Pain practices: a cross-Canada survey of pediatric oncology centers

Healthcare Professionals' Experiences of the Barriers and Facilitators to Pediatric Pain Management in the Community at End-of-Life: A Qualitative Interview Study

CONTEXTS

Inadequate pain management in community pediatric palliative care is common. Evidence to inform improved pain management in this population is limited.

OBJECTIVES

To explore the barriers and facilitators to pediatric community-based pain management for infants, children and young people at end-of-life as perceived by healthcare professionals.

METHODS

A qualitative interview study was conducted. Semi-structured interviews were undertaken with 29 healthcare professionals; 12 nurses, five GPs, five consultants and registrar doctors, two pharmacists and five support therapists working in primary, secondary or tertiary care in the United Kingdom and involved in community end-of life care of 0 to 18-year-olds.

RESULTS

The data corpus was analyzed using an inductive thematic analysis and seven themes emerged: parents' abilities, beliefs and wellbeing; working relationships between families and healthcare professionals, and between healthcare teams; healthcare professionals' knowledge, education and experience; health services delivery; nature of pain treatment; and pediatric-specific factors. Across themes, the concepts of partnership working between families and healthcare professionals, and within healthcare teams, and sharing expertise were prevalent.

CONCLUSION

Partnership working and trust between healthcare professionals and parents, and within healthcare teams, is needed for effective at-home pediatric palliative pain management. Community healthcare professionals require more education from experienced multidisciplinary teams to effectively manage pediatric pain at end-of-life and prevent emergency hospice or hospital admissions, particularly during the COVID-19 pandemic.

A mixed-methods systematic review and meta-analysis of barriers and facilitators to paediatric symptom management at end of life

BACKGROUND

Symptom management for infants, children and young people at end of life is complex and challenging due to the range of conditions and differing care needs of individuals of different ages. A greater understanding of these challenges could inform the development of effective interventions.

AIM

To investigate the barriers and facilitators experienced by patients, carers and healthcare professionals managing symptoms in infants, children and young people at end of life.

DESIGN

A mixed-methods systematic review and meta-analysis was undertaken (PROSPERO ID: CRD42019124797).

DATA SOURCES

The Cochrane Library, PROSPERO, CINAHL, MEDLINE, PsycINFO, Web of Science Core Collection, ProQuest Dissertations & Theses Database, Evidence Search and OpenGrey were electronically searched from the inception of each database for qualitative, quantitative or mixed-methods studies that included data from patients, carers or healthcare professionals referring to barriers or facilitators to paediatric end-of-life symptom management. Studies underwent data extraction, quality appraisal, narrative thematic synthesis and meta-analysis.

RESULTS

A total of 64 studies were included (32 quantitative, 18 qualitative and 14 mixed-methods) of medium-low quality. Themes were generated encompassing barriers/facilitators experienced by carers (treatment efficacy, treatment side effects, healthcare professionals' attitudes, hospice care, home care, families' symptom management strategies) and healthcare professionals (medicine access, treatment efficacy, healthcare professionals' demographics, treatment side effects, specialist support, healthcare professionals' training, health services delivery, home care). Only one study included patients' views.

CONCLUSION

There is a need for effective communication between healthcare professionals and families, more training for healthcare professionals, improved symptom management planning including anticipatory prescribing, and urgent attention paid to the patients' perspective.

Perceptions of parents and paediatricians on pain induced by bone marrow aspiration and lumbar puncture among children with acute leukaemia: a qualitative study in China

OBJECTIVE

To obtain in-depth insight into the perceptions of parents and paediatricians in China regarding current procedural pain management on bone marrow aspirations and lumbar punctures in paediatric haemato-oncology department.

DESIGN, SETTING AND PARTICIPANTS

This qualitative study was conducted in a 4500-bed university hospital in northwest China. To collect data, in-depth semistructured interviews were conducted with parents of children with acute leukaemia (n=12) and haemato-oncology paediatricians (n=11) using purposive sampling. Interviews were audiotaped and transcribed and subjected to thematic analysis.

RESULTS

The suffering of procedural pain among paediatric patients was not adequately recognised and properly treated at the paediatric haemato-oncology department. The current paediatric procedural pain management is inadequate for paediatric patients. Crucial factors were identified including lack of awareness about the damage of uncontrolled pain in children, parents' low supportive ability, the limited capacity to provide general analgesia by anaesthetists, inadequate knowledge in the usage of analgesia and sedation and lack of efficient analgesic for children's procedural pain. The participants strongly expected optimal interventions to improve paediatric procedural pain management.

CONCLUSIONS

The result suggested a perceived and actual poor management of paediatric procedural pain in haemato-oncology department in northwest China. A relevant pain management education programme for paediatricians and parents as well as an effective pain medication are urgently needed in northwest China.

TRIAL REGISTRATION

Chinese Clinical Trial Registry. Identifier: ChiCTR-INR-16007989.

Pain assessment and management in paediatric oncology: a cross-sectional audit

AIMS AND OBJECTIVES

To describe the pain assessment and management practices documented by health professionals within a tertiary-level Children's Cancer Centre and to evaluate how these practices were compared with international recommendations.

BACKGROUND

Children with cancer are vulnerable to pain due to the intensity of antineoplastic therapy. Therefore, it is imperative to ensure that current pain management practices provided to paediatric oncology inpatients are of a high quality.

DESIGN

A single-site cross-sectional audit.

METHODS

A 24-hour period of documented pain-related care in randomly selected inpatients of an Australian tertiary-level Children's Cancer Centre was examined. The current pain management practices were audited over a two-month period resulting in 258 episodes of pain-related care being reviewed.

RESULTS

Pain related to medical treatment for cancer was common (n = 146/258, 57%) and persistent. The presence of pain was not consistently recorded by health professionals (n = 75/146, 51%). Pain was mild (n = 26/75, 35%) and opioids were the mainstay of pain management interventions (n = 63/112, 56%). Adjuvants were an important component of pain management (n = 47/112, 42%), and nonpharmacological methods of managing pain were under-represented in this audit (n = 38/146, 26%). According to the Pain Management Index, pain was appropriately managed for the majority of children (n = 65/76, 87%).

CONCLUSIONS

Pain management practices did not fully reflect the recommendations of contemporary paediatric pain management. Due to limitations in the documentation of children's pain, it was difficult to determine the effectiveness of pain management interventions.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the ongoing problem of pain for children receiving antineoplastic therapy. It is recommended that health professionals routinely screen for the presence of pain during hospitalisation and assess the efficacy of pain-related care.

Can End of Life Care for the Pediatric Patient Suffering With Escalating and Intractable Symptoms Be Improved?

Over twelve thousand children are diagnosed each year with cancer, and approximately 2200 children die each year from the disease. A percentage of these patients experiences escalating and intractable distress with symptoms that include pain, dyspnea, and agitation. These symptoms may continue for hours to days. Intractable symptoms of pain, agitation, and dyspnea can be very distressing to the patient, family, and staff and often a challenge for the physicians and nursing staff to treat. To meet this challenge, The Dana-Farber Cancer Institute/Children's Hospital Cancer Care Program has made it a priority to create a process of care that includes identifying barriers to care and the development of an end-of-life (EOL) rapid response model that includes guidelines and physiciantemplated orders for rapid escalation of opioids. The goal of this quality-improvement initiative was to develop a model of care that would enable the caregivers to provide effective comfort care to any patient experiencing symptoms of rapid escalation of pain, dyspnea, and agitation. A model of care was created to overcome barriers to care. The model includes role clarification, “Guidelines for the Management of Escalating Pain/Dyspnea/Agitation at the End of Life,” and “Rapid Titration-Templated Physician Orders.” Staff feedback was solicited relative to the content, format, and usability of the guidelines and templated orders. The physician and nursing staff reported that they found the templated orders and guidelines very helpful and effective and suggested only a few edits. A retrospective chart review is currently under way. The purpose of this chart review is to systematically document and compare the record of management of rapidly escalating symptoms of pain and/or dyspnea and/or agitation prior to and after instituting the EOL Rapid Response Model of Care. Care of the EOL patient experiencing symptoms of pain, dyspnea, and agitation is challenging. The EOL Rapid Response Model of Care outlines a process of care and provides recommendations and templated physician orders for rapid titration of opioids.

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.

Psychosocial services in the first 30 days after diagnosis: results of a web-based survey of Children's Oncology Group (COG) member institutions

BACKGROUND

This study examines what proportion of families of recently diagnosed pediatric cancer patients are offered recommended psychosocial services, and if that proportion is linked to size of institution or number of psychosocial staff.

PROCEDURES

A web-based survey was offered to all institutions belonging to the Children's Oncology Group (COG).

RESULTS

Respondents from 127/212 (=59.9%) COG institutions provided information about percentage of families offered specific services within the first 30 days after diagnosis, and barriers to providing such services, as well as information about other factors that might affect their ability to provide psychosocial care. All sites reported that ≥50% of families are offered 21 of the 27 services investigated in this study. Over half of respondents (n=290) indicated that inadequate funding for staff (72%) and families' time constraints (63%) were barriers to providing psychosocial care. There was a positive relationship between the total number of psychosocial staff and the number of new patients seen annually (Pearson correlation=0.3409, P-value < 0.0004), but not between the total number of psychosocial staff and specific services offered. Most sites do not use validated assessment tools or evidence-based psychosocial interventions.

CONCLUSIONS

While some version of most recommended psychosocial services are offered across COG institutions, evidence-based psychosocial services are offered at only 11% of sites. Advances in psychosocial outcomes in pediatric oncology could be accelerated by multi-site collaboration, use of standardized assessment tools, and evidence-based interventions.

Pediatric palliative care provision around the world: a systematic review

Pediatric palliative care is recommended by many organizations. Yet, there is no information available on the progress that has been made in providing this care or the gaps that still exist in provision around the world. We conducted a systematic review to address this gap in knowledge. The systematic review identified 117 peer-reviewed and non-peer reviewed resources. Based on this information, each country was assigned a level of provision; 65.6% of countries had no known activities, 18.8% had capacity building activities, 9.9% had localized provision, and 5.7% had provision that was reaching mainstream providers. Understanding the geographic distribution in the level of provision is crucial for policy makers and funders.

Pain management practices for lumbar punctures: are we consistent?

In most pediatric oncology centers across Canada, it is now standard practice for children to be sedated for lumbar punctures (LPs). Although the use of sedation for LPs is well established in the pediatric oncology population, its use in other hospital units is not well documented. A patient record audit was completed to understand the types of pain management strategies used for LPs performed throughout a pediatric hospital. Fifty-nine patients aged between 3 days and 17 years underwent a total of 67 LPs. Pain management strategies varied among the different patient service units. Oncology patients were consistently sedated for an LP, whereas patients in the emergency department were less likely to be given any type of sedation. Recommendations are aimed at providing consistent best practice pain management for LPs throughout the hospital.

The management of pain in children with life-limiting illnesses

The management of pain in children with life-limiting illnesses is complex and unfortunately not often done effectively. Pain is a multidimensional symptom that can overshadow all other experiences of both the child and family. This article focuses on topics common to practitioners caring for children with lifelimiting illnesses, including a review of myths and obstacles to achieving adequate pain control, a review of the pathophysiology of pain, an overview of the use of opioids in children, an approach to the management of neuropathic pain, and a brief discussion of nonpharmacologic pain management strategies.

Pain in children who have life-limiting conditions

Children and adolescents who have life-limiting conditions are vulnerableto acute and chronic pain problems. Many compounding and complicatingfactors often need to be explored in this setting. Barriers to effective painmanagement include poor assessment and measurement of pain anda lack of specialist knowledge. Fears regarding the use of opioids and theirassociation with the end of life must be addressed openly and with clarity.Day-to-day management should include continual appraisal of pain issuesif quality of life is to be maximized. Pain is a complicated phenomenon. The impact of pain and the compli-cated dynamic of suffering in children and young people who have life-lim-iting conditions must not be underestimated. The clinician must be vigilantand take responsibility for all aspects of pain management in these patients.

Children's nurses' post-operative pain management practices: an observational study

BACKGROUND

Children continue to experience unrelieved moderate to severe pain post-operatively despite the evidence to guide practice being readily available. Previous studies have relied on self-report measures; there is a need to establish exactly how nurses manage children's pain in practice.

OBJECTIVES

To ascertain how nurses actually manage post-operative pain in children and whether pain management practices adhere to current best practice guidelines.

DESIGN

An observational study was carried out. Structured and unstructured data were collected.

SETTING

A children's surgical ward in the English Midlands caring for children from birth to 16 years.

PARTICIPANTS

Registered nurses (n=13) took part in the study.

METHODS

Each participant was observed continuously for a period of 5 hours per shift for two to four shifts each. The role of the observer as participant was adopted whereby the researcher could shadow the nurse and act primarily as an observer. Data were collected for 36 shifts (185 hours).

RESULTS

While nurses administered analgesic drugs when a child complained of pain, in most other areas practices did not conform to current recommendations and are in need of improvement. Nurses did not, for example, routinely assess a child's pain, nor use non-drug methods of pain relief on a regular basis.

CONCLUSIONS

The sub-optimal pain management practices may be attributable to several factors. The professional culture of nursing and/or ward culture may result in poor pain management practices being perpetuated. Nurses may not have the requisite theoretical knowledge to manage pain effectively. A lack of priority may also be attributed to pain management. These areas need exploring further.