could be treated more successfully than other symptoms. Successful symptom perception was achieved in most cases and predicted the quality of symptom treatment (R2, 0.612). Concordant assessment of symptom severity between parents and healthcare professionals (HCPs) improved the satisfaction with the care provided (p = 0.037) as well as the parental quality-of-life (p = 0.041). Even in cases with unsuccessful symptom control, parents were very satisfied with the SHPPC team's care (median 10; numeric rating scale 0–10) and rated the child's death as highly peaceful (median 9).

Significance of the results:

The quality and the concordance of symptom perception between parents and HCPs essentially influence parental quality-of-life as well as parental satisfaction and constitute a predictive factor for the quality of symptom treatment and palliative care.

Spirituality and Religion in Pain and Pain Management

Pain relief is a management problem for many patients, their families, and the medical professionals caring for them. Although everyone experiences pain to some degree, responses to it vary from one person to another. Recognizing and specifying someone else’s pain is clinically a well know challenge. Research on the biology and neurobiology of pain has given us a relationship between spirituality and pain. There is growing recognition that persistent pain is a complex and multidimensional experience stemming from the interrelations among biological, psychological, social, and spiritual factors. Patients with pain use a number of cognitive and behavioral strategies to cope with their pain, including religious/spiritual factors, such as prayers, and seeking spiritual support to manage their pain. This article provides an overview of the complex phenomenon of pain, with a focus on spiritual and religious issues in pain management.

Paediatric palliative care: a review of needs, obstacles and the future

AIM

This literature review offers a response to the current paediatric palliative care literature that will punctuate the need for a framework (i.e. the three world view) that can serve as an evaluative lens for nurse managers who are in the planning or evaluative stages of paediatric palliative care programmes.

BACKGROUND

The complexities in providing paediatric palliative care extend beyond clinical practices to operational policies and financial barriers that exist in the continuum of services for patients.

EVALUATION

This article offers a review of the literature and a framework in order to view best clinical practices, operational/policy standards and financial feasibility when considering the development and sustainability of paediatric palliative care programmes.

KEY ASPECTS

Fifty-four articles were selected as representative of the current state of the literature as it pertains to the three world view (i.e. clinical, operational and financial factors) involved in providing paediatric palliative care.

CONCLUSION

In developing efficient paediatric palliative care services, clinical, operational and financial resources and barriers need to be identified and addressed.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing management plays a crucial role in addressing the clinical, operational and financial needs and concerns that are grounded in paediatric palliative care literature.

Naloxone infusion and post-hysterectomy morphine consumption: a double-blind, placebo-controlled study

BACKGROUND

The evidence that an infusion of a low dose of naloxone reduces post-operative pain and opioid analgesic consumption is somewhat conflicting. Thus, the aim of the present study was to investigate the effect of an ultra-low dose of naloxone on patient-controlled morphine analgesia.

METHODS

Ninety patients, 35-55 years old, scheduled for total abdominal hysterectomy, were enrolled in this prospective, randomized, double-blind and placebo-controlled study. Post-operatively, they received either saline (n = 45) or naloxone (n = 45) for 24 h. A standard general anesthesia was administered in both groups. In the recovery room, patients received morphine by a patient-controlled analgesia device. An ultra-low dose of naloxone was infused intravenously at 0.25 μg/kg/h for 24 h in the intervention group. Saline was infused in the control group. Following the surgery, morphine consumption, numeric rating score for pain intensity, nausea and vomiting, pruritus, and requests for antiemetic were recorded at baseline, 30 min, 1, 4, 8,16, 20, and 24 h following their discharge from recovery.

RESULTS

Naloxone reduced morphine consumption over the first 24 post-operative hours significantly compared with the controls (saline) {19.5 [standard deviation (SD) 3.4] mg vs. 27.5 [SD 5.9] mg; P < 0.001}. The incidence and severity of nausea and vomiting was significantly reduced in the naloxone group. The incidence of pruritus and the pain scores at rest and activity were not significantly different.

CONCLUSION

Following hysterectomy, an ultra-low dose of naloxone infusion proved to reduce morphine consumption as well as the incidence and severity of opioid-induced nausea and vomiting.

Pain experience in children with advanced cancer

BACKGROUND

It is important for health care professionals to understand the pain experience in children with advanced cancer. There has been increased attention to this topic, but systematic studies are limited.

OBJECTIVE

To examine pain symptoms and management in children with advanced cancer using child self-report and nurse documentation.

METHODS

A prospective, longitudinal method was used to collect data from 62 children over a 5-month period. Children were English and Spanish speaking, ages 6 to 17 years, with advanced cancer. Nurses also provided data.

RESULTS

Across all interviews, pain was reported 56% of the time by all children. Nurses documented pain only 23% of the time. Children most frequently reported head pain (31%), followed by abdomen, lower back, leg, and feet pain (20% to 30%). Children consistently reported more intense pain compared with nurses. Nonopioids were used more frequently (45%) than opioids (32%), and nurses' perception of pain intensity was more highly correlated with administration of opioids (r = .72, P < .001). Children who died during their participation in this study received more opioids over time. Pain intensity was relatively stable over time. Nurses noted ethnicity related differences with higher pain levels for Caucasian children, who received analgesics more frequently.

DISCUSSION

The children consistently reported pain. Child self-report and nurse documentation of pain differed, as did pain management among children who died compared with those who did not. Ethnicity differences in the identification and management of pain by nurses begs further study. Overall, nurses were aware of and responsive to pain and pain management.

Symptoms in children with advanced cancer: child and nurse reports

BACKGROUND

Systematic studies on the specific symptom experience in children with advanced cancer are limited.

OBJECTIVE

The objective of the study was to examine the common symptoms and to explore commonly occurring symptoms over time.

METHODS

A prospective and longitudinal study design was used. Data were collected at 10 data points from 60 children over a 5-month period. Children ranged from 6 to 17 years old, spoke English or Spanish, were diagnosed with advanced cancer, and were receiving healthcare in 1 of 4 Southern California hospitals. Nurses' documentations of symptoms were examined.

RESULTS

The study sample was composed of children 6 to 12 years old (52%) and 13 to 17 years old (48%); 42% were female, and 58% were male. Fifty-five percent were Latino, and 30% were Caucasian. Pain, nausea, drowsiness, and energy loss were reported by children in more than 50% of the interviews. Children's and nurses' reports of symptoms were similar except children reported significantly more frequency and intensity of pain.

CONCLUSION

Children with advanced cancer were able to report and describe their symptoms. There were few differences by gender, age, and ethnicity.

IMPLICATIONS FOR PRACTICE

It is important that children's symptoms are clearly communicated to nurses, and these study findings may be used to anticipate and manage the symptoms experienced by children with advanced cancer.

Treatment of nausea and vomiting in terminally ill cancer patients

Nausea and vomiting is a common and distressing symptom complex in patients with far-advanced cancer, affecting up to 60% of individuals at some stage of their illness. The current approach to the palliative care of patients with nausea and vomiting is based on identifying the cause, understanding its pathophysiology and knowing the pharmacology of the drugs available for its amelioration. The following six main syndromes are identified: gastric stasis, biochemical, raised intracranial pressure, vestibular, mechanical bowel obstruction and ileus. A careful history, focused physical examination and appropriate investigations are needed to elucidate the syndrome and its cause, so that therapy is rational. Drugs are the mainstay of treatment in terminal cancer, and the main classes of antiemetic agents are prokinetics, dopamine antagonists, antihistamines, anticholinergics and serotonin antagonists. Dexamethasone and octreotide are also used, especially in bowel obstruction. Non-drug measures are important in relieving the associated distress. Patients should be able to die comfortably, without tubes. Despite decades of practice affirming this approach, the evidence base is weak and well designed studies are urgently needed.

Pilot study of continuous co-infusion of morphine and naloxone in children with sickle cell pain crisis

Patients with sickle cell disease experience painful crises that often require hospitalization for a continuous infusion of morphine that may cause significant pruritus. We conducted a pilot study to determine the feasibility of simultaneous continuous co-infusion of naloxone with morphine, test novel assessment instruments for pruritus, and explore whether pruritus could be reduced while maintaining effective analgesia. Patients with sickle cell disease and painful crisis requiring continuous infusion morphine received continuous co-infusion of naloxone at 0.25 (low dose) or 1.0 mcg/kg x hr (high dose). Pain scores were obtained using the FACES scale and a 100-mm visual analog scale (VAS). Itching was quantified by a modified VAS score. Evaluable data were obtained on 16 patients. Simultaneous co-infusion of naloxone and morphine was feasible, did not seem to reduce the analgesic efficacy of morphine, and was associated with no adverse effects. The high dose group reported a lower median "VAS worst itch" score than the low dose group (4.8 vs. 7.3, P = 0.08). Simultaneous continuous infusion of naloxone with morphine in pediatric patients with sickle cell disease and pain crisis was feasible and well tolerated. A quantitative pruritus score allowed us to systematically measure pruritus. Further evaluation by randomized, placebo-controlled study of 1 mcg/kg x hr naloxone in this setting is required.

Palliative care delivery in the NICU: what barriers do neonatal nurses face?

Despite the existence of a universal protocol in palliative care for dying babies and their families, provision of this type of care remains ad hoc in contemporary neonatal settings. Influential bodies such as the American Academy of Pediatrics and the World Health Organization support palliative care to this patient population, so why are such measures not universally adopted? Are there barriers that prevent neonatal nurses from delivering this type of care? A search of the literature reveals that such barriers may be significant and that they have the potential to prevent dying babies from receiving the care they deserve. The goal of this literature review is to identify these barriers to providing palliative care in neonatal nursing. Results of the research have been used to determine item content for a survey to conceptualize and address these barriers.

Ensuring pain relief for children at the end of life

Pain management in the context of pediatric palliative care can be challenging. The present article reviews, through a case-based presentation, the nonpharmacological and pharmacological methods used to ensure adequate pain control in children facing end of life. Details on the impressive range of opioid dosages required and routes of administration are highlighted from published literature and clinical experience. Where available, evidence-based recommendations are provided. Potential side effects of pain medication and barriers to good pain control are discussed. Novel analgesics and innovative delivery methods are presented as future tools enhancing pain relief at the end of life. Some challenges to ethically grounded research in this important context of care are reviewed.

End-of-life decisions and palliative care in a children's hospital

OBJECTIVE

To investigate clinical and demographic factors affecting the nature of end-of-life decisions and pediatric palliative care.

DESIGN

Charts of 236 expired children were retrospectively reviewed for presence of endof- life care (EOLC) discussions and spiritual support, the nature of EOLC decisions, and the degree of opioid analgesics (OA) and sedatives (SDT) administration.

RESULTS

Approximately 60% of patients had EOLC discussion, of whom 87.4% obtained an EOLC decision, mostly opting for withholding therapy (68.8%). Presence of EOLC discussion was associated with a longer hospital stay (univariate analyses: odds ratio [OR] = 1.9; p < 0.029), higher number of failed organs (OR = 2.5; p < 0.003), chronic illnesses (OR = 2.4; p < 0.002), spiritual support (OR = 1.8; p < 0.028) and respiratory diseases (OR = 3.1; p < 0.0006). Younger patients and those with higher number of failed organs were more likely to have withdrawal of therapy (OR = 10.9 and 6.0; p < 0.0001 and <0.002, respectively), whereas patients with chronic illness opted for withholding of therapy (OR = 3.1; p < 0.006). Spiritual support was associated with higher use of both OA and SDT (OR = 1.9 and 2.3; p < 0.014 and p < 0.005, respectively). Younger patients received less OA and SDT (OR = 0.2 and 0.4, respectively; p < 0.0001). Multivariate analyses showed that EOLC discussion is associated with higher use of OA and SDT (OR = 4.4 and 4.2; p < 0.00001 and p < 0.0001, respectively), whereas younger age is associated with withdrawal of therapy (OR = 8.3; p < 0.0005) and lower use of SDT (OR = 0.23; p < 0.0001).

CONCLUSIONS

Patterns of care at the end of life vary in children with differing clinical and demographic characteristics. Because EOLC discussions are associated with greater focus on palliative care, strategies to enhance EOLC communications for pediatric patients should be further evaluated.

Palliative Care and Pediatrics

This article reviews the unique challenges of pediatric palliative medicine. These challenges originate from the specific epidemiology of pediatric diseases for which palliative care is indicated and the necessity to provide child-focused, family-oriented, relationship-centered medical care. The emphasis of the ultimate aims of pediatric palliative care is to care for the body, mind, and spirit, to enhance quality of life, and to minimize suffering.

New and lingering controversies in pediatric end-of-life care

OBJECTIVES

Professional societies, ethics institutes, and the courts have recommended principles to guide the care of children with life-threatening conditions; however, little is known about the degree to which pediatric care providers are aware of or in agreement with these guidelines. The study's objectives were to determine the extent to which physicians and nurses in critical care, hematology/oncology, and other subspecialties are in agreement with one another and with widely published ethical recommendations regarding the withholding and withdrawing of life support, the provision of adequate analgesia, and the role of parents in end-of-life decision-making.

METHODS

Three children's hospitals and 4 general hospitals with PICUs in eastern, southwestern, and southern parts of the United States were surveyed. This population-based sample was composed of attending physicians, house officers, and nurses who cared for children (age: 1 month to 18 years) with life-threatening conditions in PICUs or in medical, surgical, or hematology/oncology units, floors, or departments. Main outcome measures included concerns of conscience, knowledge and beliefs, awareness of published guidelines, and agreement or disagreement with guidelines.

RESULTS

A total of 781 clinicians were sampled, including 209 attending physicians, 116 house officers, and 456 nurses. The overall response rate was 64%. Fifty-four percent of house officers and substantial proportions of attending physicians and nurses reported, "At times, I have acted against my conscience in providing treatment to children in my care." For example, 38% of critical care attending physicians and 25% of hematology/oncology attending physicians expressed these concerns, whereas 48% of critical care nurses and 38% of hematology/oncology nurses did so. Across specialties, approximately 20 times as many nurses, 15 times as many house officers, and 10 times as many attending physicians agreed with the statement, "Sometimes I feel we are saving children who should not be saved," as agreed with the statement, "Sometimes I feel we give up on children too soon." However, hematology/oncology attending physicians (31%) were less likely than critical care (56%) and other subspecialty (66%) attending physicians to report, "Sometimes I feel the treatments I offer children are overly burdensome." Many respondents held views that diverged widely from published recommendations. Despite a lack of awareness of key guidelines, across subspecialties the vast majority of attending physicians (range: 92-98%, depending on specialty) and nurses (range: 83-85%) rated themselves as somewhat to very knowledgeable regarding ethical issues.

CONCLUSIONS

There is a need for more hospital-based ethics education and more interdisciplinary and cross-subspecialty discussion of inherently complex and stressful pediatric end-of-life cases. Education should focus on establishing appropriate goals of care, as well as on pain management, medically supplied nutrition and hydration, and the appropriate use of paralytic agents. More research is needed on clinicians' regard for the dead-donor rule.

The initiative for pediatric palliative care: an interdisciplinary educational approach for healthcare professionals

There is growing empirical evidence that the U.S. healthcare system fails to meet the needs of children with life-threatening conditions and their families. The confluence of several recent developments has created a critical window of opportunity for improving clinical practice and institutional effectiveness in pediatric palliative care. This article presents an innovative, comprehensive approach to pediatric palliative care education that was developed by the Initiative for Pediatric Palliative Care, a consortium of seven academic children's hospitals, Education Development Center, the National Association of Children's Hospitals and Related Institutions, the New York Academy of Medicine, the Society of Pediatric Nursing, and the Association of Medical School Pediatric Department Chairs. The approach is based on needs assessment research with clinicians and parents and reflects a commitment to culturally respectful, family-centered care of children with life-threatening conditions. The pedagogy combines principles of adult education, includes families as teachers, and integrates affective and cognitive dimensions to enhance learning.

Issues and challenges in palliative care for children with cancer

Although the majority of children with cancer are cured of their illness, the children who die from their disease or complications require special care at the end of life. We present special issues and challenges unique to pediatric palliative care and suggest ways in which we can face these issues and address the challenges. The care must be family centered and balance the needs of the health-care system, the child, and the family. The way in which the care is delivered, the services provided, and the place in which that care is given are not carved into a simple protocol. Quality of life is an important concept that is often overlooked. Educational initiatives for patients, families, health-care providers, and third-party payers are essential. Reimbursement for palliative care services presents a large barrier to provision of appropriate services to all children and families in need. Hypothesis-driven research must be developed to help us learn more about how best to deliver end-of-life care to children and their families.

The effects of a small-dose naloxone infusion on opioid-induced side effects and analgesia in children and adolescents treated with intravenous patient-controlled analgesia: a double-blind, prospective, randomized, controlled study

Opioids are frequently associated with side effects such as nausea, vomiting, and pruritus. We hypothesized that a prophylactic, continuous small-dose naloxone infusion would reduce the incidence of opioid-induced side effects without affecting analgesia or opioid consumption. In this prospective, double-blind, randomized, controlled clinical trial, we studied 46 postoperative patients (M:F, 21:25), averaging 14 +/- 2.5 yr and 53 +/- 17 kg, at the start of morphine IV patient-controlled analgesia. Patients were randomized to either saline (control, n = 26) or naloxone 0.25 microg . kg(-1) . h(-1) (n = 20). We found that the incidence and severity of pruritus (77% versus 20%; P < 0.05) and nausea (70% versus 35%; P < 0.05) was significantly more frequent in the placebo group compared with the naloxone group. Morphine consumption (1.02 +/- 0.41 mg . kg(-1) . d(-1) versus 1.28 +/- 0.61 mg . kg(-1) . d(-1)), pain scores at rest (4 +/- 2 versus 3 +/- 2), and pain scores with coughing (6 +/- 2 versus 6 +/- 2) were not different. We conclude that, in children and adolescents, a small-dose naloxone infusion (0.25 microg . kg(-1) . h(-1)) can significantly reduce the incidence and severity of opioid-induced side effects without affecting opioid-induced analgesia. When initiating morphine IV patient-controlled analgesia for the treatment of moderate to severe pain, clinicians should strongly consider starting a concomitant small-dose naloxone infusion.

End-of-life care for children and adolescents

OBJECTIVES

To describe the complexities in end-of-life care of children and adolescents dying cancer-related deaths.

DATA SOURCES

Research studies, review articles, and government reports.

CONCLUSION

The complexities in providing competent and compassionate care to the dying child and the family is intense, undeniable, and may in some clinical situations be unavoidable.

IMPLICATIONS FOR NURSING PRACTICE

It is important for all those involved with the care at the end of life for a child or adolescent dying a cancer-related death create the framework that will support the provikion of competent and compassionate end-of-life care.

Issues and challenges in palliative care for children with cancer

Although the majority of children with cancer are cured of their illness, the children who die from their disease or complications require special care at the end of life. We present special issues and challenges unique to pediatric palliative care and suggest ways in which we can face these issues and address the challenges. The care must be family centered and balance the needs of the health-care system, the child, and the family. The way in which the care is delivered, the services provided, and the place in which that care is given are not carved into a simple protocol. Quality of life is an important concept that is often overlooked. Educational initiatives for patients, families, health-care providers, and third-party payers are essential. Reimbursement for palliative care services presents a large barrier to provision of appropriate services to all children and families in need. Hypothesis-driven research must be developed to help us learn more about how best to deliver end-of-life care to children and their families.

Managing side effects of childhood cancer treatment

This article focuses on the nurse's role as a member of the supportive care team for the child diagnosed with cancer and the family. The most common side effects of the cancer treatment are discussed in depth in this article. The adequate management of the side effects experienced by the child receiving cancer therapy may greatly influence the child's quality of life.

Home management of pain in sickle cell disease: a daily diary study in children and adolescents

PURPOSE

To determine the incidence of pain and the types of home pain management techniques used by children and adolescents with sickle cell disease (SCD) and their caregivers.

PATIENTS AND METHODS

Thirty-seven children and adolescents (ages 6-21 years) with SCD used a self-report pain diary twice daily to report their pain experience and its management for 6 months to 3 years. A total of 18,377 diary days representing 514 distinct pain episodes were analyzed.

RESULTS

Pain related to SCD was reported on 2592 days and 2326 nights, with analgesic medication taken on 88% of days and 76% of nights. A single oral analgesic was used on 58% of these days. On the remaining days, multiple analgesics were used in a variety of combinations. More frequent analgesic dosing was reported on days with more intense pain. Pain relief was substantially better for analgesic combinations than for single analgesics, particularly for moderate to severe pain.

CONCLUSIONS

Pain went untreated on a modest number of days, and many patients relied on relatively ineffective single analgesics. Other patients and families appropriately used potent analgesic combinations in a time-contingent and intensity-dependent pattern. This study suggests that recurrent acute pain from SCD can be successfully managed at home with appropriate training and supervision, and suggests several areas for intervention to improve patient outcomes.

Caring for children with advanced cancer integrating palliative care

The care of children with advanced cancer is multifaceted. Treatment should focus on continued efforts to control the underlying illness whenever possible. At the same time, children and their families should have access to interdisciplinary care aimed at promoting optimal physical, psychological and spiritual wellbeing. Open and compassionate communication can best facilitate meeting the goals of these children and families. However, there remain significant barriers to achieving optimal care related to lack of formal education, reimbursement issues and the emotional impact of caring for a dying child. Future research efforts should focus on ways to enhance communication, symptom management and quality of life for children with advanced cancer and their families. As efforts to break down barriers and create the evidence base continue, we conclude as follows: this is a most rewarding part of the practice of medicine. A kind word and caring attitude are remembered for decades.

Pain management for the child with cancer in end-of-life care: APON position paper

Although there have been major advances in the treatment of childhood cancer with an overall survival rate of more than 70%, cancer continues to be the leading cause of death in children resulting from disease. In 1998, 2,500 children in the United States died of cancer-related causes. Each year cancer kills more children than asthma, diabetes, cystic fibrosis, congenital anomalies, and acquired immunodeficiency syndrome combined. The Association of Pediatric Oncology Nurses (APON) is the leading professional organization for nurses caring for children and adolescents with cancer and their families. The highest standards of nursing practice are achieved through education, research, certification, advocacy, and affiliation. It is the position of APON that pain in the child dying of cancer can be effectively managed. This can be accomplished by making the prevention and alleviation of pain a primary goal, partnering with the patient and parents, and aggressively using appropriate pharmacologic and non-pharmacologic interventions. The pediatric oncology nurse has an essential role in the child's pain management at the end of life through nursing assessment, identifying expected outcomes, and performing and evaluating interventions.

Pediatric palliative care

This article presents a model of integrated palliative care for children with life-limiting illnesses, with emphasis on collaboration of care over time among family, primary care providers, and several other groups of providers. Some of the unique aspects of caring for children related to normal developmental changes and the family unit are considered. Issues related to pain and to specific diseases are also reviewed.