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Forcina V, Vakeesan B, Paulo C, Mitchell L, Bell JA, Tam S, Wang K, Gupta AA, Lewin J. Perceptions and attitudes toward clinical trials in adolescent and young adults with cancer: a systematic review. ADOLESCENT HEALTH MEDICINE AND THERAPEUTICS 2018; 9:87-94. [PMID: 29942170 PMCID: PMC6005317 DOI: 10.2147/ahmt.s163121] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose Although cancer clinical trials (CT) offer opportunities for novel treatments that may lead to improved outcomes, adolescents and young adults (AYA) are less likely to participate in these trials as compared to younger children and older adults. We aimed to identify the perceptions and attitudes toward CT in AYA that influence trial participation. Materials and methods A systematic review of cancer literature was conducted that assessed perceptions and attitudes toward CT enrollment limited to AYA patients (defined as age 15–39). We estimated the frequency of identified themes by pooling identified studies. Results In total, six original research articles were identified that specifically addressed perceptions or attitudes that influenced CT participation in AYA patients. Three studies were conducted at pediatric centers – one at an AYA unit, one at an adult cancer hospital, and one was registry based. Major themes identified for CT acceptability included: hope for positive clinical affect, altruism, and having autonomy. Potential deterrents included: prolonged hospitalization, worry of side effects, and discomfort with experimentation. Conclusion Limited information is available with regard to the perceptions and attitudes toward CT acceptability among AYA patients, especially those treated at adult cancer centers, which prevents generalization of data and themes. Future research assessing strategies for understanding and supporting CT decision-making processes among AYA represents a key focus for future funding to improve CT enrollment.
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Affiliation(s)
- Victoria Forcina
- Adolescent and Young Adult Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Branavan Vakeesan
- Adolescent and Young Adult Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Chelsea Paulo
- Adolescent and Young Adult Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Laura Mitchell
- Adolescent and Young Adult Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Jennifer Ah Bell
- Joint Center for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Seline Tam
- Adolescent and Young Adult Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Kate Wang
- Adolescent and Young Adult Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Abha A Gupta
- Adolescent and Young Adult Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada.,Division of Hematology/Oncology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jeremy Lewin
- Adolescent and Young Adult Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada.,ONTrac, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Aligning guidelines and medical practice: Literature review on pediatric palliative care guidelines. Palliat Support Care 2017; 15:474-489. [PMID: 28065197 DOI: 10.1017/s1478951516000882] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Palliative care for children is becoming an important subspecialty of healthcare. Although concurrent administration of curative and palliative care is recommended, timely referral to pediatric palliative care (PPC) services remains problematic. This literature review aims to identify barriers and recommendations for proper implementation of palliative care for children through the looking glass of PPC guidelines. METHOD To identify studies on PPC guidelines, five databases were searched systematically between 1960 and 2015: Scopus, PubMed, PsycINFO, the Web of Science, and CINAHL. No restrictions were placed on the type of methodology employed in the studies. RESULTS Concerning barriers, most of the papers focused on gaps within medical practice and the lack of evidence-based research. Common recommendations therefore included: training and education of healthcare staff, formation of a multidisciplinary PPC team, research on the benefits of PPC, and raising awareness about PPC. A small number of publications reported on the absence of clear guidance in PPC documents regarding bereavement care, as well as on the difficulties and challenges involved in multidisciplinary care teams. SIGNIFICANCE OF RESULTS Our results indicate that a critical assessment of both the research guidelines and medical practice is required in order to promote timely implementation of PPC for pediatric patients.
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Snaman JM, Torres C, Duffy B, Levine DR, Gibson DV, Baker JN. Parental Perspectives of Communication at the End of Life at a Pediatric Oncology Institution. J Palliat Med 2016; 19:326-32. [DOI: 10.1089/jpm.2015.0253] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jennifer M. Snaman
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Carlos Torres
- Department of Psychology, University of Memphis, Memphis, Tennessee
| | | | - Deena R. Levine
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Deborah V. Gibson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Justin N. Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, Tennessee
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4
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Bateman LB, Tofil NM, White ML, Dure LS, Clair JM, Needham BL. Physician Communication in Pediatric End-of-Life Care: A Simulation Study. Am J Hosp Palliat Care 2015; 33:935-941. [PMID: 26169522 DOI: 10.1177/1049909115595022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The objective of this exploratory study is to describe communication between physicians and the actor parent of a standardized 8-year-old patient in respiratory distress who was nearing the end of life. METHODS Thirteen pediatric emergency medicine and pediatric critical care fellows and attendings participated in a high-fidelity simulation to assess physician communication with an actor-parent. RESULTS Fifteen percent of the participants decided not to initiate life-sustaining technology (intubation), and 23% of participants offered alternatives to life-sustaining care, such as comfort measures. Although 92% of the participants initiated an end-of-life conversation, the quality of that discussion varied widely. CONCLUSION Findings indicate that effective physician-parent communication may not consistently occur in cases involving the treatment of pediatric patients at the end of life in emergency and critical care units. PRACTICE IMPLICATIONS The findings in this study, particularly that physician-parent end-of-life communication is often unclear and that alternatives to life-sustaining technology are often not offered, suggest that physicians need more training in both communication and end-of-life care.
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Affiliation(s)
- Lori Brand Bateman
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nancy M Tofil
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marjorie Lee White
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Leon S Dure
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Belinda L Needham
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Boss R, Nelson J, Weissman D, Campbell M, Curtis R, Frontera J, Gabriel M, Lustbader D, Mosenthal A, Mulkerin C, Puntillo K, Ray D, Bassett R, Brasel K, Hays R. Integrating palliative care into the PICU: a report from the Improving Palliative Care in the ICU Advisory Board. Pediatr Crit Care Med 2014; 15:762-7. [PMID: 25080152 PMCID: PMC4184991 DOI: 10.1097/pcc.0000000000000209] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE This review highlights benefits that patients, families and clinicians can expect to realize when palliative care is intentionally incorporated into the PICU. DATA SOURCES We searched the MEDLINE database from inception to January 2014 for English-language articles using the terms "palliative care" or "end of life care" or "supportive care" and "pediatric intensive care." We also hand-searched reference lists and author files and relevant tools on the Center to Advance Palliative Care website. STUDY SELECTION Two authors (physicians with experience in pediatric intensive care and palliative care) made final selections. DATA EXTRACTION We critically reviewed the existing data and tools to identify strategies for incorporating palliative care into the PICU. DATA SYNTHESIS The Improving Palliative Care in the ICU Advisory Board used data and experience to address key questions relating to: pain and symptom management, enhancing quality of life, communication and decision-making, length of stay, sites of care, and grief and bereavement. CONCLUSIONS Palliative care should begin at the time of a potentially life-limiting diagnosis and continue throughout the disease trajectory, regardless of the expected outcome. Although the PICU is often used for short term postoperative stabilization, PICU clinicians also care for many chronically ill children with complex underlying conditions and others receiving intensive care for prolonged periods. Integrating palliative care delivery into the PICU is rapidly becoming the standard for high quality care of critically ill children. Interdisciplinary ICU staff can take advantage of the growing resources for continuing education in pediatric palliative care principles and interventions.
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Affiliation(s)
- Renee Boss
- 1Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD. 2Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. 3Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, NY. 4Center for Health Research, College of Nursing, Wayne State University, Detroit, MI. 5Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA. 6Cerebrovascular Center, Cleveland Clinic, Cleveland, OH. 7VA Palo Alto Health Care System, Palo Alto, CA. 8Section of Palliative Care, North Shore-Long Island Jewish Health System, Manhasset NY. 9Department of Surgery, New Jersey Medical School-University of Medicine and Dentistry of New Jersey, Newark, NJ. 10Hartford Hospital, Hartford, CT. 11Department of Physiological Nursing, University of California, San Francisco, CA. 12Lehigh Valley Health Network, Allentown, PA. 13Boise, Meridian, & Mountain States Tumor Institute, St. Luke's Hospital, Boise, ID. 14Departments of Surgery and Health Policy, Medical College of Wisconsin, Milwaukee WI 15Departments of Rehabilitation Medicine, Pediatrics and Bioethics & Humanities, University of Washington School of Medicine, Seattle, WA
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Hileli I, Weyl Ben Arush M, Hakim F, Postovsky S. Association between religious and socio-economic background of parents of children with solid tumors and DNR orders. Pediatr Blood Cancer 2014; 61:265-8. [PMID: 23940107 DOI: 10.1002/pbc.24712] [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] [Received: 04/10/2013] [Accepted: 07/08/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND The influence of socio-economic and religious background on decisions made by parents of children with incurable cancer regarding DNR orders is not fully understood. PROCEDURE A retrospective analysis of medical charts of patients who died between January 2000 and January 2011 was performed. The following data were sought: written evidence of DNR discussion with parents, religious background, educational level, monthly income. RESULTS There was evidence of a discussion on DNR in 73/90 charts. DNR consent was obtained in 14/17 (82.4%) cases where at least one parent had >15 years of education versus in only 24/45 (53.3%) cases where both parents had ≤15 years education as determined by univariate analysis (P = 0.03). DNR consent was also more likely to be obtained among parents of children with income >10,000 NIS (24/30, 80.0% vs. 20/38, 52.6%, P = 0.013). Parents of Jewish (22/30, 73.3%), Islamic (16/26, 61.5%), and Christian (8/9, 88.9%) background were equally likely to provide DNR consent. However, Druze families were less likely to do so (2/8, 25.0%, P = 0.036). CONCLUSIONS The process of decision-making to a DNR request was associated with parents' educational level and monthly family income, and not by religious background, with the exception of Druze families.
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Affiliation(s)
- Inbal Hileli
- Department of Pediatric Oncology/Hematology, Meyer Children's Hospital, Rambam Health Care Campus, and Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Baker JN, Leek AC, Salas HS, Drotar D, Noll R, Rheingold SR, Kodish ED. Suggestions from adolescents, young adults, and parents for improving informed consent in phase 1 pediatric oncology trials. Cancer 2013; 119:4154-61. [PMID: 24006119 DOI: 10.1002/cncr.28335] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/09/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Informed consent for a pediatric oncology phase 1 trial is a delicate process, and is made more complex by the difficulty of the information and the requirement for parental consent, and patient assent when applicable. This analysis identifies suggestions for improving the informed consent process received from parents and adolescent and young adult patients (aged 14 years-21 years) who had the option of participating in a phase 1 pediatric oncology trial. METHODS A total of 57 parents and 20 patients completed interviews as part of a multisite, prospective, descriptive study. These transcribed interviews were studied using established content analysis methods. RESULTS Parent and patient responses contained 220 suggestions and 54 suggestions, respectively. A total of 21 unique suggestions for improvement emerged in 3 main themes: 1) provision of more information; 2) structure and presentation of the informed consent process, and 3) suggestions for physicians conducting the process. Common suggestions included providing more specific information about the trial, allowing more time for decision-making, and using different methods to deliver information. CONCLUSIONS Participants involved in the informed consent process for a phase 1 trial provided specific recommendations to research teams to enhance the process. Physician/investigators should be informed of these recommendations and develop and test interventions incorporating them.
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Affiliation(s)
- Justin N Baker
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, Tennessee
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Williams-Reade J, Lamson AL, Knight SM, White MB, Ballard SM, Desai PPP. Paediatric palliative care: a review of needs, obstacles and the future. J Nurs Manag 2013; 23:4-14. [PMID: 23944156 DOI: 10.1111/jonm.12095] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2013] [Indexed: 01/16/2023]
Abstract
AIM This literature review offers a response to the current paediatric palliative care literature that will punctuate the need for a framework (i.e. the three world view) that can serve as an evaluative lens for nurse managers who are in the planning or evaluative stages of paediatric palliative care programmes. BACKGROUND The complexities in providing paediatric palliative care extend beyond clinical practices to operational policies and financial barriers that exist in the continuum of services for patients. EVALUATION This article offers a review of the literature and a framework in order to view best clinical practices, operational/policy standards and financial feasibility when considering the development and sustainability of paediatric palliative care programmes. KEY ASPECTS Fifty-four articles were selected as representative of the current state of the literature as it pertains to the three world view (i.e. clinical, operational and financial factors) involved in providing paediatric palliative care. CONCLUSION In developing efficient paediatric palliative care services, clinical, operational and financial resources and barriers need to be identified and addressed. IMPLICATIONS FOR NURSING MANAGEMENT Nursing management plays a crucial role in addressing the clinical, operational and financial needs and concerns that are grounded in paediatric palliative care literature.
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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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10
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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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Saad R, Huijer HAS, Noureddine S, Muwakkit S, Saab R, Abboud MR. Bereaved parental evaluation of the quality of a palliative care program in Lebanon. Pediatr Blood Cancer 2011; 57:310-6. [PMID: 21394892 DOI: 10.1002/pbc.23082] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Accepted: 01/20/2011] [Indexed: 11/07/2022]
Abstract
BACKGROUND Palliative care (PC) is important in Pediatric Oncology as more than 20% of children with cancer still die despite modern treatment. As a significant number of children reside in countries with limited resources; more research in PC is needed there. This study aimed at evaluating the quality of care provided to children with cancer at the Children's Cancer Center of Lebanon (CCCL) during their last month of life as perceived by the bereaved parents. PROCEDURE Between 2002 and 2007, 76 children with cancer treated at CCCL succumbed to their disease. Twenty-nine of the bereaved parents were interviewed at home about the symptoms and suffering experienced by their children during the last month of life, communication with the healthcare team, quality of care delivered, and recommendations for improving care. RESULTS Fatigue, anorexia, and pain were the most prevalent symptoms and edema was the most distressing. The overall communication with the healthcare team and the overall quality of care delivered was rated as "very good" to "excellent" by 86.2% and 93.1% of the participants, respectively. Parents suggested improving the organization of care, the communication, and the availability of human and material resources. CONCLUSIONS This study is the first conducted in Lebanon to evaluate the quality of pediatric palliative care (PPC). The parents' experiences in our country were similar to those described in other countries, religions, and cultures. Significant strengths and weaknesses in the management of the dying children, from the parents' perspective, were uncovered and recommendations for improving practice were made.
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Affiliation(s)
- Rima Saad
- Children's Cancer Center of Lebanon, American University of Beirut Medical Center, Beirut, Lebanon.
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The caring continuum: role of the pediatric critical care advanced practice nurse in palliative care program development. Crit Care Nurs Q 2010; 33:292-7. [PMID: 20551744 DOI: 10.1097/cnq.0b013e3181ecd5a2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A caring continuum to children at the close of life can be established by broadening the scope of intervention available to these children in the ICU, general pediatric unit, and the clinic with critical care based advanced practice nursing team, providing close interdisciplinary coordination of complex care.
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Maurer SH, Hinds PS, Spunt SL, Furman WL, Kane JR, Baker JN. Decision making by parents of children with incurable cancer who opt for enrollment on a phase I trial compared with choosing a do not resuscitate/terminal care option. J Clin Oncol 2010; 28:3292-8. [PMID: 20498399 DOI: 10.1200/jco.2009.26.6502] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Parents of children with incurable cancer make complex and difficult decisions about remaining treatment options. We compared the self-reported rationale, good parent definition, and desired clinical staff behaviors of parents who recently decided for phase I (P1) chemotherapy with parents who chose a do not resuscitate (DNR) or terminal care (TC) option. PATIENTS AND METHODS Sixty-two parents of 58 children were asked for the basis of their decision, their definition of a good parent, and what staff behaviors supported their good parent role. After semantic content analysis, results were compared in the P1 versus DNR/TC groups. These categories were mutually exclusive but did not necessarily represent an either/or decision. RESULTS Thirty-one decisions were for P1 chemotherapy and 27 for DNR/TC. Median survival time after study enrollment was greater in the P1 group (0.4 v 0.1 years). Most P1 group parents reported having felt compelled to continue cancer-directed therapy (71% v 7%), whereas those who opted for DNR/TC cited quality of life (QOL; 74% v 3%) and patient wishes (67% v 13%). Decision factors common to both groups were medical facts, doing right, and others' opinions. Both groups believed that a good parent did right, provided support and presence, and sacrificed for the child. The groups desired similar support from clinicians and expressed gratitude. CONCLUSION Despite similar definitions of a good parent and desired staff behaviors, parents in the P1 group reported having felt compelled to continue cancer-directed therapy, whereas QOL and patient wishes were emphasized in decisions for DNR/TC.
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Affiliation(s)
- Scott H Maurer
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN 38105, USA.
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14
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Abstract
There is broad consensus that withholding or withdrawing medical interventions is morally permissible when requested by competent patients or, in the case of patients without decision-making capacity, when the interventions no longer confer a benefit to the patient or when the burdens associated with the interventions outweigh the benefits received. The withdrawal or withholding of measures such as attempted resuscitation, ventilators, and critical care medications is common in the terminal care of adults and children. In the case of adults, a consensus has emerged in law and ethics that the medical administration of fluid and nutrition is not fundamentally different from other medical interventions such as use of ventilators; therefore, it can be forgone or withdrawn when a competent adult or legally authorized surrogate requests withdrawal or when the intervention no longer provides a net benefit to the patient. In pediatrics, forgoing or withdrawing medically administered fluids and nutrition has been more controversial because of the inability of children to make autonomous decisions and the emotional power of feeding as a basic element of the care of children. This statement reviews the medical, ethical, and legal issues relevant to the withholding or withdrawing of medically provided fluids and nutrition in children. The American Academy of Pediatrics concludes that the withdrawal of medically administered fluids and nutrition for pediatric patients is ethically acceptable in limited circumstances. Ethics consultation is strongly recommended when particularly difficult or controversial decisions are being considered.
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Linton JM, Feudtner C. What accounts for differences or disparities in pediatric palliative and end-of-life care? A systematic review focusing on possible multilevel mechanisms. Pediatrics 2008; 122:574-82. [PMID: 18762528 DOI: 10.1542/peds.2007-3042] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal was to clarify potential mechanisms underlying differences/disparities in pediatric palliative and end-of-life care. METHODS We systematically searched online databases to identify articles relating to differences/disparities in pediatric palliative and end-of-life care, retaining 19 studies for evaluation. We then augmented this search with a broader review of the literature on the mechanisms of differences/disparities in adult palliative and end-of-life care, general pediatrics, adult medicine, and pain. RESULTS The concept of reciprocal interaction can organize and illuminate interacting mechanisms across 3 levels of human organization, namely, broader contextual influences on patients and clinicians, specific patient-provider engagements, and specific patients. By using this rubric, we identified 10 distinct mechanisms proposed in the literature. Broader contextual influences include health care system structures; access to care; and poverty, socioeconomic status, social class, and family structure. Patient-clinician engagements encompass clinician bias, prejudice, and stereotypes; concordance of race; quality of information exchange; and trust. Patient-specific features include perceptions of control; religion and spirituality; and medical conditions. CONCLUSIONS Differences and disparities in pediatric palliative and end-of-life care can be understood as arising from various mechanisms that interact across different levels of human organization, and this interactive multilevel model should be considered in designing studies or planning interventions to understand differences and to ameliorate disparities.
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Affiliation(s)
- Julie M Linton
- Division of General Pediatrics, Children's Hospital of Philadelphia, 3535 Market St, Room 1523, Philadelphia, PA 19104, USA
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16
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Abstract
High-quality pediatric palliative care should be an expected standard in the United States, especially since the publication of the numerous position statements such as "Precepts of Palliative Care for Children and Adolescents and Their Families," a joint statement created by the Association of Pediatric Oncology Nurses, the National Association of Neonatal Nurses, and the Society of Pediatric Nurses. Although many barriers still exist, dedicated individuals and teams strive to promote models of excellence and improve care for children with life-threatening conditions and their families. The Pediatric Advanced Care Team, a joint project of Dana-Farber Cancer Institute and Children's Hospital, Boston, is one such interdisciplinary pediatric palliative care consultation service. Founded in 1997, we have grown and learned from formal study and our extensive clinical work with families, children, and our colleagues. This article describes our journey as an interdisciplinary team forging a new service within two renowned medical institutions in which historically the primary emphasis of care has been on cure and innovation. Although these values remain, our work has resulted in an increased acceptance of balancing treatment of the underlying disease or condition along with treatment of the physical, psychosocial, and spiritual needs of the child and family through life or death. One of our goals is to help promote a balance of hope for cure with hope for comfort, dignity, and integrity for every child and family.
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Affiliation(s)
- Janet Duncan
- Pediatric Advanced Care Team, DFCI and Children's Hospital, Boston, MA, and Weill Cornell Medical School, New York, NY, USA.
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Brandon D, Docherty SL, Thorpe J. Infant and child deaths in acute care settings: implications for palliative care. J Palliat Med 2007; 10:910-8. [PMID: 17803413 DOI: 10.1089/jpm.2006.0236] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Despite 56% of child deaths occurring in inpatient hospital settings, who these children are and how they die has not been fully described. The purpose of this study was to identify the characteristics of those infants and children who die in acute care settings, and describe the extent to which palliative care was used prior to their deaths. METHODS This study used a retrospective descriptive design. The 2000 Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) was analyzed to define the national population of infants and children who die in acute care settings. In addition, medical records of a random sample of deaths at a large academic children's hospital were reviewed to further characterize the events surrounding childhood deaths. RESULTS The 2000 HCUP-KID included 13,643 deaths of children less than 18 years of age, representing an estimated 26,571 infant and child deaths, nationally. One hundred eleven infants and children who died at an academic children's hospital over four years were included in a detailed chart review. The majority of the deaths in both databases occurred in males, whites, and infants less than 12 months of age. Of the children who died in the academic children's hospital, most died in a critical care unit (86%). Fifty-four percent of the HCUP-KID deaths occurred in general hospitals and 46% occurred in children's hospitals. Children who died in children's hospitals had more complex chronic conditions (CCC) than in general hospitals. Regardless of hospital type, the most prevalent CCC categories were neuromuscular, cardiovascular, respiratory, congenital/genetic, and malignancies. CONCLUSIONS The results of this study suggest that large numbers of children die in both general and children's hospitals with a wide variety of illnesses and at all ages, indicating that all acute care pediatric providers need a working knowledge of and access to end-of-life and palliative care services.
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Affiliation(s)
- Debra Brandon
- Department of Pediatrics, Duke University, Durham, North Carolina 27710, USA.
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18
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Abstract
The medical practitioner in the community is in a unique position to assist children and their families from the time of diagnosis with a life-threatening condition through to the end of life. The purpose of this article is to inform medical practitioners who care for children with complex, chronic, and life-limiting conditions about pediatric palliative care in the community. It is intended as a guide to improve understanding about (1) the misconceptions and barriers surrounding the provision of care in the community for children with chronic, complex, and life-limiting conditions; (2) the availability of services for care in the community; (3) challenges concerning out-of hospital do-not-attempt-resuscitation orders for children; and (4) reimbursement issues that impact the provision of care.
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