Cultural and religious considerations in pediatric palliative care

Bereavement Support for Siblings after Neonatal Loss: an Online Survey of U.S. Training Centers

OBJECTIVE

The aim of this study was to examine bereavement support for siblings of patients who die in the neonatal intensive care unit (NICU) given the adverse effects of unprocessed grief and the paucity of information on children whose newborn siblings die STUDY DESIGN:  This was an anonymous online original survey assessing pre-COVID-19 pandemic bereavement services for NICU families, clinicians' attitudes toward support interventions, challenges, and center characteristics. In spring 2020, nurse managers at 81 U.S. centers with neonatology and maternal-fetal medicine fellowship programs were asked to identify the individual most knowledgeable in their NICU's bereavement support services; these individuals were invited by email to complete an original online survey. Chi testing and odds ratios (ORs) compared responses from centers reporting involvement of palliative care teams (PCT) in NICU sibling bereavement versus no PCT.

RESULTS

Fifty-six percent (45 of 80) of invitees responded. Most (77%) NICUs permitted perimortem sibling visitation. Challenges included sparse community resources and limited direct sibling contact. Sixty-nine percent (n = 31) of centers were grouped as PCT. PCT respondents reported eightfold higher chances of providing direct education to the sibling (OR, 7.7; 95% confidence interval, 1.7-34; p = 0.01). Views on appropriateness of sharing educational information with extended family, babysitters, and teachers did not differ. While notifying pediatricians of families experiencing NICU death was more common in PCT (p = 0.02), most respondents reported having "no individual responsible for such communications" (52% PCT vs. 100%, p = 0.001).

CONCLUSION

Despite limited direct contact with siblings of NICU patients who die, efforts are made to involve them in bereavement activities. Opportunities to support these children were identified. Where available, palliative care teams can help provide bereaved siblings with direct education. We recommend formalizing communication mechanisms to ensure that if a NICU patient dies and has surviving siblings, the outpatient physicians caring for these siblings are informed.

KEY POINTS

· Palliative care enhanced sibling support.. · Resource and visitation limits hinder support.. · Teams sporadically briefed siblings' physicians..

Co-designing strategies to improve advance care planning among people from culturally and linguistically diverse backgrounds with cancer: iCanCarePlan study protocol

BACKGROUND

Advance care planning (ACP) describes the process of supporting individuals at any age or stage of health to consider and share their personal values, life goals, and preferences regarding future health care. Engaging in ACP is associated with better-quality of care in which people receive care in lines with their wishes, values and preferences. Direct translations of ACP guides and resources do not attend to the considerable inter- and intra-ethnic variations in cultural and religious or spiritual beliefs that shape preferences among people from culturally and linguistically diverse (CALD) backgrounds. ICanCarePlan is a three-year project that aims to determine the prevalence of ACP documentation among people from CALD backgrounds with cancer, identify resources available and their use to support ACP among CALD communities, identify barriers and facilitators of person-centred ACP, and to develop, through co-design with consumers and clinicians, approaches that enhance the process ACP for people from CALD backgrounds.

METHOD

A mixed-method sequential approach will be used comprising of four studies. Study one is retrospective medical record review of approximately 1500 medical records to establish the prevalence of ACP documentation among CALD patient records in cancer services. Study two is a document analysis synthesising the resources available in the Australian health system to support ACP. Study three is a qualitative study with healthcare staff and consumers to explore barriers and enablers of person-centred ACP. Evidence generated from studies one to three will inform the conduct of co-design with stakeholders to develop approaches to improve ACP processes among CALD communities. Language, technical and financial support for meaningful involvement with consumers from CALD backgrounds throughout this project is outlined. A plan for distress management is also made due to sensitive nature of the topic. The research project has also established a project steering group consisting of three consumer members who are from CALD backgrounds.

DISCUSSION

The project will address a national priority issue for a growing population of CALD communities in Australia. The project will provide novel evidence of ACP among CALD communities and novel strategies developed with stakeholders to enhance uptake and experiences of ACP.

A scoping review of guidelines and frameworks for advance care planning for adolescents and young adults with life-limiting or life-threatening conditions

BACKGROUND

Advance care planning discussions are crucial in the management and support of individuals with life-limiting or life-threatening conditions. Few studies have examined best practices for advance care planning with adolescents and young adults.

AIM

To identify core components of current guidelines, frameworks and tools for advance care planning discussions with adolescents and young adults with life-limiting or life-threatening conditions and their families.

DESIGN

A scoping review of the literature was conducted followed by a thematic analysis of the included papers. The scoping review was reported according to the Joanna Briggs Institute approach to the conduct of scoping reviews.

DATA SOURCES

Five databases [Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, PsycInfo, PubMed and Scopus] were searched for English-language papers published between inception until January 2023.

RESULTS

The search yielded 2976 papers, of which 9 met the inclusion criteria. Five main themes were identified: (i) utilisation of standardised documents and protocols; (ii) shared decision-making between the adolescents and young adults, their families and the healthcare team; (iii) the importance of open and honest communication with adolescents and young adults during advance care planning discussions; (iv) individualisation and flexibility in the advance care planning process and (v) timing of advance care planning initiation.

CONCLUSIONS

Results highlight the importance of engaging adolescents and young adults in advance care planning and considering their unique needs when initiating and framing these discussions. Our findings can be used by healthcare professionals to inform advance care planning in this group.

Development of the Parental Experience with Care for Children with Serious Illnesses (PRECIOUS) quality of care measure

BACKGROUND

Parent-reported experience measures are part of pediatric Quality of Care (QoC) assessments. However, existing measures were not developed for use across multiple healthcare settings or throughout the illness trajectory of seriously ill children. Formative work involving in-depth interviews with parents of children with serious illnesses generated 66 draft items describing key QoC processes. Our present aim is to develop a comprehensive parent-reported experience measure of QoC for children with serious illnesses and evaluate its content validity and feasibility.

METHODS

For evaluating content validity, we conducted a three-round Delphi expert panel review with 24 multi-disciplinary experts. Next, we pre-tested the items and instructions with 12 parents via cognitive interviews to refine clarity and understandability. Finally, we pilot-tested the full measure with 30 parents using self-administered online surveys to finalize the structure and content.

RESULTS

The Delphi expert panel review reached consensus on 68 items. Pre-testing with parents of seriously ill children led to consolidation of some items. Pilot-testing supported feasibility of the measure, resulting in a comprehensive measure comprising 56 process assessment items, categorized under ten subthemes and four themes: (1) Professional qualities of healthcare workers, (2) Supporting parent-caregivers, (3) Collaborative and holistic care, and (4) Efficient healthcare structures and standards. We named this measure the PaRental Experience with care for Children with serIOUS illnesses (PRECIOUS).

CONCLUSIONS

PRECIOUS is the first comprehensive measure and has the potential to standardize assessment of QoC for seriously ill children from parental perspectives. PRECIOUS allows for QoC process evaluation across contexts (such as geographic location or care setting), different healthcare workers, and over the illness trajectory for children suffering from a range of serious illnesses.

"Tie your camel first, then rely on God": reconceptualizing Javanese Islamic values to support palliative care at home

BACKGROUND

In the last decade, there has been a growing concern to make palliative care more culturally sensitive and contextually appropriate. This concern is also relevant in Indonesia, where the progress of palliative care, particularly in home-based care, has been slow. Like elsewhere in the world, there has been a growing awareness of the importance of shifting from a curative orientation towards a palliative one, especially in cases where further medical treatment is futile. In this paper we argue that the development of palliative care practices would benefit greatly from learning about the values that are important for patients, families, and health professionals. It is important to understand these values to support forms of care that aim to enhance quality of life. To demonstrate this, we analyse the care values people in rural Java evoke in their home palliative care practices.

METHODS

We conducted an eight-month ethnographic study involving forty-nine patients, families, and health professionals.

RESULTS

We identified three specific Javanese Islamic values: making an effort (ikhtiar), being sincere (ikhlas), and being in a state of surrender (pasrah). These values influenced the participants' activities in a palliative care setting. Based on our findings, we suggest three strategies to incorporate these values into palliative care practices and to better facilitate palliative care's integration into Javanese Muslim communities. The first strategy is to include efforts to reduce suffering and improve the quality of life using the concept of ikhtiar. The second strategy is to foster sincerity (ikhlas) to help patients and families accept the realities of their condition and provide care for patients at home. The last strategy is to clarify that palliative care is not synonymous with 'giving up' but can be seen as an act of pious surrender.

CONCLUSIONS

Our study identified three Islamic-Javanese values that can be incorporated to strategies aiming at enhancing palliative care practices, resulting in care focused on improving quality of life rather than futile attempts at a cure.

Mood assessments of family caregivers of patients with severe brain injury in China

OBJECTIVES

Long-term care of severe brain injury patients places a significant mental burden on family caregivers, yet few studies have reported the situation in China. We aimed to describe the mood states of family caregivers of patients with severe brain injury and examine the influencing factors that affect caregivers' moods.

METHODS

Cross-sectional survey was used to assess the mood profiles of Chinese family caregivers between February 2019 and February 2020. Demographic data of caregivers and patients, the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder scale (GAD-7) were used to assess the level of depressive and anxiety symptoms. The quality of life score was also assessed by a visual analog scale, and the Coma Recovery Scale-Revised was used to assess the patient's consciousness.

RESULT

One hundred and one patients with severe brain injury (57 unresponsive wakefulness syndrome, UWS) between the age of 14 and 70 and their main family caregivers were enrolled in the study. Most caregivers displayed depressive (n = 62) and anxiety symptoms (n = 65), with 17 and 20 of these family caregivers reporting (moderately) severe depressive symptom and severe anxiety symptom, respectively. The caregiver's depressive symptom level significantly decreased as the patient's injury lasted longer (r =  - 0.208, P = 0.037). Moreover, the age of the patient negatively related to the levels of depressive (r =  - 0.310, P = 0.002) and anxiety symptoms (r =  - 0.289, P = 0.003) in caregivers. There was a significant positive correlation between anxiety and depressive symptoms scores in family caregivers (r = 0.838, P < 0.001). The higher the level of anxiety (r =  - 0.273, P = 0.006) and depressive symptoms (r =  - 0.265, P = 0.007), the worse the quality of life.

CONCLUSION

Many family caregivers of patients with severe brain injury experience various levels of anxiety and depressive symptoms in China. Tailor-made psychological help seems imperative. Researchers and doctors can provide information about patient's conditions to assist family members in discussing rehabilitation options for patients in different states of consciousness will help to ease anxiety of family caregivers.

Palliative team involvement in end-of-life care for Jewish and Muslim children in Jerusalem: A unique clinical and cultural context

OBJECTIVES

Pediatric palliative care services improve the quality of life for children with life-limiting and life-threatening diseases, although little has been published about variation based on cultural and religious factors. This article sets out to describe clinical and cultural characteristics of pediatric end-of-life patients in a majority Jewish and Muslim country with religious and legal constraints around end-of-life care.

METHODS

We conducted a retrospective chart review of 78 pediatric patients who died during a 5-year period and could potentially have utilized pediatric palliative care services.

RESULTS

Patients reflected a range of primary diagnoses, most commonly oncologic diseases and multisystem genetic disorders. Patients followed by the pediatric palliative care team had less invasive therapies, more pain management and advance directives, and more psychosocial support. Patients from different cultural and religious backgrounds had similar levels of pediatric palliative care team follow-up but certain differences in end-of-life care.

SIGNIFICANCE OF RESULTS

In a culturally and religiously conservative context that poses constraints on decision-making around end-of-life care, pediatric palliative care services are a feasible and important means of maximizing symptom relief, as well as emotional and spiritual support, for children at the end of life and their families.

Pediatric palliative care across continents: Communication and shared-decision-making

Despite the significant growth and development of pediatric palliative care worldwide, significant challenges remain. One of those challenges is shared decision-making, by which parents, families and professionals all work together to develop a plan of care that reflects both the medical facts and the patient's family's values. Shared decision-making about palliative care and about death and dying may mean different things in different cultures and countries. It is therefore important to learn and compare practices around the world.

Supporting the Family After the Death of a Child or Adolescent

Whether death occurs in the context of a chronic illness or as the sudden loss of a previously healthy infant, child, or adolescent, the death of a child is a highly stressful and traumatic event. Psychosocial support for families after the death of a child embodies core medical values of professional fidelity, compassion, respect for human dignity, and promotion of the best interests of a grieving family. The pediatrician has an important role in supporting the family unit after the death of a child through a family-centered, culturally humble, trauma-informed approach. This clinical report aims to provide the pediatrician with a review of the current evidence on grief, bereavement, and mourning after the loss of a child and with practical guidance to support family caregivers, siblings, and the child's community. Pediatricians have an important role in helping siblings and helping families understand sibling needs during grief. Ways for pediatricians to support family members with cultural sensitivity are suggested and other helpful resources in the community are described.

Issues Related to Children-Faced by Armed Forces Families When Caring for Patients in Palliative Care - A Qualitative Study

Objectives

Access to palliative care is limited, especially in rural India. Children needing care by palliative teams may themselves be patients, or siblings and children of patients. Armed forces families face characteristic lifestyle challenges - frequent transfers, living in difficult and remote areas, serving personnel staying apart from families for long periods - very different from issues faced by civilians. Military service increases the risk of psychosocial burden for serving personnel as well as families. Most depend on private and state medical services for palliative care so it is important for the palliative community to understand their issues. This study aimed to explore the issues related to children - faced by armed forces families when caring for patients in palliative care.

Material and Methods

Qualitative study based on thematic analysis of semi-structured interviews with caregivers - either serving personnel or their dependents, in three centres.

Results

Analysis of the 15 interviews showed that armed forces families face complex challenges related to children when caring for the palliative patient due to frequent movement, lack of paediatric palliative services in far-flung areas, disruption of the continuity of care, social isolation, language, and cultural barriers when living in non-native areas, inability to build and access family and community support and financial burden due to restrictive reimbursement policies.

Conclusion

Although medical and administrative support within the organisation provides a cushion, wives have to manage alone in the father's prolonged absence, and safety is a concern for children when living outside the campuses and serving personnel report guilt, anger, and helplessness at not being present when needed. Awareness of these issues can enable palliative workers to provide more meaningful support tailored to the needs of service families.

Examining the Cultural Appropriateness of Advance Care Planning Tools for Adolescents and Young Adults With Cancer: An Example of Cross-Cultural Adaptation of the Voicing My CHOiCES Tool

Advance care planning (ACP) is crucial in supporting optimal, patient-centered care for adolescents and young adults (AYAs) with life-limiting illnesses and can reduce unwanted outcomes at end-of-life. While several ACP tools and interventions have been designed for AYAs, most of these were developed in the United States of America (USA). This paper describes a study designed to adapt the AYA ACP tool, Voicing My CHOiCES (VMC), for the Australian population. A 2-stage mixed methods approach was used. Stage 1 involved a multiperspective interview to determine changes for the new Australian VMC. Participants were AYAs between the ages of 15 to 25, healthcare professionals, and parents. For each section, participants responded to questions targeting the helpfulness and usefulness of the items as well as open-ended questions about any suggested content or formatting changes. Stage 2 used think-aloud interviews asking AYA cancer patients and survivors aged between 15 and 39 years to respond to proposed changes for the Australian VMC. Stage 1 participants suggested changes to all pages of VMC, with proposed changes being based around language, content, and format. Stage 2 participants qualitatively confirmed the acceptability of these changes. Our data suggests that even between similar Western cultures, significant adaptations can be made to make ACP tools more culturally appropriate. More research is needed to further adapt ACP tools like VMC for culturally and linguistically diverse groups and to ensure these tools can be accessed by all AYAs with life-limiting illness.

An agenda to develop Pediatric Palliative care programs to serve children with life-threatening and life-limiting conditions in the Gulf Cooperation Council countries

Medical advances have increased the number of children living with life-threatening/life-limiting illnesses worldwide, including in Gulf Cooperation Council (GCC) countries. Pediatric palliative care (PPC) is a relatively young subspecialty that cares for children with life-threatening/life-limiting illnesses and their families. PPC aims to alleviate physical, psychological, and social distress in children with life-threatening/life-limiting illnesses and their families and improve their quality of life. PPC is an essential service that should be implemented in all nations, as it is a human right. Moreover, a core value of PPC services is to alleviate children's suffering, irrespective of cure availability. Hence, the global consensus on palliative services must be universal and include developing countries with limited resources. While PPC services are growing internationally, the GCC countries have yet to implement these valuable services in the region. This work aims to define the local base information important to facilitating the PPC program. We explored and identified the information vital for establishing a successful program, which was then categorized and mapped into subgroups. In doing so, we outline a roadmap to facilitate the smooth introduction of PPC in GCC countries to benefit the lives of children with life-limiting illnesses.

Spiritual and cultural influences on end-of-life care and decision-making in NICU

Understanding and respecting the spiritual beliefs, ethnic roots, cultural norms and customs of individual families is essential for neonatologists to provide clinically appropriate and humane end-of-life care. This review describes the religious/philosophical principles, cultural-related practices/rituals, and traditions in end-of-life care in major spiritual groups of today's multi-cultural, multi-faith societies. The spiritual groups include Christians, Muslims, Jewish Judaism believers and Asian religious/philosophy followers such as Buddhists, Hindus, Taoists, Confucianism devotees and ancestral worshippers. It is vital to understand that substantial variation in views and practices may exist even within the same religion and culture in different geographic locations. Ethical views and cultural practices are not static elements in life but behave in a fluidic and dynamic manner that could change with time. Interestingly, an evolving pattern has been observed in some Asian and Middle East countries that more parents and/or religious groups are beginning to accept a form of redirection of care most compatible with their spiritual belief and culture. Thus, every family must be assessed and counseled individually for end-of-life decision-making. Also, every effort should be made to comply with parents' requests and to treat infants/parents of different religions and cultures with utmost dignity so that they have no regret for their irreversible decisions.

Pediatric Oncology, Palliative Care and Low- or Middle- Income Countries: A Call for Action

Pediatric oncology, which includes cancer screening and therapy in children, poses significant challenges in low- and middle-income countries (LMICs). Palliative care improves children's and their families' quality of life. In LMICs, palliative care resources are scarce, resulting in poor symptom management, psychological support, and spiritual care. All relevant English-language articles on pediatric palliative oncology were searched in PubMed, Google Scholar, Scopus, and Medline databases using the following keywords: "Pediatric Oncology," "Pediatric Palliative Oncology," "Pediatric Palliative Care," "Palliative Care," "Child Cancer," and "Lower- and Middle-Income Countries." This study highlights the significance of incorporating palliative care early in therapy and the recommendations may improve the competence of information provided by medical professionals to patients and families. LMICs have the potential to improve overall treatment and outcomes for child cancer patients and their families by prioritizing the integration of palliative care, guaranteeing a compassionate and dignified attitude toward the disease.

The Science to Spirituality in Paediatric Palliative Care: A Commentary

Spirituality in paediatric palliative care remains an enigma across both the Eastern and Western worlds. There is no absolute science to it, and it can be a barrier to effective palliative care to be delivered. This article aims to discuss the barriers to and recommendations for discussing this sensitive topic with children and their families to enhance the quality of palliative care rendered, with the aid of case studies to illustrate the underestimated importance of spirituality in paediatric palliative care.

Navigating Cultural Diversity in the Selection of Cardiovascular Device Treatments: A Comprehensive Review

In cardiology, patients' cultural beliefs, linguistic differences, lack of knowledge, and socioeconomic status can create barriers to choosing device treatment. To address this issue, we conducted a thorough literature review using online databases such as PubMed, Google Scholar, and Texas Tech University Health Sciences Center's research portal. Our review found that cultural, religious, and linguistic barriers can contribute to patients' apprehension and reservations about device placement. These barriers can also impact patients' adherence to treatment and clinical outcomes. Patients from lower socioeconomic backgrounds may have difficulty accessing and affording device-based treatments. Additionally, fear and inadequate understanding of surgical procedures can deter patients from accepting device treatment in cardiology. To overcome these cultural barriers, healthcare providers must raise awareness about the benefits of device treatment and provide better training to overcome these challenges. It is crucial to address the unique needs of patients from different cultural backgrounds and socioeconomic statuses to ensure they receive the care they need.

Attitudes toward the Care of Children with Cancer in Saudi: An Exploratory Survey

The ethical challenges of pediatric cancer care across Arab countries are not well addressed, despite medical advancements and increased awareness of children's rights. The ethical challenges related to pediatric cancer in Saudi Arabia were investigated by surveying 400 respondents at King Abdulaziz Medical City in Riyadh, Jeddah, and Dammam, Saudi Arabia, from four groups: pediatricians, medical students, nurses, and parents of children with cancer. Respondents' characteristics were surveyed across three outcomes: awareness of care, knowledge, and parent consent/child assent, developed from a systematic review and a qualitative analysis. A majority of respondents (89.0%) considered pediatric cancer different from adult cancer. Families considered alternative treatment, according to 64.3% of respondents, while 88.0% emphasized understanding the family's needs and values. Furthermore, 95.8% of respondents believed physicians should offer time for pedagogy, 92.3% viewed parental consent as essential, and 94.5% thought that sufficient discussion about the plan and type of treatment should precede consent. However, child assent showed lower levels of agreement, with only 41.3% and 52.5% agreeing with getting child assent and having a discussion. Finally, 56% agreed that parents might refuse suggested treatment, while only 24.3% agreed that the child could refuse it. In all these ethical considerations, nurses and physicians showed significantly more positive results compared with other groups.

Adapting the Voicing My CHOiCES Advance Care Planning Communication Guide for Australian Adolescents and Young Adults with Cancer: Appropriateness, Acceptability, and Considerations for Clinical Practice

Background: Adolescents and young adults (AYAs) with life-threatening illnesses need support to discuss and voice their end-of-life choices. Voicing My CHOiCES (VMC) is a research-informed American advanced care planning guide designed to help facilitate these difficult discussions. This multi-perspective study aimed to evaluate its appropriateness, acceptability, and clinical considerations for Australian AYAs with cancer. Procedure: Forty-three participants including AYAs who were either undergoing or recently completed cancer treatment, their parents, and multidisciplinary health professionals assessed the acceptability of each VMC section quantitatively (appropriateness-yes/no, helpfulness and whether content caused stress-1 = not at all, to 5 = very) and qualitatively (sources of stress). AYAs also assessed the benefit and burden of completing several sections of the document, to inform clinical considerations. We conducted a mixed-methods analysis to obtain descriptive statistics and to identify prominent themes. Results: In terms of acceptability, almost all participants (96%) rated VMC as appropriate overall. Perceived helpfulness to their situation (to themselves/their child/their patients), to others, and stressfulness were rated, on average, as 4.1, 4.0, and 2.7/5, respectively. Stress was attributed to individual and personal factors, as well as interpersonal worries. All sections were considered more beneficial than burdensome, except for the Spiritual Thoughts section (Section 6). Conclusions: While VMC is an acceptable advance care planning guide for AYAs with cancer, changes to the guide were suggested for the Australian context. Health professionals implementing VMC will need to address and mitigate anticipated sources of stress identified here. Future research evaluating the impact of a new culturally adapted Australian VMC guide is an important next step. Finally, the clinical implications of the present study are suggested.

Nursing Practice and Care Structure for Children and Their Families in Need of Pediatric Palliative and End-of-Life Care in Japan: A Nationwide Survey

Many nurses experience difficulties in pediatric palliative care practice. The study aimed to describe the current situation and structure of pediatric palliative and end-of-life care nursing practices for children and their families in Japan. The research subjects were nurses working in hospitals; facilities for persons with severe physical, motor, and intellectual disabilities; and home-visit nursing stations. The practice ratio was calculated using a 79-item survey form, and factor analysis was conducted. A total of 113 facilities (acceptance rate: 26.5%) and 777 nurses (response rate: 44.6%) responded. Five items had a "Practicing" ratio of ≥90%. In factor analysis, 7 domains were identified: "preparing to face the time of death with the child and family," "ensuring child-centered care," "managing symptoms with the child and family," "considering and coordinating for the child's peaceful time of death," "understanding and respecting the culture of the child and family," "assessing the child and family as a whole person," and "performing self-reflection on an ethical issue." Nurses' practice of pediatric palliative care differs by practice domain. It is necessary to reflect on the educational programs under development to improve the quality of life of children and their families.

The impacts of the scope of benefits expansion on hospice care among adult decedents: a nationwide longitudinal observational study

OBJECTIVES

Compared to aggressive treatment for patients at the end stage of life, hospice care might be more likely to satisfy such patients' need and benefits and improve their dignity and quality of life. Whether the reimbursement policy expansion affect the use of hospice care among various demographics characteristics and health status was unknown. Therefore, the purpose of this study was to explore the impacts of reimbursement policy expansion on hospice care use, and to investigate the effects on people with various demographics characteristics and health status.

METHODS

We used the 2001-2017 Taiwan NHI claims data, Death Registry, and Cancer Registry in this study, and we included people who died between 2002 and 2017. The study period was divided into 4 sub-periods. hospice care use and the initiation time of 1st hospice care use were used as dependent variables; demographic characteristics and health status were also collected.

RESULTS

There were 2,445,781 people who died in Taiwan during the study period. The results show that the trend of hospice care use increased over time, going steeply upward after the scope of benefits expansion, but the initiation time of 1st hospice care use did not increase after the scope of benefits expansion. The results also show that the effects of expansion varied among patients by demographic characteristics.

CONCLUSION

The scope of benefits expansion might induce people's needs in hospice care, but the effects varied by demographic characteristics. Understanding the reasons for the variations in all populations would be the next step for Taiwan's health authorities.

Congruent Communication: Addressing Culture and Care for a Seriously Ill Rohingya Infant

Pediatric palliative care teams seek to collaboratively promote the quality of life for children with serious medical illness in the context of the values expressed by the patient and family. Especially for infants with high medical fragility, shared decision making can be a complex task that often requires flexibility to respond to the clinical circumstances at hand, as well as contextualization within the family culture. In this paper, we present the case of an infant with a severe congenital brain malformation who was born in an American hospital to a Rohingya-speaking, Burmese family whose care preferences seemed to oscillate between comfort-focused and life-prolonging without clear acknowledgement of the consequences of shifting between treatment plans. Discussion of this case helps to illustrate the cultural factors, ethical challenges, and systems-level issues that can arise for medical teams in seeking to promote patient-centered care that respects family values while also honoring the principle of nonmaleficience.

Implementing Spiritual Care in the Pediatric Complex Care Clinic

A project integrated a Clinical Pastoral Education Fellow into a clinic designed to treat children with medical complexity (CMC). The integration of a chaplain into the care team fulfilled the goal of increasing accessibility to spiritual care through a quality improvement project and seemed to positively affect patients and the interdisciplinary team itself. These efforts demonstrate the need for research to better understand the relationship between spiritual screenings, interventions, and outcomes for CMC patients.

A grounded theory study on the dynamics of parental grief during the children's end of life

AIM

Parents are increasingly confronted with loss during their child's end of life. Healthcare professionals struggle with parental responses to loss. This study aimed to understand parental coping with grief during their child's end of life.

METHODS

A grounded theory study was performed, using semi-structured interviews with parents during the child's end of life and recently bereaved parents. Data were collected in four children's university hospitals and paediatric homecare services between October 2020 and December 2021. A multidisciplinary team conducted the analysis.

RESULTS

In total, 38 parents of 22 children participated. Parents strived to sustain family life, to be a good parent and to ensure a full life for their child. Meanwhile parents' grief increased because of their hypervigilance towards signs of loss. Parents' coping with grief is characterised by an interplay of downregulating grief and connecting with grief, aimed at creating emotional space to be present and connect with their child. Parents connected with grief when it was forced upon them or when they momentarily allowed themselves to.

CONCLUSION

The parents' ability to engage with grief becomes strained during the end of life. Healthcare professionals should support parents in their search for a balance that facilitates creating emotional space.

Validation of Kiswahili version of WHOQOL-HIV BREF questionnaire among people living with HIV/AIDS in Tanzania- a cross sectional study

Introduction

World Health Organization (WHO) has developed HIV specific quality of life tool called World Health Organization Quality of Life brief questionnaire in HIV population (WHOQOL-HIV BREF) for assessing the quality of life of people living with HIV/AIDS (PLWHA). Despite its sound validity and reliability from several studies, the developers recommend it to be validated in different cultures to assess its psychometric properties before its adoption. The study aimed at evaluating the validity and reliability of the Kiswahili version of the WHOQOL-HIV BREF questionnaire in Tanzania among people living with HIV/AIDS.

Methods

a cross-sectional study with 103 participants recruited via systematic random sampling. The internal consistency of the questionnaire was assessed by the Cronbach alpha coefficient. Validity of the WHOQOL-HIV BREF was assessed through analysis of construct, concurrent, convergent and discriminant validity. The model performance was assessed by exploratory and confirmatory factor analysis.

Results

the mean age of the participants was 40.5 ± 9.702 years. The internal consistency of the items of the Kiswahili version of WHOQOL-HIV BREF shows Cronbach's alpha values of 0.89-0.90 (p < 0.001). Analysis of test-retest reliability showed a statistically significant Intra-class correlation (ICC) of 0.91 - 0.92 (p < 0.001). The spiritual and physical domains were highly discriminated from the rest of the domains (Psychological, Environmental, Social and Independent domain).

Conclusion

Kiswahili WHOQOL-HIV BREF tool was found to have good validity and reliability among Tanzanian people living with HIV/AIDS. These findings provide support for the use of this tool in assessing the quality of life in Tanzania.

"Between Wings of Hope and Fear": Muslim Parents' Experiences with the American Health Care System

Background and Objectives: Historically marginalized religious and cultural groups are at risk for lower quality of care than majority groups. No study to date specifically queries Muslim experiences with the American health care system (AHCS). We performed a thematic analysis of Muslim parents' interactions with the AHCS and how their background informs their approach to care. Methods: This was a qualitative study of Muslim parents of children with life-limiting conditions in the Research Triangle Area from December 2019 to March 2019. We conducted semistructured interviews with parents to assess their experiences with the AHCS. We probed interview transcripts using descriptive content analysis with NVivo10. Results: We interviewed 10 parents in the Research Triangle Area. All patients were female, most were married, most spoke at least one other language in addition to English, and most were not born in the United States. Several themes emerged highlighting open communication with care teams, willingness to share religious affiliations, and the importance of leaning into faith and accepting God's will. Conclusions: A thematic analysis of Muslim parents' interactions with the AHCS describes value in honest communication, mixed concerns about how providers will react to their religious affiliation, and emphasizes the importance of leaning heavily into faith and accepting God's plan. Future studies evaluating needs of Muslim patients, especially those with different diagnoses, language barriers, and a larger sample size will further delineate needs to minimize inequalities in care.

Family Communication About Cancer in Korea: A Dyadic Analysis of Parent-Adolescent Conversation

Parent-adolescent communication is important in the context of childhood cancer. However, we know little about the communication experiences between Korean adolescents and their parents. Here, we conducted a secondary analysis of interview data from a qualitative descriptive study to explore Korean parent-adolescent communication experiences as a unit. Specifically, our dyadic analysis of individual interviews with seven Korean adolescents with cancer and at least one parent included inductive analysis at the individual level and cross-analysis to generate themes. The main theme was "Experience the same thing, but see it differently," along three subthemes: (1) different expectations for parent-adolescent communication, (2) different views on communication challenges, and (3) limited sharing and no progress in the conversation. Overall, our findings provide insights into different communication expectations and preferences between Korean adolescents and parents, and reasons for communication challenges, while emphasizing the individualized assessment of parent-adolescent communication between them.

Pediatric neuropalliative care

Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.

Experiences with the end-of-life decision-making process in children with cancer, their parents, and healthcare professionals: A systematic review and meta-ethnography

BACKGROUND

Decision-making during the end-of-life (EOL) phase for children with cancer is extremely difficult for parents. We synthesized the qualitative experiences of children with cancer, parents, and healthcare professionals (HCPs), and their social interactions during the EOL decision-making process in the pediatric oncology setting.

METHODS

Meta-ethnography was used to conduct a systematic review and meta-synthesis. We searched four online databases to identify original studies published in English and Japanese and examined 21 relevant studies. Two Japanese reviewers discussed the differences/relationships and included studies that synthesized the translated qualitative findings. A conceptual model of social interactions was created.

RESULTS

We identified four themes regarding children's, parents', and HCPs' experiences: hope and confrontation with the child's death, guidance and support during uncertainty, awareness of being protected and having hope, and mutual unspoken integration of values.

CONCLUSIONS

These themes evince the experiences of children, parents, and HCPs during the EOL decision-making process and suggests a complex three-way social interaction model. While considering such distinctive social interactions during a child's EOL, this study revealed the sharing of prudent information and psychosocial support by HCPs. The findings indicate that hope and uncertainty are key elements for effectively understanding the experiences of children and parents and that EOL decision-making should not be rushed but should be supported by leaving room for uncertainty and acknowledging parents' emotional needs and fostering new hope. Further research into how hope can be further supported in situations that are rife with uncertainty is needed.

Pediatric palliative care for children with cancer: a concept analysis using Rodgers' evolutionary approach

BACKGROUND

Providing access to pediatric palliative care (PPC) for children living with a serious illness, such as cancer, is of critical importance, although this specialized intervention, as a novel concept, still seems vague and complicated. The present study analyzed the concept of PPC for children with cancer.

METHODS

Rodgers' evolutionary method was employed for the concept analysis. Articles on PPC, particularly those for children suffering from cancer, published between 2010 and 2021 were searched in valid academic research databases. The inclusion criteria for the full-text articles were based on the characteristics, antecedents, and consequences of PPC for children with cancer.

RESULTS

In total, 19 relevant articles were selected and then reviewed and analyzed after applying the inclusion criteria and the final sampling. The analysis of the concept of PPC for children affected with cancer revealed four characteristics, including "PPC as holistic and integrated care", "PPC as patient- and family-centered care", "PPC as early-start continuous care", and "PPC as interdisciplinary and team-based care". Some effective factors could also act as antecedents for this concept, i.e., health care providers' training and expertise as well as human resources and financing. Moreover, improved quality of life, symptom reduction, and coordination between patient care and family support were among the PPC consequences for such children.

CONCLUSIONS

The study results demonstrated that delivering PPC to children with cancer demanded a comprehensive view of its various dimensions. Furthermore, numerous factors need to be delineated for its accurate and complete implementation.

Trends in quality indicators of end-of-life care for women with gynecologic malignancies in Ontario, Canada

OBJECTIVE

A large body of research has validated several quality indicators of end-of-life (EOL) cancer care, but few have examined these in gynecologic cancer at a population-level. We examined patterns of EOL care quality in patients with gynecologic cancers across 13 years in Ontario, Canada.

METHODS

We conducted a population-based, retrospective cohort study of gynecologic cancer decedents in Ontario from 2006 to 2018 using linked administrative health care databases. Proportions of quality indices were calculated, including: emergency department (ED) use, hospital or intensive care unit (ICU) admission, chemotherapy ≤14 days of death, cancer-related surgery, tube or intravenous feeds, palliative home visits, and hospital death. We used multivariable logistic regression to examine factors associated with receipt of aggressive and supportive care.

RESULTS

There were 16,237 included decedents over the study period; hospital death rates decreased from 47% to 37%, supportive care use rose from 65% to 74%, and aggressive care remained stable (16%). Within 30 days of death, 50% were hospitalized, 5% admitted to ICU, and 67% accessed palliative homecare. Within 14 days of death, 31% visited the ED and 4% received chemotherapy. Patients with vulvovaginal cancers received the lowest rates of aggressive and supportive care. Using multivariable analyses, factors associated with increased aggressive EOL care use included younger age, shorter disease duration, lower income quintiles, and rural residence.

CONCLUSIONS

Over time, less women dying with gynecologic cancers in Ontario experienced death in hospital, and more accessed supportive care. However, the majority were still hospitalized and a significant proportion received aggressive care in the final 30 days of life.

How can advance care planning tools help young people's voices be heard?

The integration of the child or young person (CYP) in conversations around advance care planning (ACP) is an important area of paediatric practice. These discussions provide CYP with the opportunity to voice their values, goals and preferences, enabling health-care professionals to ensure they are aligned with their planned course of treatment. This process, often undertaken within the context of the child's family, empowers children to participate in decisions and experience the dignity of self-determination. It also facilitates an increased understanding between the CYP and those involved in their care. The objectives of this paper are to highlight the importance of these conversations for paediatricians and identify barriers, both real and perceived, that may prevent them from engaging with a CYP about their preferences for future care including focusing more on discussion with the parents, and concern about or not having the skills to engage the child in such sensitive conversations. Triggers that can prompt clinicians to undertake ACP are also discussed. A further complexity is that after seeking their perspective, it may become apparent that the CYP may hold different views and perspectives to their parents and/or clinician. This review article will especially examine elements of end-of-life conversations that are critical to support the important goal of listening to the voice of the CYP. This includes considerations around timing, legal aspects, ethical tensions that arise when amplifying a child's voice, clinician/team-member roles, clinical process considerations, and the use of specific interventions and ACP tools to facilitate these conversations with CYP.

Thinking globally to improve care locally: A Delphi study protocol to achieve international clinical consensus on best-practice end-of-life communication with adolescents and young adults with cancer

For the sizeable subset of adolescents and young adults whose cancer is incurable, developmentally appropriate end-of-life discussions are critical. Standards of care for adolescent and young adult end-of-life communication have been established, however, many health-professionals do not feel confident leading these conversations, leaving gaps in the implementation of best-practice end-of-life communication. We present a protocol for a Delphi study informing the development and implementation of clinician training to strengthen health-professionals’ capacity in end-of-life conversations. Our approach will inform training to address barriers to end-of-life communication with adolescents and young adults across Westernized Adolescent and Young Adult Cancer Global Accord countries. The Adolescent and Young Adult Cancer Global Accord team involves 26 investigators from Australia, New Zealand, the United States, Canada and the United Kingdom. Twenty-four consumers, including adolescents and young adults with cancer history and carers, informed study design. We describe methodology for a modified Delphi questionnaire. The questionnaire aims to determine optimal timing for end-of-life communication with adolescents and young adults, practice-related content needed in clinician training for end-of-life communication with adolescents and young adults, and desireability of evidence-based training models. Round 1 involves an expert panel of investigators identifying appropriate questionnaire items. Rounds 2 and 3 involve questionnaires of international multidisciplinary health-professionals, followed by further input by adolescents and young adults. A second stage of research will design health-professional training to support best-practice end-of-life communication. The outcomes of this iterative and participatory research will directly inform the implementation of best-practice end-of-life communication across Adolescent and Young Adult Cancer Global Accord countries. Barriers and training preferences identified will directly contribute to developing clinician-training resources. Our results will provide a framework to support further investigating end-of-life communication with adolescents and young adults across diverse countries. Our experiences also highlight effective methodology in undertaking highly collaborative global research.

Fifteen-minute consultation: How to communicate with parents who have a child on life support with no hope of recovery

A child on life support with no hope of recovery is the worst nightmare for parents and for paediatricians. Unfortunately, some children have illnesses or injuries that are not compatible with life. Being in a vegetative state with no meaningful interaction does not safeguard children from feeling discomfort and pain. Letting nature take its course and allowing the child to die may well be the least worse option. However, this decision is fraught with difficulties for parents and for clinicians and can lead to unnecessary and painful conflict between them, even leading to court proceedings. In this paper, the impact of having a child on life support is discussed and recommendations are given in order to improve professional communication. It is hoped that an understanding of the impact on parents, cultural considerations, and the psychiatric concepts of 'denial', 'projection', the 'meta-level', 'transference', 'countertransference' and the techniques of 'motivational interviewing' will help clinicians prevent a breakdown of trust and improve doctor-parent relationships in these tragic cases.

Defining Core Competencies and a Call to Action: Dissecting and Embracing the Crucial and Multifaceted Social Work Role in Pediatric Palliative Care

While social workers are a well-established, part of the pediatric palliative care team, this manuscript presents the first published definition of the core competencies of a pediatric palliative care social worker. National experts in the field, guided by the pediatric special interest group of the Social Work Hospice and Palliative Network (SWHPN), worked together to articulate, and define core competencies. As the field of pediatric palliative care (PPC) continues to grow and develop, these competencies will help to better delineate the specific skill base of social workers in PPC. Such competencies may also create clearer role definition for emerging PPC social workers, guide training, clinical supervision, and mentorship in the field. They can also support improved interdisciplinary practice by assisting interprofessional colleagues in understanding and articulating the critical role of social workers as part of the PPC team. Additionally, such competencies may contribute to the growing development of role descriptions necessary for the hiring of social workers onto growing PPC teams, while also providing a framework for the creation and support of curricula centered on the subspeciality education and training of the next generation of PPC social workers.

Clinician End-of-Life Experiences With Pediatric Muslim Patients at a US Quaternary Care Center

CONTEXT

A small, growing body of data exist discussing the experiences of Muslim patients with the palliative care system, both in the United States and abroad, as well as providers' experiences with Muslim patients. However, no studies evaluate clinician experiences with Muslim patients in the United States, and none address the unique dynamics of pediatric clinician experiences with Muslim patients and their families in the EOL setting.

OBJECTIVES

The purpose of this study is to perform a thematic analysis of clinician experiences with pediatric Muslim patients and families at the end of life.

METHODS

This was a qualitative study of pediatric clinicians at Duke University Medical Center in the Pediatric Intensive Care Unit, Pediatric Cardiac Intensive Care Unit, and Pediatric Bone Marrow Unit from August 2018 to February 2019. We conducted semistructured interviews with nurses, attending physicians, and social workers to assess participants' experiences caring for Muslim patients and families. We analyzed interview transcripts using descriptive content analysis with NVivo10.

RESULTS

We interviewed 16 clinicians at Duke University Medical Center Pediatric Intensive Care Unit, Pediatric Cardiac Intensive Care Unit, and Pediatric Bone Marrow Unit. Five physicians, five social workers, and six nurses were interviewed. The majority of providers were female, Caucasian, and Christian in an institution where Muslim patients are a significant minority. Several themes emerged highlighting language barriers, difficulty engaging with Muslim families, variations in approach to care and communication, discomfort with gender roles, moral distress with unrelatable decision-making, and external pressures on patient decision-making.

CONCLUSION

A thematic analysis of pediatric clinicians at a quaternary care center in the Southern United States yielded several prominent themes. Many clinicians recognize they likely provide disparate care to minority patients for a variety of reasons encompassing the above barriers. As we work to care for an increasingly diverse patient population, more research into barriers to care and effective educational methods is needed.

Guidance for Pediatric End-of-Life Care

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.

Rate of and Factors Associated with Palliative Care Referral among Patients Declined for Liver Transplantation

Background: End-stage liver disease (ESLD) is associated with high morbidity and mortality, with liver transplantation as the only existing cure. Despite reduced quality of life and limited life expectancy, referral to palliative care (PC) rarely occurs. Moreover, there is scarcity of data on the appropriate timing and type of PC intervention needed. Aim: To evaluate PC utilization and documentation in ESLD patients declined or delisted for transplant at a tertiary care medical center with a large liver transplantation program. Methods: We performed a retrospective cohort study of all patients discussed in Liver Transplant Committee (LTC) at our academic medical center between August 2018 and May 2020 in the United States. Patients declined or delisted for liver transplantation were included. Baseline demographics, model for end-stage liver disease (MELD) score, decompensation events, and reason for transplant ineligibility were recorded. The primary outcome was PC referral. Secondary outcomes included survival from LTC decision, time from LTC decision to PC referral, and code status in relation to PC referral. Results: Of 769 patients discussed at LTC, 135 were declined for transplantation. Thirty-seven (27%) received referral to PC. When adjusting for body mass index and age, MELD score of 21-30 had odds ratio (OR) of 4.5 (95% confidence interval [CI]: 1.7-12.3) and MELD score >30 had OR of 12.8 (95% CI: 3.9-47.7) for PC referral when compared with MELD score <20. When adjusting for MELD score, presence of ascites had OR of 4.6 (95% CI: 1.1-19.1) and presence of multiple complications had OR of 2.2 (95% CI: 2.2-3.8). Conclusions: Only 37 (27%) patients delisted or declined for liver transplantation were referred to PC. MELD score and degree of decompensation were important factors associated with referral. Continued exploration of these data could help guide future studies and help determine timing and criteria for PC referral.

De la beneficencia a la ciencia, de la moral a la ética

El Trabajo Social Sanitario (TSS) nace del acompañamiento a personas enfermas y en el final de la vida. Más de un siglo después de que las pioneras de la profesión empezaran a reflexionar sobre los valores, técnicas y marco ético que deben guiar la intervención, sigue habiendo más interrogantes que respuestas. Actualmente la profesión afronta nuevos retos y conflictos que obligan a reflexionar y cuestionar aspectos del quehacer diario. La apuesta por un modelo de intervención biopsicosocial y centrado en la persona, todavía en construcción, requiere una actitud crítica con el estado del bienestar y el espejismo de la atención integrada que, aunque cada vez hay más esfuerzos, sigue sin cuajar. Este artículo plantea algunos conflictos éticos a partir de tres experiencias de acompañamiento de las trabajadoras sociales sanitarias de una unidad de atención paliativa pediátrica y paciente crónico complejo.

Impact of End-of-Life Circumstances on the Adjustment of Bereaved Siblings of Children Who Died from Cancer

The aim of this study was to examine the impact of end-of-life (EoL) circumstances on grief and internalizing symptoms among bereaved siblings. Bereaved families (N = 88) were recruited from three sites 3-12 months (M = 11.57, SD = 3.48) after their child's death from cancer. One sibling per family aged 8-17 years (M = 12.41, SD = 2.64) was randomly selected to participate. Families completed measures of siblings' grief and internalizing symptoms, as well as a structured interview about circumstances surrounding the death. Mother and sibling reports of EoL circumstances were generally concordant, except there was a discrepancy between mothers and children about whether or not children expected their sibling's death (t(75) = 1.52, p = .018). Mother reports of sibling internalizing symptoms were above the normative mean (t(83) = 4.44, p ≤ .001 (M = 56.01 ± 12.48), with 39% (n = 33) in the borderline/clinical range. Sibling opportunity to say goodbye was associated with greater grief-related growth (t(79) = - 1.95, p = .05). Presence at the death and wishing they had done something differently were both associated with greater grief (t(80) = - 2.08, p = .04 and t(80) = - 2.24, p = .028, respectively) and grief-related growth (t(80) = - 2.01, p = .048 and t(80) = - 2.31, p = .024, respectively). However, findings were primarily unique to sibling report, with few mother-reported effects. The adjustment of bereaved siblings may be affected by certain modifiable circumstances surrounding the death of their brother or sister. A proportion of bereaved siblings had elevated internalizing symptoms irrespective of circumstances at EoL. Further work is needed to understand predictors of adjustment among bereaved siblings to provide better support and optimize their outcomes.

Advance care planning and the parental geographical background in pediatric palliative home care: a retrospective chart review

The relevance to acknowledge the parental migration history in pediatric palliative care is widely recognized. However, its influence on integral parts of advance care planning (ACP) is unknown. In this non-interventional cohort study, we aimed at identifying systematic differences between pediatric palliative patients with varying parental countries of origin regarding medical orders for life-sustaining treatment and the location of patients' death. Two hundred eighty-eight pediatric cases in an ambulant pediatric palliative care setting in Germany were retrospectively analyzed using multinomial logistic regression models. Agreements on medical orders for life-sustaining treatment (MOLST) differed significantly between patients with varying parental countries of origin. Full code orders for life-sustaining treatment were made more often in Turkish families than in German families. There were no significant associations between the patients' location of death and the parental countries of origin. However, confounder-analysis revealed a strong association between the patients' underlying disease and the orders for life-sustaining treatment as well as the location of death.Conclusions: Even this study indicates that the parental geographical background as an important sociocultural aspect might have an impact on ACP decisions for children and adolescents with life-limiting conditions, other factors as the patients' underlying disease can be more crucial for decision making in pediatric palliative care. The reason for the differences found might lay in cultural preferences or barriers to appropriate care. The inclusion of sociocultural aspects in decision-making is crucial to guarantee culture-sensitive, patient-centered pediatric palliative care.

The end-of-life care in the emergency department setting with respect to the Middle East countries and comparison with the Western countries

Patients who are affected with severe chronic illness or in need for end-of-life care ((EOLC), they are mainly treated in the emergency departments (EDs) to provide the utmost amount of care for their condition. The major aspects which impact the accessibility of care in the ED include the clinical, social, and economic factors in different regions of countries. In recent years as the EOLC has been provided, it has been observed that patients experiencing EOL and dealing with a dying process do not always achieve the experience what resonates with a good death. The main cause of concern for these patients is the problem that in the ED they do not have access to palliative care options, mainly the ones who are suffering from noncancer ailments. These patients are provided palliative care at a very later stage in the ED when they could have been provided with palliative management at home in an earlier manner. EOLC plays a very critical role in ensuring that terminally ill patients are given a proper and adequate amount of care. The present article aims to highlight the EOLC in the ED in the Middle-Eastern regions. We aim to present a broader view that has impacted the current situation of EOLC in the Middle East regions and demonstrate a description of the EOLC in an ED setting between the Middle Eastern regions and western culture focusing on the following five important factors: Situation acceptance in the ED, cultural compatibility of bioethics, treatment perspective, skills among clinical providers and physician's attitude. In this literature review, we present the evidence associated with the EOLC in the ED setting with respect to the Middle East countries and bring out their differences in the religious, clinical, social, ethical, and economic aspects in comparison with the Western countries. We also tried to determine the differences between the two regions in terms of the principle of explaining the fatal diagnosis or poor prognosis, family relations, and do-not-resuscitate decision. This comparative analysis will help to bring out the gaps in the quality of care in the ED in the Middle East countries and promote the development of well-assessed policies and strategies to improve EOLC. The findings of this study and the future interventions that can be implemented to improve the structure and design of the EOLC that will act as a guiding force to execute evidence-based quality improvement program.

End of life communication among caregivers of children with cancer: A qualitative approach to understanding support desired by families

OBJECTIVES

Clinicians and parents are encouraged to have open and honest communication about end of life with children with cancer, yet there remains limited research in this area. We examined family communication and preferred forms of support among bereaved caregivers of children with cancer.

METHODS

Bereaved caregivers were recruited through a closed social media group to complete an online survey providing retrospective reports of end of life communication with their child and preferences for communication support from health-care providers. The sample of 131 participants was mostly female (77.9%; n = 102) with an average age of 49.15 (SD = 8.03) years. Deceased children were of an average age of 12.42 years (SD = 6.01) and nearly 90% of children died within 5 years of diagnosis.

RESULTS

Most caregivers spoke with their child about their prognosis (61.8%; n = 131) and death (66.7%; n = 99). Half of children (48%; n = 125) asked about death, particularly older children (51.9% ≥12 years; p = 0.03). Asking about dying was related to having conversations about prognosis (p ≤ 0.001) and death (p ≤ 0.001). Most caregivers (71.8%; n = 94) wanted support to talk to their children. Fewer wanted providers to speak to children directly (12.2%; n = 16) or to be present while caregivers spoke to the child (19.8%; n = 26). Several themes emerged from a content analysis of open-ended responses regarding preferences for provider support.

SIGNIFICANCE OF RESULTS

Most caregivers discussed issues pertaining to end of life irrespective of demographic or medical factors. Qualitative themes provide insight into support desired by families to help with these difficult conversations.

In the name of the family? Against parents' refusal to disclose prognostic information to children

Parents frequently attempt to shield their children from distressing prognostic information. Pediatric oncology providers sometimes follow parental request for non-disclosure of prognostic information to children, invoking what we call the stability of the family argument. They believe that if they inform the child about terminal prognosis despite parental wishes, cohesion and family structure will be severely hampered. In this paper, we argue against parental request for non-disclosure. Firstly, we present the stability of the family argument in more detail. We, then, set out the (conceptual, legal, systemic) entitativity of the family and the kind of value the stability of the family argument assumes, before we set on to critically evaluate the argument. Our analysis shows that disclosure of prognostic information to children does not necessarily destabilize the family to a greater extent than non-disclosure. In fact, a systemic perspective suggests that mediated disclosure is more likely to result in a (long-term) stability of the family than non-disclosure. It is in the interest of the family to resist the initial aversive reaction to delivering bad news. In the final part, we draw a set of recommendations on how to facilitate decision-making in face of parental request for non-disclosure.

Redefining the Relationship: Palliative Care in Critical Perinatal and Neonatal Cardiac Patients

Patients with perinatal and neonatal congenital heart disease (CHD) represent a unique population with higher morbidity and mortality compared to other neonatal patient groups. Despite an overall improvement in long-term survival, they often require chronic care of complex medical illnesses after hospital discharge, placing a high burden of responsibility on their families. Emerging literature reflects high levels of depression and anxiety which plague parents, starting as early as the time of prenatal diagnosis. In the current era of the global COVID-19 pandemic, the additive nature of significant stressors for both medical providers and families can have catastrophic consequences on communication and coping. Due to the high prognostic uncertainty of CHD, data suggests that early pediatric palliative care (PC) consultation may improve shared decision-making, communication, and coping, while minimizing unnecessary medical interventions. However, barriers to pediatric PC persist largely due to the perception that PC consultation is indicative of “giving up.” This review serves to highlight the evolving landscape of perinatal and neonatal CHD and the need for earlier and longitudinal integration of pediatric PC in order to provide high-quality, interdisciplinary care to patients and families.

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

OBJECTIVES

To describe palliative, concurrent, and hospice care in pediatric oncology in the United States (US), we present a clinical scenario illustrating palliative and hospice care, including eligibility for concurrent care, insurance coverage and billing, barriers to accessing quality pediatric palliative and hospice care, and implications for oncology nursing practice.

DATA SOURCES

Peer-reviewed articles, clinical practice guidelines, professional organizations, and expert clinical opinion examining pediatric oncology, palliative care, and hospice care.

CONCLUSION

Understanding the goals of palliative and hospice care and the differences between them is important in providing holistic, goal-directed care.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses play a pivotal role in supporting the goals of pediatric palliative care and hospice care and in educating patients and their families. Nurses form trusting relationships with pediatric oncology patients and their families and are in a position to advocate for best palliative care practices as disease progresses to end of life, including when appropriate concurrent care or hospice.

Clinical Characteristics of the End-of-Life Phase in Children with Life-Limiting Diseases: Retrospective Study from a Single Center for Pediatric Palliative Care

Background: Data on the end-of-life phase of children receiving palliative care are limited. The purpose of this study is to investigate the spectrum of symptoms of terminally ill children, adolescents, and young adults, depending on their underlying disease. Methods: Findings are based on a 4.5-year retrospective study of 89 children who received palliative care before they died, investigating the symptomatology of the last two weeks before death. Results: In this study, the most common clinical symptomatology present in children undergoing end-of-life care includes pain, shortness of breath, anxiety, nausea, and constipation. Out of 89 patients included in this study, 47% suffered from an oncological disease. Oncological patients had a significantly higher symptom burden at the end of life (p < 0.05) compared to other groups, and the intensity of symptoms increased as the underlying disease progressed. The likelihood of experiencing pain and nausea/vomiting was also significantly higher in oncological patients (p = 0.016). Conclusions: We found that the underlying disease is associated with marked differences in the respective leading clinical symptom. Therefore, related to these differences, symptom management has to be adjusted according to the underlying disease, since the underlying disorder seems to exert an influence on the severity of symptoms and thereby on the modality and choice of treatment. This study is intended to aid underlying disease-specific symptom management at the end-of-life care for children, adolescents, and young adults, with a specific focus on end-of-life care in a home environment.