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Imai L, Gray MM, Kim BJH, Lyle ANJ, Bock A, Weiss EM. Clinician perception of care at the end of life in a quaternary neonatal intensive care unit. Front Pediatr 2023; 11:1197360. [PMID: 37384313 PMCID: PMC10293892 DOI: 10.3389/fped.2023.1197360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/16/2023] [Indexed: 06/30/2023] Open
Abstract
Introduction Care for neonates at the end of life (EOL) is often challenging for families and medical teams alike, performed suboptimally, and requires an experienced and compassionate clinician. Much literature exists on adult and pediatric EOL care, but limited studies examine the neonatal process. Methods We aimed to describe clinicians' experiences around EOL care in a single quaternary neonatal intensive care unit as we implemented a standard guideline using the Pediatric Intensive Care Unit-Quality of Dying and Death 20 tool. Results Surveys were completed by 205 multidisciplinary clinicians over three time periods and included 18 infants at EOL. While most responses were high, a meaningful minority were below goal (<8 on 0-10 scale) for troubling symptom management, conflict between parents and staff, family access to resources, and parent preparation of symptoms. Comparison between Epochs revealed improvement in one symptom management and four communication categories. Satisfaction scores related to education around EOL were better in later Epochs. Neonatal Pain, Agitation, and Sedation Scale scores were low, with few outliers. Discussion These findings can guide those aiming to improve processes around neonatal EOL by identifying areas with the greatest challenges (e.g., conflict management) and areas that need further study (e.g., pain management around death).
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Affiliation(s)
- Lauren Imai
- Division of Neonatology, Children’s Hospital Colorado, Aurora, CO, United States
| | - Megan M. Gray
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Brennan J. H. Kim
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Allison N. J. Lyle
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Amber Bock
- Department of Hospital Medicine, Seattle Children’s Hospital, Seattle, WA, United States
| | - Elliott Mark Weiss
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, WA, United States
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Currie ER, Wolfe J, Boss R, Johnston EE, Paine C, Perna SJ, Buckingham S, McKillip KM, Li P, Dionne-Odom JN, Ejem D, Morvant A, Nichols C, Bakitas MA. Patterns of Pediatric Palliative and End-of-Life Care in Neonatal Intensive Care Patients in the Southern U.S. J Pain Symptom Manage 2023; 65:532-540. [PMID: 36801354 DOI: 10.1016/j.jpainsymman.2023.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/19/2023] [Accepted: 01/30/2023] [Indexed: 02/18/2023]
Abstract
CONTEXT Despite high rates of mortality among infants in the Southern U.S., little is known about the timing of pediatric palliative care (PPC), the intensity of end-of-life care, and whether there are differences among sociodemographic characteristics. OBJECTIVES To describe PPC patterns and treatment intensity during the last 48 hours of life among neonatal intensive care unit (NICU) patients in the Southern U.S. who received specialized PPC. METHODS Medical record abstraction of infant decedents who received PPC consultation in two NICUs (in Alabama and Mississippi) from 2009 to 2017 (n = 195) including clinical characteristics, palliative and end-of-life care characteristics, patterns of PPC, and intensive medical treatments in the last 48 hours of life. RESULTS The sample was racially (48.2% Black) and geographically (35.4% rural) diverse. Most infants died after withdrawal of life-sustaining interventions (58%) and had do not attempt resuscitation orders documented (75.9%); very few infants enrolled in hospice (6.2%). Initial PPC consult occurred a median of 13 days after admission and a median of 17 days before death. Infants with a primary diagnosis of genetic or congenital anomaly received earlier PPC consultation (P = 0.02) compared to other diagnoses. In the last 48 hours of life, NICU patients received intensive interventions including mechanical ventilation (81.5%), CPR (27.7%) and surgeries or invasive procedures (25.1%). Black infants were more likely to receive CPR compared to White infants (P = 0.04). CONCLUSION Overall, PPC consultation occurred late in NICU hospitalizations, infants received high-intensity medical interventions in the last 48 hours of life, and there are disparities in intensity of treatment interventions at end of life. Further research is needed to explore if these patterns of care reflect parent preferences and goal concordance.
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Affiliation(s)
- Erin R Currie
- School of Nursing (E.R.C.), University of Alabama at Birmingham, 1701 University Blvd., Birmingham, Alabama, USA.
| | - Joanne Wolfe
- Department of Pediatrics (J.W.), Boston, USA; Harvard Medical School
| | - Renee Boss
- Johns Hopkins University School of Medicine (R.B.)
| | - Emily E Johnston
- The University of Alabama at Birmingham Heersink School of Medicine (E.E.J.), Department of Pediatric Hematology-Oncology
| | | | - Samuel J Perna
- University of Alabama at Birmingham (S,J.P.), Department of Medicine, Gerontology, Geriatrics, and Palliative Care
| | - Susan Buckingham
- University of Alabama at Birmingham (S.B.), Palliative and Hospice Medicine
| | | | - Peng Li
- The University of Alabama at Birmingham School of Nursing (P.L., J.N.O., D.E., M.A.B.)
| | - James N Dionne-Odom
- The University of Alabama at Birmingham School of Nursing (P.L., J.N.O., D.E., M.A.B.)
| | - Deborah Ejem
- The University of Alabama at Birmingham School of Nursing (P.L., J.N.O., D.E., M.A.B.)
| | | | | | - Marie A Bakitas
- The University of Alabama at Birmingham School of Nursing (P.L., J.N.O., D.E., M.A.B.)
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Banazadeh M, Rafii F. A Concept Analysis of Neonatal Palliative Care in Nursing: Introducing a Dimensional Analysis. Compr Child Adolesc Nurs 2020:1-26. [PMID: 32790478 DOI: 10.1080/24694193.2020.1783029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/10/2020] [Indexed: 10/23/2022]
Abstract
Despite the increasing need for neonatal palliative care, it is not adequately implemented in practice. This analysis aimed to clarify the dimension of the neonatal palliative care concept to increase understanding of the concept to give more insight into clinical practice. Using dimensional analysis methodology, 46 English language papers from 2001-2018 were analyzed. The coding of the literature for the perspective, context, conditions, process, and consequences of the concept was completed. Five dimensions informed the conceptualization of this concept and interrelationships among their themes/sub-themes were presented in the matrix named, "improving quality of life and death". Within the family-centered care perspective and under different conditions/contexts through the processes of neonate's comfort and providing holistic care, the consequences of this care were improving quality of life/a good death. Family-centered care was the fundamental dimension and essential to achieving the consequences. The other dimensions of context, conditions, and processes were also affected by the family's needs, preferences, culture, and expectations. This analysis reinforces that neonatal palliative care is a multidimensional concept. To provide the standard of neonatal palliative care an integrated plan to get together many stakeholders including community, parents, clinical staff, policymakers, insurance authorities, health care systems, and education system is required. All NICUs should have neonatal palliative care-trained nurses and protocols with a family-centered care approach to focus on the quality of life of neonates with life-threatening conditions from diagnosis of disease to death. Regular training and educational courses on neonatal palliative care and family-centered care principles can make nurses more sensitive to their advocacy role.
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Affiliation(s)
- Marjan Banazadeh
- School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
- Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Forough Rafii
- School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
- Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran
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Abstract
BACKGROUND Infants who are admitted to a neonatal intensive care unit (NICU) may experience significant symptom burden. Parents are often distressed by these symptoms, which can affect their long-term coping and distress. There is limited research examining nurse perceptions of infant well-being (symptoms, suffering, and quality of life [QOL]) and associations with nurse distress. OBJECTIVE The objective of this descriptive study was to explore associations between nurse perceptions of infant well-being and self-reported distress. METHODS Nurses caring for infants with potentially life-threatening/life-limiting conditions were recruited from a Level IV NICU in the Midwestern United States as a part of a study on infant symptom burden. Nurses reported their perceptions of infant well-being and their own distress on a 5-point Likert scale. Surveys were administered at the bedside weekly for up to 12 weeks, depending on length of stay. Infant suffering and QOL were examined in relation to nurse distress. A cross-classified multilevel model was used to account for dependence within nurse and within patient. RESULTS A total of 593 surveys were collected from nurses. Using a cross-classified multilevel model with variables entered simultaneously, nurse perceptions of greater infant suffering and lower infant QOL were significantly associated with greater nurse distress. DISCUSSION Preliminary evidence shows that greater perceived infant suffering and lower perceived infant QOL may be associated with greater levels of self-reported distress in NICU nurses. Further work is needed to better understand factors related to symptom management in the NICU and the potential role of caregiver distress and compassion fatigue in NICU nurses.
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Neonatal Palliative, End of Life, and Hospice Care Across Multiple Settings. Adv Neonatal Care 2020; 20:101-102. [PMID: 32221134 DOI: 10.1097/anc.0000000000000729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Learning directly from bereaved parents about their experiences in the neonatal intensive care unit (NICU) can improve services at end-of-life (EOL) care. Parents who perceive that their infant suffered may report less satisfaction with care and may be at greater risk for distress after the death. Despite calls to improve EOL care for children, limited research has examined the EOL experiences of families in the NICU. PURPOSE We examined parent perceptions of their infant's EOL experience (eg, symptom burden and suffering) and satisfaction with care in the NICU. METHODS/SEARCH STRATEGY Forty-two mothers and 27 fathers (representing 42 infants) participated in a mixed-methods study between 3 months and 5 years after their infant's death (mean = 39.45 months, SD = 17.19). Parents reported on healthcare satisfaction, unmet needs, and infant symptoms and suffering in the final week of life. FINDINGS/RESULTS Parents reported high levels of healthcare satisfaction, with relative strengths in providers' technical skills and inclusion of the family. Greater perceived infant suffering was associated with lower healthcare satisfaction and fewer well-met needs at EOL. Parents' understanding of their infant's condition, emotional support, communication, symptom management, and bereavement care were identified as areas for improvement. IMPLICATIONS FOR PRACTICE Parents value comprehensive, family-centered care in the NICU. Additionally, monitoring and alleviating infant symptoms contribute to greater parental satisfaction with care. Improving staff knowledge about EOL care and developing structured bereavement follow-up programs may enhance healthcare satisfaction and family outcomes. IMPLICATIONS FOR RESEARCH Prospective studies are needed to better understand parental perceptions of EOL care and the influence on later parental adjustment.
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Moslemi M, Nikfarid L, Nourian M, Nasiri M, Rezayi F. Translation, Cultural, and Age-Related Adaptation and Psychometric Properties of Persian Version of "Quality of Dying and Death" in Nurses Working in Neonatal Intensive Care Units. Indian J Palliat Care 2020; 26:34-39. [PMID: 32132781 PMCID: PMC7017712 DOI: 10.4103/ijpc.ijpc_119_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/10/2019] [Accepted: 11/02/2019] [Indexed: 11/25/2022] Open
Abstract
Background: Death and dying care is an area with less attention in nursing. This even is evidenced as more challenging in some populations such as neonates. Neonatal intensive care unit (NICU) nurses should be aware of the quality of care they provide for dying neonates and their families to find the areas which need attention. Objective: The aim of this study was to assess the psychometric features of the Quality of Dying and Death (QODD) questionnaire in NICU nurses in Tehran, the capital city of Iran. Methods: This methodological study was conducted in 2017. For this purpose, using census method, 130 NICU nurses working in selected hospitals participated. After the backward–forward translation, based on the method proposed by the International Test Commission, the psychometric properties of the Persian QODD were examined through the assessment of the face, content and construct validity, internal consistency, and stability. Results: Final Persian QODD's content and face validity were accepted through a qualitative method. In the confirmatory factor analysis, the original version of QODD was not confirmed. Subsequently, an exploratory factor analysis was carried out in which phrases were included in three dimensions (symptom control, preparation for death of neonate, and professional attention) that explained 75% of the variance. Cronbach's alpha values ranged from 0.82 to 0.88 for these three dimensions. The intraclass correlation coefficient (ICC) was ICC = 0.94 between two tests performed with a 2-week interval on twenty eligible nurses. Conclusions: The Persian version of QODD has acceptable psychometric properties in nurses working with the neonatal population and can be used to investigate the NICU nurses' opinion on the QODD provided in NICU patients.
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Affiliation(s)
- Mahsa Moslemi
- Department of Pediatric Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Lida Nikfarid
- Department of Pediatric Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Manijeh Nourian
- Department of Pediatric Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maliheh Nasiri
- Department of Pediatric Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ferershteh Rezayi
- Department of Pediatric Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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When a Child Dies in the PICU: Practice Recommendations From a Qualitative Study of Bereaved Parents. Pediatr Crit Care Med 2019; 20:e447-e451. [PMID: 31206499 DOI: 10.1097/pcc.0000000000002040] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Around the world, the PICU is one of the most common sites for hospitalized children to die. Although ensuring the best possible care experience for these children and their families is important, clear recommendations for end-of-life and bereavement care, arising from the parents themselves, remain limited within current literature. This report aims to describe bereaved parents' recommendations for improvements in end-of-life care and bereavement follow-up when a child dies in intensive care. DESIGN Thematic analysis of incidental data from a larger grounded theory study. SETTING Four Australian PICUs. SUBJECTS Twenty-six bereaved parents participated in audio-recorded, semi-structured interviews in 2015-2016. Interviews explored their experiences of having a child die in intensive care and their experiences of end-of-life care and bereavement follow-up. Data pertaining to this report were analyzed via thematic analysis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Bereaved parents identified several areas for care delivery and improvement across three time periods: during hospitalization; during the dying phase; and during bereavement. During hospitalization, parents' recommendations focused on improved communication, changes to the physical environment, better self-care resources, and provision of family support. During the dying phase, parents suggested private, de-medicalized rooms, familiar staff members, and support to leave the hospital. Recommendations for care after death focused mainly on the provision of ongoing support from the hospital or local bereavement services, as well as improved information delivery. CONCLUSIONS Findings from this study offer many concrete recommendations for improvements in care both during and after a child's death. These recommendations range from simple practice changes to larger organizational modifications, offering many potential avenues for change and improvement both on an individual healthcare provider level and within individual PICUs.
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Cortezzo DE, Bowers K, Cameron Meyer M. Birth Planning in Uncertain or Life-Limiting Fetal Diagnoses: Perspectives of Physicians and Parents. J Palliat Med 2019; 22:1337-1345. [PMID: 31063010 DOI: 10.1089/jpm.2018.0596] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Providers often use birth plans to document parents' wishes for their fetus with a life-limiting condition. Objective: The objective of the study was to (1) discover important components of a birth plan for parents and providers who carry them out, and (2) understand the experience of parents and providers with birth plans. Methods: The study design involves mixed-methods, descriptive, exploratory survey. This involves parents (n = 20) of a pregnancy complicated by a life-limiting diagnosis and providers who care for them (n = 116). The approach involves descriptive and univariate analyses for quantitative data and thematic analysis for qualitative data. Results: Consistent components for families and physicians were diagnosis and medical management of the infant. Families gave greater emphasis on memory-making preferences. Parents feel birth plans give them a sense of control. Themes emerged from parents' experience of creating a birth plan are as follows: sense of control, therapeutic, memory making, effective communication, feeling prepared, and unexpected events. Most physicians feel comfortable discussing goals of care with families but report insufficient time. The importance of components of birth plans and perception of the parents' understanding of the prognosis varied by specialty. Discussion: Birth plans are beneficial and provide a greater sense of control for parents. Most physicians feel comfortable utilizing them. More than one-third of the physicians do not feel that they have time to complete a birth plan with parents. Communication between physicians and families about limitations of the plan and the potential trajectories could be improved. Communication between maternal and neonatal care providers regarding parent expectations and understanding could also be improved.
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Affiliation(s)
- DonnaMaria E Cortezzo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Neonatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Pain and Palliative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Katherine Bowers
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Pilkey J, Harlos M, Hohl C. Designing A Canadian Pediatric Palliative Care Residency Program. J Palliat Care 2018. [DOI: 10.1177/082585971102700215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jana Pilkey
- J Pilkey (corresponding author): Department of Family Medicine, Section of Palliative Medicine, University of Manitoba, and Palliative Care Program, Winnipeg Regional Health Authority, St. Boniface General Hospital, A8024 – 409 Tache Ave. Winnipeg, Manibota, Canada R2H 2A6
| | - Mike Harlos
- Department of Family Medicine, Section of Palliative Medicine, University of Manitoba, and Palliative Care Program, Winnipeg Regional Health Authority, St. Boniface General Hospital, Winnipeg, Manitoba, Canada
| | - Christopher Hohl
- Department of Pediatrics, University of Manitoba, and Palliative Care Program, Winnipeg Regional Health Authority, St. Boniface General Hospital, Winnipeg, Manitoba, Canada
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Grimston M, Butler AE, Copnell B. Critical care nurses' experiences of caring for a dying child: A qualitative evidence synthesis. J Adv Nurs 2018; 74:1752-1768. [PMID: 29729652 DOI: 10.1111/jan.13701] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 02/27/2018] [Accepted: 04/04/2018] [Indexed: 11/30/2022]
Abstract
AIM To synthesize qualitative research examining the experience of critical care nurses caring for a dying child. BACKGROUND Caring for a dying child remains one of the most difficult aspects of nursing, potentially leading to personal and professional distress. A thorough understanding of this experience for critical care nurses allows for improved delivery of care and support for the nurse. DESIGN A qualitative evidence synthesis was undertaken, informed by Thomas and Harden's thematic synthesis methodology. DATA SOURCES Studies were retrieved from CINAHL Plus, Scopus, OVID Medline, and Embase, alongside hand-searching reference lists in February 2016. REVIEW METHODS Two reviewers independently assessed each study using a multistep screening process and performed critical appraisal of each included study. Data were extracted onto a predeveloped tool and analysed using thematic analysis. RESULTS There is a blurred line between the role of the nurse as a person or a professional while caring for the child and family throughout hospitalization and during and after the death. Each stage of care involves tasks and emotions that highlight the changing dominance of the nurse as either a person or professional. CONCLUSION Personal, interpersonal, and contextual factors affect delivery of care and impact of the death of the child on the critical care nurse. Reviewing individual and institutional practices could improve provision of care, interprofessional collaboration, and support provided to staff involved.
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Affiliation(s)
- Mitchell Grimston
- Education and Training Service, Nepean Blue Mountains Local Health District, Penrith, NSW, Australia
- Nepean Emergency Department, Penrith, NSW, Australia
| | - Ashleigh E Butler
- Louis Dundas Centre for Children's Palliative Care, Institute of Child Health, UCL/Great, London, UK
- School of Nursing and Midwifery, Monash University, Melbourne, Australia
| | - Beverley Copnell
- School of Nursing and Midwifery, La Trobe University, Melbourne, Australia
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Butler AE, Hall H, Copnell B. Bereaved parents' experiences of the police in the paediatric intensive care unit. Aust Crit Care 2018; 32:40-45. [PMID: 29571596 DOI: 10.1016/j.aucc.2018.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 02/02/2018] [Accepted: 02/05/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND A child's death in the intensive care unit is often sudden and unexpected, requiring the involvement of the state coroner to investigate both the cause and the circumstances surrounding the death. This process often involves the police, who arrive in intensive care to identify the body and collect statements from the parents. At present, very little is known about parents' experiences of this process. OBJECTIVES To explore bereaved parents' experiences of police presence in intensive care, as part of routine coronial investigations. The findings arose from a larger study on bereaved parents' experiences of the death of a child in the intensive care unit. METHODS Secondary analysis of incidental data from a larger grounded theory study. Nine bereaved parents from two paediatric intensive care units (PICUs) mentioned police presence in the PICU during their original audio-recorded, semistructured interviews. These data were extracted, and thematic analysis techniques were used to identify key themes. RESULTS Three main concepts were identified with the parents' experiences: (i) timing of police interviews; (ii) the impacts of police presence; and (iii) the demeanour of the officers. Overall, the parents' experiences of police presence were negative. They felt that police arrived too soon after their child's death and took too long taking their statements, hindering their ability to say goodbye. The presence of police officers also made parents feel as though they were being accused of involvement in their child's death. Finally, several participants also experienced inappropriate or unsympathetic attitudes from the police officers attending their child's death. CONCLUSIONS Findings from our study indicate that parents' experiences of police presence in the PICU as part of a coronial investigation may be negative, leaving lasting impressions on their experiences of their child's death. These findings provide areas for improvements in care delivery and the treatment of newly bereaved parents during the early phases of a coronial investigation.
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Affiliation(s)
- Ashleigh E Butler
- School of Nursing and Midwifery, Monash University, Victoria, Australia; Adult and Paediatric Intensive Care Unit, Monash Health, Victoria, Australia.
| | - Helen Hall
- School of Nursing and Midwifery, Monash University, Victoria, Australia.
| | - Beverley Copnell
- School of Nursing and Midwifery, Monash University, Victoria, Australia.
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Haug S, Farooqi S, Wilson CG, Hopper A, Oei G, Carter B. Survey on Neonatal End-of-Life Comfort Care Guidelines Across America. J Pain Symptom Manage 2018; 55:979-984.e2. [PMID: 29129740 DOI: 10.1016/j.jpainsymman.2017.10.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/30/2017] [Accepted: 10/31/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT Infants of age less than one year have the highest mortality rate in pediatrics. The American Academy of Pediatrics published guidelines for palliative care in 2013; however, significant variation persists among local protocols addressing neonatal comfort care at the end-of-life (EOL). OBJECTIVES The purpose of this study was to evaluate current neonatal EOL comfort care practices and clinician satisfaction across America. METHODS After institutional review board approval (516005), an anonymous, electronic survey was sent to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine. Members of the listserv include neonatologists, neonatal fellow physicians, neonatal nurses, and neonatal nurse practitioners from across America (U.S. and Canada). RESULTS There were 346/3000 (11.5%) responses with wide geographic distribution and high levels of intensive care responding (46.1% Level IV, 50.9% Level III, 3.0% Level II). Nearly half (45.2%) reported that their primary institution did not have neonatal comfort care guidelines. Of those reporting institutional neonatal comfort care guidelines, 19.1% do not address pain symptom management. Most guidelines also do not address gastrointestinal distress, anxiety, or secretions. Thirty-nine percent of respondents stated that their institution did not address physician compassion fatigue. Overall, 91.8% of respondents felt that their institution would benefit from further education/training in neonatal EOL care. CONCLUSION Across America, respondents confirmed significant variation and verified many institutions do not formally address neonatal EOL comfort care. Institutions with guidelines commonly appear to lack crucial areas of palliative care including patient symptom management and provider compassion fatigue. The overwhelming majority of respondents felt that their institutions would benefit from further neonatal EOL care training.
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Affiliation(s)
- Shelly Haug
- Neonatology Loma Linda University Children's Hospital, Loma Linda, California, USA.
| | - Sara Farooqi
- Neonatology Loma Linda University Children's Hospital, Loma Linda, California, USA
| | | | - Andrew Hopper
- Neonatology Loma Linda University Children's Hospital, Loma Linda, California, USA
| | - Grace Oei
- Clinical Ethics Loma Linda University Children's Hospital, Loma Linda, California, USA
| | - Brian Carter
- Bioethics Center Children's Mercy Hospital, Kansas City, Missouri, USA
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Patterns of Care at the End of Life for Children and Young Adults with Life-Threatening Complex Chronic Conditions. J Pediatr 2018; 193:196-203.e2. [PMID: 29174080 PMCID: PMC5794525 DOI: 10.1016/j.jpeds.2017.09.078] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/14/2017] [Accepted: 09/27/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To characterize patterns of care at the end of life for children and young adults with life-threatening complex chronic conditions (LT-CCCs) and to compare them by LT-CCC type. STUDY DESIGN Cross-sectional survey of bereaved parents (n = 114; response rate of 54%) of children with noncancer, noncardiac LT-CCCs who received care at a quaternary care children's hospital and medical record abstraction. RESULTS The majority of children with LT-CCCs died in the hospital (62.7%) with more than one-half (53.3%) dying in the intensive care unit. Those with static encephalopathy (AOR, 0.19; 95% CI, 0.04-0.98), congenital and chromosomal disorders (AOR, 0.28; 95% CI, 0.09-0.91), and pulmonary disorders (AOR, 0.08; 95% CI, 0.01-0.77) were significantly less likely to die at home compared with those with progressive central nervous system (CNS) disorders. Almost 50% of patients died after withdrawal or withholding of life-sustaining therapies, 17.5% died during active resuscitation, and 36% died while receiving comfort care only. The mode of death varied widely across LT-CCCs, with no patients with pulmonary disorders dying receiving comfort care only compared with 66.7% of those with CNS progressive disorders. A majority of patients had palliative care involvement (79.3%); however, in multivariable analyses, there was distinct variation in receipt of palliative care across LT-CCCs, with patients having CNS static encephalopathy (AOR, 0.07; 95% CI, 0.01-0.68) and pulmonary disorders (AOR, 0.07; 95% CI, 0.01-.09) significantly less likely to have palliative care involvement than those with CNS progressive disorders. CONCLUSIONS Significant differences in patterns of care at the end of life exist depending on LT-CCC type. Attention to these patterns is important to ensure equal access to palliative care and targeted improvements in end-of-life care for these populations.
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Garten L, Ohlig S, Metze B, Bührer C. Prevalence and Characteristics of Neonatal Comfort Care Patients: A Single-Center, 5-Year, Retrospective, Observational Study. Front Pediatr 2018; 6:221. [PMID: 30177959 PMCID: PMC6109761 DOI: 10.3389/fped.2018.00221] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 07/18/2018] [Indexed: 11/13/2022] Open
Abstract
Objective: To investigate the prevalence and characteristics of neonates with life-limiting or life-threatening conditions who receive care focused exclusively on comfort. Methods:Retrospective chart review of all newborn infants admitted to a level III perinatal center within a 5 year period. Results:1,777 of 9,878 infants (18.0%) had life-limiting or life-threatening conditions. 149 (1.5% of all neonates) were categorized as comfort care patients with death being anticipated within hours to weeks. 34.2% of comfort care patients suffered from conditions specific to the neonatal period, 28.9% were preterm infants at the limit of viability, and 22.8% were patients with congenital complex chronic conditions. In 80.5% of all comfort care patients treatment goals were re-directed toward a comfort-care-only regimen only once that life-prolonging therapies were demonstrated to be unhelpful. 136/149 comfort care patients (91.3%) died in hospital, while 13 (8.7%) were discharged home or into a hospice. Median age at death for comfort care patients was 3 days after birth (interquartile range 1-15.5 days), and delivery room death immediately after birth occurred in 37 patients (27.2%). Conclusions: The vast majority of neonatal comfort care patients died in the hospital during the first week of life. However, almost one in 10 comfort care patients were discharged to home or hospice, suggesting that planning transition out of the NICU should be routinely discussed for all infants receiving comfort care.
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Affiliation(s)
- Lars Garten
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sjoukje Ohlig
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Boris Metze
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Abstract
The purpose of palliative care (PC) is to minimize suffering and improve quality of life. Although PC has been well studied, the experience of neonatal intensive care unit (NICU) nurses in Brazil, where little PC training is provided, requires further investigation. The objective of this study was to explore the PC experiences of Brazilian NICU nurses. An exploratory, qualitative, descriptive study was conducted using semistructured, individual interviews with NICU nurses. This study was conducted in a 30-bed NICU in a teaching hospital in Sao Paulo, Brazil. A convenience sample of registered nurses (N = 9) was recruited. Interviews were recorded and transcribed verbatim, and thematic analysis was used to analyze the data. Four themes were identified: (a) living with the grief, (b) identifying with the family, (c) providing humane care, and (d) feeling unprepared. Nurses experienced intense grief while providing PC. They closely identified with the families and aimed to provide humane care that respected the families' values and the infants as human beings. The nurses also felt they lacked adequate training in PC and expressed a need for additional education and emotional support. NICU nurses need adequate education and emotional support to ensure quality nursing care for this vulnerable population of infants and their families.
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Actividad asistencial y costes en los últimos 3 meses de vida de pacientes fallecidos con cáncer en Euskadi. GACETA SANITARIA 2017; 31:524-530. [DOI: 10.1016/j.gaceta.2016.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 06/02/2016] [Accepted: 06/14/2016] [Indexed: 11/22/2022]
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Butler AE, Hall H, Copnell B. The changing nature of relationships between parents and healthcare providers when a child dies in the paediatric intensive care unit. J Adv Nurs 2017; 74:89-99. [DOI: 10.1111/jan.13401] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Ashleigh E. Butler
- School of Nursing and Midwifery; Monash University; Clayton Vic. Australia
| | - Helen Hall
- School of Nursing and Midwifery; Monash University; Clayton Vic. Australia
| | - Beverley Copnell
- School of Nursing and Midwifery; Monash University; Clayton Vic. Australia
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Roth A, Rapoport A, Widger K, Friedman JN. General paediatric inpatient deaths over a 15-year period. Paediatr Child Health 2017; 22:80-83. [PMID: 29479186 DOI: 10.1093/pch/pxx005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objective To retrospectively review trends of general paediatric inpatient deaths at a tertiary care children's hospital over a 15-year period. Methods Data were collected for all patients who died on the general paediatric wards or paediatric intensive care unit (PICU) during 1998, 2005 or 2012 and had a 'general paediatric condition'-an underlying condition or diagnosis that would normally result in admission to a general paediatric ward. Data were related to: demographics, health services utilization, information about provision and orders related to cardiopulmonary resuscitation (CPR) at time of death and involvement of palliative care services. Results Eighty-five inpatients met inclusion criteria: 35 in 1998, 27 in 2005 and 23 in 2012. Nearly 95% of general paediatric patients who died in 1998 did so in the PICU, 59.3% in 2005 and 69.6% in 2012. The median age of death decreased from 3 years in 1998 to 2 years in 2012. The proportion of patients with 'no CPR' orders at time of death increased from 31.4% in 1998 to 87.0% in 2012. Similarly, the proportion of patients with palliative care team involvement prior to death increased from less than 10% in 1998 to 73.9% in 2012. Conclusions The absolute number of inpatient general paediatric deaths has decreased from 1998 to 2012 at this hospital. A larger proportion of these deaths are occurring on the general paediatric wards rather than in the PICU over time. 'No CPR' orders and palliative care consultations are becoming more prevalent in these patients prior to death.
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Affiliation(s)
- Amanda Roth
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Adam Rapoport
- Paediatric Advanced Care Team (PACT), The Hospital for Sick Children, Toronto, Ontario
- Emily's House Children's Hospice, Toronto, Ontario
- Departments of Paediatrics and Family & Community Medicine, University of Toronto, Toronto, Ontario
| | - Kimberley Widger
- Paediatric Advanced Care Team (PACT), The Hospital for Sick Children, Toronto, Ontario
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario
| | - Jeremy N Friedman
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario
- Department of Paediatrics, University of Toronto, Toronto, Ontario
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20
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Abstract
BACKGROUND The survival rate for infants born with life-threatening problems has improved greatly over the last few decades. Nevertheless, infants still die in neonatal intensive care units (NICUs) every day. Despite existing standards of care, some aspects of end-of-life care (EOLC) are still not delivered consistently. Little is known about how NICU nurses' individual experiences affect EOLC. PURPOSE The purpose of this study was to explore, through lived and told stories, the affective, interactional, and meaning-related responses that NICU nurses have while caring for dying infants and their families. Coping strategies and changes in practice were also explored. METHODS Thirty-six members of the National Association of Neonatal Nurses submitted written narratives about an EOLC experience during which the nurse experienced strong emotions. FINDINGS Narrative analysis revealed many affective responses, but 3 were the most frequent: responsibility, moral distress, and identification. Coping methods included healthy and less healthy strategies, such as colleague support, informal and formal debriefing, practicing intentional gratefulness, avoidance, and compartmentalization. Changes in practice identified were universally described as professional growth through the use of reflective practice. IMPLICATIONS FOR PRACTICE & RESEARCH Educators should discuss the range of emotions experienced by caregivers related to EOLC and healthy coping strategies and encourage the use of reflective practice as a facilitator of professional growth. Nurse leaders should promote supportive environments in NICUs and ensure debriefing opportunities for nurses who have recently cared for a dying infant. Future research should focus on formulating interventions to utilize debriefing with NICU nurses and perhaps the development of EOLC mentors.
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Currie ER, Christian BJ, Hinds PS, Perna SJ, Robinson C, Day S, Meneses K. Parent Perspectives of Neonatal Intensive Care at the End-of-Life. J Pediatr Nurs 2016; 31:478-89. [PMID: 27261370 DOI: 10.1016/j.pedn.2016.03.023] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 03/23/2016] [Accepted: 03/31/2016] [Indexed: 11/17/2022]
Abstract
This descriptive qualitative study explored parent experiences related to their infant's neonatal intensive care unit (NICU) hospitalization, end-of-life care, and palliative care consultation. "Life and death in the NICU environment" emerged as the primary theme with the following categories: ups and downs of parenting in the NICU, decision-making challenges in the NICU, and parent support. Parents encountered challenges with areas for improvement for end-of-life and palliative care in the NICU. Further research is necessary to understand barriers with integrating palliative care and curative care in the NICU, and how NICU care affects bereavement and coping outcomes after infant death.
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Affiliation(s)
- Erin R Currie
- University of Alabama at Birmingham School of Nursing, Birmingham, AL.
| | | | - Pamela S Hinds
- Nursing Research and Quality Outcomes, Children's National Health System, Washington, DC.
| | - Samuel J Perna
- University of Alabama at Birmingham School of Medicine, Birmingham, AL.
| | - Cheryl Robinson
- University of Alabama at Birmingham School of Nursing, Birmingham, AL.
| | - Sara Day
- St. Jude Children's Research Hospital, Memphis, TN.
| | - Karen Meneses
- University of Alabama at Birmingham School of Nursing, Birmingham, AL.
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Barnett MD, Maurer SH, Wood GJ. Pediatric Palliative Care Pilot Curriculum. Am J Hosp Palliat Care 2016; 33:829-833. [DOI: 10.1177/1049909115590965] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Prior research has shown that less than 40% of pediatric program directors believe their graduating residents competent in palliative care. While many curricula have been developed to address this need, few have demonstrated improved comfort and/or knowledge with palliative care principles. The purpose of this study was to test a pocket card educational intervention regarding resident knowledge and comfort with palliative care principles. Methods: Pocket reference cards were created to deliver fundamentals of pediatric palliative care to resident learners; didactics and case studies emphasized principles on the cards. Self-reported comfort and objective knowledge were measured before and after the curriculum among residents. Results: Of 32 post-graduate year 2 (PGY2) residents, 23 (72%) completed the pre-test survey. The post-test was completed by 14 PGY2 residents (44%) and 16 of 39 PGY3/4 residents (41%). There was improvement in comfort with communication, as well as pain and symptom management among the residents. Knowledge of palliative care principles improved in part, with only a few survey questions reaching statistical significance. 100% of respondents recommended the cards be provided to their colleagues. Conclusion: This longitudinal curriculum, designed specifically for pediatric residents, was built into an existing training program and proved to be popular, feasible, and effective at improving comfort with basic palliative care principles.
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Affiliation(s)
- Michael D. Barnett
- Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of General Pediatrics and Adolescent Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Scott H. Maurer
- Division of Pediatric Hematology/Oncology and Blood & Marrow Transplantation, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Gordon J. Wood
- Midwest Palliative & Hospice Care Center, Glenview, IL, USA
- Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Abstract
OBJECTIVES Most deaths in U.S. PICUs occur after a decision has been made to limitation or withdrawal of life support. The objective of this study was to describe the clinical characteristics and outcomes of children whose families discussed limitation or withdrawal of life support with clinicians during their child's PICU stay and to determine the factors associated with limitation or withdrawal of life support discussions. DESIGN Secondary analysis of data prospectively collected from a random sample of children admitted to PICUs affiliated with the Collaborative Pediatric Critical Care Research Network between December 4, 2011, and April 7, 2013. SETTING Seven clinical sites affiliated with the Collaborative Pediatric Critical Care Research Network. PATIENTS Ten thousand seventy-eight children less than 18 years old, admitted to a PICU, and not moribund at admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Families of 248 children (2.5%) discussed limitation or withdrawal of life support with clinicians. By using a multivariate logistic model, we found that PICU admission age less than 14 days, reduced functional status prior to hospital admission, primary diagnosis of cancer, recent catastrophic event, emergent PICU admission, greater physiologic instability, and government insurance were independently associated with higher likelihood of discussing limitation or withdrawal of life support. Black race, primary diagnosis of neurologic illness, and postoperative status were independently associated with lower likelihood of discussing limitation or withdrawal of life support. Clinical site was also independently associated with likelihood of limitation or withdrawal of life support discussions. One hundred seventy-three children (69.8%) whose families discussed limitation or withdrawal of life support died during their hospitalization; of these, 166 (96.0%) died in the PICU and 149 (86.1%) after limitation or withdrawal of life support was performed. Of those who survived, 40 children (53.4%) were discharged with severe or very severe functional abnormalities, and 15 (20%) with coma/vegetative state. CONCLUSIONS Clinical factors reflecting type and severity of illness, sociodemographics, and institutional practices may influence whether limitation or withdrawal of life support is discussed with families of PICU patients. Most children whose families discuss limitation or withdrawal of life support die during their PICU stay; survivors often have substantial disabilities.
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24
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Ananth P, Melvin P, Feudtner C, Wolfe J, Berry JG. Hospital Use in the Last Year of Life for Children With Life-Threatening Complex Chronic Conditions. Pediatrics 2015; 136:938-46. [PMID: 26438707 PMCID: PMC4621793 DOI: 10.1542/peds.2015-0260] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although many adults experience resource-intensive and costly health care in the last year of life, less is known about these health care experiences in children with life-threatening complex chronic conditions (LT-CCCs). We assessed hospital resource use in children by type and number of LT-CCCs. METHODS A retrospective analysis of 1252 children with LT-CCCs, ages 1 to 18 years, who died in 2012 within 40 US children's hospitals of the Pediatric Health Information System database. LT-CCCs were identified with International Classification of Diseases, 9th Revision, Clinical Modification codes. Using generalized linear models, we assessed hospital admissions, days, costs, and interventions (mechanical ventilation and surgeries) in the last year of life by type and number of LT-CCCs. RESULTS In the last year of life, children with LT-CCCs experienced a median of 2 admissions (interquartile range [IQR] 1-5), 27 hospital days (IQR 7-84), and $142 562 (IQR $45 270-$410 087) in hospital costs. During the terminal admission, 76% (n = 946) were mechanically ventilated; 36% (n = 453) underwent surgery. Hospital use was greatest (P < .001) among children with hematologic/immunologic conditions (99 hospital days [IQR 51-146]; cost = $504 145 [IQR $250 147-$879 331]) and children with ≥3 LT-CCCs (75 hospital days [IQR 28-132]; cost = $341 222 [IQR $146 698-$686 585]). CONCLUSIONS Hospital use for children with LT-CCCs in the last year of life varies significantly across the type and number of conditions. Children with hematologic/immunologic or multiple conditions have the greatest hospital use. This information may be useful for clinicians striving to improve care for children with LT-CCCs nearing the end of life.
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Affiliation(s)
- Prasanna Ananth
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center,
| | - Patrice Melvin
- Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, Massachusetts
| | - Chris Feudtner
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joanne Wolfe
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center,,Division of Pediatric Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, and
| | - Jay G. Berry
- Division of General Pediatrics, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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25
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Pediatric palliative care: current evidence and evidence gaps. J Pediatr 2015; 166:1536-40.e1. [PMID: 25799195 DOI: 10.1016/j.jpeds.2015.02.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/30/2015] [Accepted: 02/06/2015] [Indexed: 11/23/2022]
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26
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Samsel C, Lechner BE. End-of-life care in a regional level IV neonatal intensive care unit after implementation of a palliative care initiative. J Perinatol 2015; 35:223-8. [PMID: 25341197 DOI: 10.1038/jp.2014.189] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 08/28/2014] [Accepted: 09/02/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We hypothesized that the implementation of a neonatal palliative care initiative will result in improved markers of end-of-life care. STUDY DESIGN A retrospective and prospective chart review of neonatal intensive care unit deaths was performed for 24 months before, 16 months during and 24 months after the implementation of palliative care provider education and practice guidelines (n=106). Ancillary care, redirection of care, palliative medication usage and outcome meetings in the last 48 h of life and basic demographic data were compared between epochs. Parametric and nonparametric analysis was performed. RESULT There was an increase in redirection of care and palliative medication usage and a decrease in variability of use of end-of-life interventions (P=0.012, 0.022 and <0.001). CONCLUSION The implementation of a neonatal palliative care initiative was associated with increases in palliative interventions for neonates in their final 48 h of life, suggesting that such an initiative may enhance end-of-life care.
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Affiliation(s)
- C Samsel
- 1] Department of Neonatology, Women and Infants Hospital, Providence, RI, USA [2] Triple Board Residency Program, Brown University and Rhode Island Hospitals, Providence, RI, USA
| | - B E Lechner
- 1] Department of Neonatology, Women and Infants Hospital, Providence, RI, USA [2] Warren Alpert Medical School of Brown University, Providence, RI, USA
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Younge N, Smith PB, Goldberg RN, Brandon DH, Simmons C, Cotten CM, Bidegain M. Impact of a palliative care program on end-of-life care in a neonatal intensive care unit. J Perinatol 2015; 35:218-22. [PMID: 25341195 PMCID: PMC4491914 DOI: 10.1038/jp.2014.193] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 09/11/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Evaluate changes in end-of-life care following initiation of a palliative care program in a neonatal intensive care unit. STUDY DESIGN Retrospective study comparing infant deaths before and after implementation of a Palliative Care Program comprised of medication guidelines, an individualized order set, a nursing care plan and staff education. RESULT Eighty-two infants died before (Era 1) and 68 infants died after implementation of the program (Era 2). Morphine use was similar (88% vs 81%; P =0.17), whereas benzodiazepines use increased in Era 2 (26% vs 43%; P=0.03). Withdrawal of life support (73% vs 63%; P=0.17) and do-not-resuscitate orders (46% vs 53%; P=0.42) were similar. Do-not-resuscitate orders and family meetings were more frequent among Era 2 infants with activated palliative care orders (n=21) compared with infants without activated orders (n=47). CONCLUSION End-of-life family meetings and benzodiazepine use increased following implementation of our program, likely reflecting adherence to guidelines and improved communication.
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Affiliation(s)
- N Younge
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - P B Smith
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - R N Goldberg
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - D H Brandon
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - C Simmons
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - C M Cotten
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - M Bidegain
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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Butler A, Hall H, Willetts G, Copnell B. Parents' experiences of healthcare provider actions when their child dies: an integrative review of the literature. J SPEC PEDIATR NURS 2015; 20:5-20. [PMID: 25443391 DOI: 10.1111/jspn.12097] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 10/21/2014] [Accepted: 10/26/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE To review, critique and synthesise current research studies that examine parental perceptions of healthcare provider actions during and after the death of a child. CONCLUSIONS Five main themes were synthesised from the literature: staff attitudes and affect; follow-up care and ongoing contact; communication; attending to the parents; and continuity of care. PRACTICE IMPLICATIONS This review helps to identify important aspects of paediatric end-of-life care as recognised by parents, with the intention of placing the family at the centre of any future end-of-life care education or policy/protocol development.
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Affiliation(s)
- Ashleigh Butler
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia; Adult and Paediatric Intensive Care Unit, Monash Health, Melbourne, Victoria, Australia
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Bogetz JF, Ullrich CK, Berry JG. Pediatric hospital care for children with life-threatening illness and the role of palliative care. Pediatr Clin North Am 2014; 61:719-33. [PMID: 25084720 DOI: 10.1016/j.pcl.2014.05.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Under increasing pressure to contain costs, hospitals are challenged to provide high-quality care to an increasingly complex group of children with life-threatening illness (LTI) that often worsen over time. Pediatric palliative care is an essential component of optimal hospital care delivery for these children and their families. This article describes (1) the current landscape of pediatric hospital care for children with LTI, (2) the connection between palliative care and hospital care for such children, and (3) the relationship between health care reform and palliative care for children with LTI.
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Affiliation(s)
- Jori F Bogetz
- Division of General Pediatrics, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, 770 Welch Road, Suite 100, Palo Alto, CA 94304, USA.
| | - Christina K Ullrich
- Pediatric Palliative Care and Pediatric Hematology/Oncology, Dana-Farber Cancer Institute and Boston Children's Hospital, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Jay G Berry
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Room 212.2, 21 Autumn Street, Boston, MA 02115, USA
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30
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Abstract
Management of the infant in the neonatal intensive care unit (NICU) focuses on stabilization and survival but sometimes death is an inevitable outcome. Dying neonates deserve a good death. It is unknown whether we are providing neonates with a good death. This article introduces a framework describing components needed for a good death in the NICU. Initially based on an adult model, this new framework incorporates appropriate components of Emanuel and Emanuel's framework ( 1998 ) and puts them into a context applicable to neonates. The proposed concepts and relationships will require future testing and revision as indicated by the evidence.
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Affiliation(s)
- Christine A. Fortney
- The Ohio State University College of Nursing, Columbus, Ohio, 1013 Vernon Road, Bexley, Ohio 43209, (614) 231-8985 (home), (614) 302-2490 (cell),
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31
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Friebert S. Best practice in pediatric palliative care: Giving voice to the voiceless. PROGRESS IN PALLIATIVE CARE 2013. [DOI: 10.1179/0969926012z.00000000049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Chang E, MacLeod R, Drake R. Characteristics influencing location of death for children with life-limiting illness. Arch Dis Child 2013; 98:419-24. [PMID: 23599439 DOI: 10.1136/archdischild-2012-301893] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether demographic and diagnostic characteristics were associated with location of death in a series of children with life-limiting illnesses. DESIGN A population-level case series was carried out by reviewing mortality records. Sociodemographic characteristics, diagnosis and referral to paediatric palliative care (PPC) were analysed for association with location of death. SETTING New Zealand PARTICIPANTS Children and young people aged 28 days-18 years who died from a life-limiting illness between 2006 and 2009 inclusive. MAIN OUTCOME MEASURES Location of death-home, hospital, other. RESULTS Of 494 deaths, 53.6% (256/494) died in hospital and 41.9% (203/494) died at home. Asian (OR=2.66, 95% CI 1.17 to 6.04) and Pacific children (OR=2.22, 95% CI 1.15 to 4.29) had an increased risk of death in hospital compared with European children, while children with cancer (adjusted OR=0.48, 95% CI 0.3 to 0.75) and children referred to the PPC service (adjusted OR=0.60, 95% CI 0.38 to 0.96) had a decreased risk. Population-attributable risk for referral to the PPC service was 28.2% (95% CI 11.25 to 47.75). CONCLUSIONS Most children in New Zealand with a life-limiting illness die in hospital with a significant influence resulting from ethnic background, diagnosis and referral to the PPC service. These findings have implications for resourcing PPC services and end-of-life care.
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Affiliation(s)
- Emily Chang
- Starship Palliative Care Service, Starship Children's Health, Auckland City Hospital, Private Bag, 92024, Auckland 1142, New Zealand.
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Ho C, Straatman L. A review of pediatric palliative care service utilization in children with a progressive neuromuscular disease who died on a palliative care program. J Child Neurol 2013; 28:40-4. [PMID: 22447847 DOI: 10.1177/0883073812439345] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recent studies and consensus statements have expressed the need to involve palliative care services in the care of children with progressive neuromuscular diseases (PMD), yet there have been no reviews of the utilization of palliative care services by children who died on a palliative care program. We conducted a retrospective chart review of all children who had a PMD who died on a single-center palliative care program. Twenty cases were identified. Services utilized by these patients included respite care, transition services, pain and symptom management, and end-of-life care. Prominent symptoms in the last 24 hours of life included respiratory distress, pain, nausea/vomiting, and anxiety; however, symptom management was very good. Utilization of services differed depending on the disease trajectory, with respite playing a critical role in the care of children with PMD. Good symptom management can be achieved.
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Affiliation(s)
- Charles Ho
- University of Western Ontario, London, Ontario, Canada
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Aschenbrenner AP, Winters JM, Belknap RA. Integrative review: parent perspectives on care of their child at the end of life. J Pediatr Nurs 2012; 27:514-22. [PMID: 22920662 DOI: 10.1016/j.pedn.2011.07.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Revised: 07/15/2011] [Accepted: 07/16/2011] [Indexed: 10/17/2022]
Abstract
This integrative review aims to describe parents' perspectives on end-of-life care for their children. Fifteen publications from a literature search of the Cochrane databases, CINAHL, MEDLINE, and PSYCHinfo were included in the review. Recurring themes included poor communication/lack of information, strained relationships/inadequate emotional support, parental need to maintain parent/child relationships in life and death, quality of care continues after the death of the child, influence of services/planning on parent/child impacts quality of life, and the difficult decision to terminate life support. No studies were identified that focused on parents' perspectives on the care their child received at the end of life. Further research that focuses on the special needs of parents at this difficult time is needed.
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Pelant D, McCaffrey T, Beckel J. Development and implementation of a pediatric palliative care program. J Pediatr Nurs 2012; 27:394-401. [PMID: 22703687 DOI: 10.1016/j.pedn.2011.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 05/25/2011] [Accepted: 06/02/2011] [Indexed: 10/17/2022]
Abstract
Palliative care, long-used in the adult setting, is new to the pediatric setting. Research indicates that palliative care reduces length of stay and use of aggressive end-of-life interventions, improves quality of life, and provides hope. It balances provision of coordinated care with building of family memories and preparation for the child's death with celebration of the child's life. We advocate implementation of pediatric palliative care in any hospital that cares for children. This article provides a model outlining critical steps and considerations for establishing a successful pediatric palliative care program.
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Lindley LC. Trends in services among pediatric hospice providers during 2002 to 2008. Am J Hosp Palliat Care 2012; 30:68-74. [PMID: 22523121 DOI: 10.1177/1049909112444001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The medical complexities involved in caring for children at end of life have increased during the past few decades. This study sought to understand what hospice services were offered for these children and to examine service trends among pediatric hospice providers over a 7-year (2002-2008) timeframe. The number of core hospice services diminished in 2003 (IRR = 0.873, 95% CI [0.795,0.971]) and 2004 (IRR = 0.889, 95% CI [0.793, 0.995]); however, by 2008 there was an increase in offering core (IRR = 1.130, 95% CI [1.038,1.230]), noncore (IRR = 1.117, 95% CI [1.013,1.231]), and other hospice (IRR = 1.117, 95% CI [1.005,1.583]) services among pediatric providers. These findings highlight the importance of family-clinician communication about needed services prior to admitting children to hospice care.
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Affiliation(s)
- Lisa C Lindley
- College of Nursing, University of Tennessee, Knoxville, Knoxville, TN 37996, USA.
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Hill K, Coyne I. Palliative care nursing for children in the UK and Ireland. ACTA ACUST UNITED AC 2012; 21:276-81. [DOI: 10.12968/bjon.2012.21.5.276] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Implementing a Program to Improve Pediatric and Pediatric ICU Nurses’ Knowledge of and Attitudes Toward Palliative Care. J Hosp Palliat Nurs 2012. [DOI: 10.1097/njh.0b013e318236df44] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lindley LC. Health Care Reform and Concurrent Curative Care for Terminally Ill Children: A Policy Analysis. J Hosp Palliat Nurs 2011; 13:81-88. [PMID: 22822304 PMCID: PMC3401095 DOI: 10.1097/njh.0b013e318202e308] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Within the Patient Protection and Affordable Care Act of 2010 or health care reform, is a relatively small provision about concurrent curative care that significantly affects terminally ill children. Effective on March 23, 2010, terminally ill children, who are enrolled in a Medicaid or state Children's Health Insurance Plans (CHIP) hospice benefit, may concurrently receive curative care related to their terminal health condition. The purpose of this article was to conduct a policy analysis of the concurrent curative care legislation by examining the intended goals of the policy to improve access to care and enhance quality of end of life care for terminally ill children. In addition, the policy analysis explored the political feasibility of implementing concurrent curative care at the state-level. Based on this policy analysis, the federal policy of concurrent curative care for children would generally achieve its intended goals. However, important policy omissions focus attention on the need for further federal end of life care legislation for children. These findings have implications nurses.
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Affiliation(s)
- Lisa C Lindley
- University of North Carolina - Chapel Hill, School of Nursing
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Beckstrand RL, Rawle NL, Callister L, Mandleco BL. Pediatric nurses' perceptions of obstacles and supportive behaviors in end-of-life care. Am J Crit Care 2010; 19:543-52. [PMID: 20026650 DOI: 10.4037/ajcc2009497] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Each year 55 000 children die in the United States, and most of these deaths occur in hospitals. The barriers and supportive behaviors in providing end-of-life care to children should be determined. OBJECTIVE To determine pediatric intensive care unit nurses' perceptions of sizes, frequencies, and magnitudes of selected obstacles and helpful behaviors in providing end-of-life care to children. METHOD A national sample of 1047 pediatric intensive care unit nurses who were members of the American Association of Critical-Care Nurses were surveyed. A 76-item questionnaire adapted from 3 similar surveys with critical care, emergency, and oncology nurses was mailed to possible participants. Nurses who did not respond to the first mailing were sent a second mailing. Nurses were asked to rate the size and frequency of listed obstacles and supportive behaviors in caring for children at the end of life. RESULTS A total of 474 usable questionnaires were received from 985 eligible respondents (return rate, 48%). The 2 items with the highest perceived obstacle magnitude scores for size and frequency means were language barriers and parental discomfort in withholding and/or withdrawing mechanical ventilation. The highest supportive behavior item was allowing time alone with the child when he or she has died. CONCLUSIONS Pediatric intensive care unit nurses play a vital role in caring for dying children and the children's families. Overcoming language and communication barriers with children's families and between interdisciplinary team members could greatly improve the end-of-life experience for dying children.
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Affiliation(s)
- Renea L. Beckstrand
- Renea L. Beckstrand is an associate professor, Nicole L. Rawle is working in pediatrics, and Lynn Callister and Barbara L. Mandleco are professors in the College of Nursing, Brigham Young University, Provo, Utah
| | - Nicole L. Rawle
- Renea L. Beckstrand is an associate professor, Nicole L. Rawle is working in pediatrics, and Lynn Callister and Barbara L. Mandleco are professors in the College of Nursing, Brigham Young University, Provo, Utah
| | - Lynn Callister
- Renea L. Beckstrand is an associate professor, Nicole L. Rawle is working in pediatrics, and Lynn Callister and Barbara L. Mandleco are professors in the College of Nursing, Brigham Young University, Provo, Utah
| | - Barbara L. Mandleco
- Renea L. Beckstrand is an associate professor, Nicole L. Rawle is working in pediatrics, and Lynn Callister and Barbara L. Mandleco are professors in the College of Nursing, Brigham Young University, Provo, Utah
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Knapp CA. Research in Pediatric Palliative Care: Closing the Gap Between What Is and Is Not Known. Am J Hosp Palliat Care 2009; 26:392-8. [DOI: 10.1177/1049909109345147] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pediatric palliative care provides physical and psychosocial care to children with life-limiting illnesses and their families. Services are provided by physicians, nurses, volunteers, and other providers in a myriad of settings. Over the past 30 years, a portfolio of research has amassed on palliative care. Yet, much remains unknown, particularly about pediatric palliative care. This article is the first in a series and it provides a general overview of what is known and unknown about the provision and need for pediatric palliative care. Subsequent articles will focus on specific topics such as decision making and support care. The purpose of this series is to inform and promote discussion about research in pediatric palliative care.
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Affiliation(s)
- Caprice A. Knapp
- Departments of Epidemiology and Health Policy Research and the Institute for Child Health Policy, University of Florida, Gainesville, Florida,
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Orsey AD, Belasco JB, Ellenberg JH, Schmitz KH, Feudtner C. Variation in receipt of opioids by pediatric oncology patients who died in children's hospitals. Pediatr Blood Cancer 2009; 52:761-6. [PMID: 18989880 DOI: 10.1002/pbc.21824] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Opioids are a cornerstone of palliation of pain. We sought to assess variation in opioid prescription during the last week of life among a cohort of pediatric oncology patients who died while hospitalized. PROCEDURE We used detailed hospital administrative data from the Pediatric Health Information System (PHIS) regarding 1,466 subjects 0-24 years of age who were treated at 33 hospitals between 2001 and 2005. RESULTS Among the 1,466 subjects hospitalized at the time of their death, 56% received opioids every day during the hospitalized portion of their last week of life, while 44% did not. This proportion varied substantially across hospitals (range 0-90.5%). After multivariate adjustment for individual-level characteristics, the hospital-level effect on the odds of continuous prescription of opioids during the hospitalized portion of the last 7 days of life continued to vary significantly among hospitals, accounting for 10.5% of the variance in the receipt of daily opioid (P < 0.001). CONCLUSION Opioid prescription during the hospitalized portion of the last week of life varies substantially among hospitals, even after adjustment for clinical characteristics of the patients. The reasons for this significant variation, especially the component explained by hospital-level and not patient-level factors, warrant more scrutiny.
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Affiliation(s)
- Andrea D Orsey
- Division of Hematology/Oncology, Connecticut Children's Medical Center, Hartford, Connecticut 06106, USA.
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Feudtner C, Hexem KR, Shabbout M, Feinstein JA, Sochalski J, Silber JH. Prediction of pediatric death in the year after hospitalization: a population-level retrospective cohort study. J Palliat Med 2009; 12:160-9. [PMID: 19207060 DOI: 10.1089/jpm.2008.0206] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The study of how the quality of pediatric end-of-life care varies across systems of health care delivery and financing is hampered by lack of methods to adjust for the probability of death in populations of ill children. OBJECTIVE To develop a prognostication models using administratively available data to predict the probability of in-hospital and 1-year postdischarge death. METHODS Retrospective cohort study of 0-21 year old patients admitted to Pennsylvania hospitals from 1994-2001 and followed for 1-year postdischarge mortality, assessing logistic regression models ability to predict in-hospital and 1-year postdischarge deaths. RESULTS Among 678,365 subjects there were 2,202 deaths that occurred during the hospitalization (0.32% of cohort) and 860 deaths that occurred 365 days or less after hospital discharge (0.13% of cohort). The model predicting hospitalization deaths exhibited a C statistic of 0.91, with sensitivity of 65.9% and specificity of 92.9% at the 99th percentile cutpoint; while the model predicting 1-year postdischarge deaths exhibited a C statistic of 0.92, with sensitivity of 56.1% and specificity of 98.4% at the 99th percentile cutpoint. CONCLUSIONS Population-level mortality prognostication of hospitalized children using administratively available data is feasible, assisting the comparison of health care services delivered to children with the highest probability of dying during and after a hospital admission.
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Affiliation(s)
- Chris Feudtner
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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